Breast Cancer and Augmentation Mammaplasty

Plastic surgeons today face an increasing demand from patients for breast augmentation. A survey by the American Society for Aesthetic Plastic Surgery reported 203,310 breast augmentations in 2000, an increase of 101 percent since 1997. Unfortunately, women today should realize that one in eight will develop breast cancer at some point in their lives. In other words, 25,000 of the women who had breast augmentation in the year 2000 can be expected to develop breast cancer. This awesome reality demands that we provide for our patients with breast augmentation a thorough discussion about breast cancer and alternative surgical approaches for implant placement. The information obtained within the preoperative consultation should allow the patient to make an informed decision regarding both the immediate risks and long-term consequences of the procedure. Our patients must understand the impact of the augmentation procedure on the currently available diagnostic and therapeutic surgical approaches to breast cancer treatment. We believe the following points should be a part of the preoperative discussion with the patient undergoing breast augmentation: The presence of an implant, whether above or below the muscle, obscures some percentage of the breast tissue, making the mammogram potentially less effective. The comparison by Silverstein et al. of preaugmentation and postaugmentation mammograms in 54 women showed a 36 to 44 percent decrease in mammographically visualized breast tissue with subglandular implants and a 15 to 25 percent decrease with submuscular implants.1 The presence of capsular contracture was found to be an important determinant of mammographic limitations in another study of 68 patients. Using preaugmentation and postaugmentation mammograms, a 30 percent reduction in visualized tissue was found with minimal capsular contracture, whereas moderate or severe capsular contracture resulted in a 50 percent loss of visualized tissue.2 Breast cancers developing in patients with implants may not be visualized mammographically. False negative mammograms have been reported in several series of patients with implants with breast cancer: 25 patients, 12 percent false negative3; 42 patients, 40 percent false negative4; 6 patients, 67 percent false negative5; and 18 patients, 67 percent false negative.6 Despite the mammographic difficulties in patients with breast implants, long-term studies have not demonstrated an increased risk of delayed detection of breast cancer in the patient with augmentation or a poorer prognosis when cancer does develop. The Los Angeles study of the 37 women who developed breast cancer within the cohort of 3182 women who underwent breast augmentation between 1959 and 1981 demonstrated a similar stage distribution to that of all patients with breast cancer in Los Angeles County. The 5-year survival rate of the augmented group was also equivalent to expected rates established by the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results program.7 A Canadian study compared the stage at diagnosis and survival of 41 women who developed breast cancer after augmentation mammaplasty with all other patients with breast cancer (13,246) diagnosed in Alberta from 1973 to 1990. Lymph node positivity and distant metastases were equivalent, and the 5- and 10-year survival rates did not differ between the two groups.8 Tissue diagnosis of a palpable or mammographic breast abnormality can be made by needle techniques in most patients. An open biopsy rather than a needle technique is often recommended for patients with implants. Diagnosis of a palpable or mammographic or sonographic abnormality by needle aspiration or core needle biopsy yields a definitive answer with essentially no injury to the breast. The distortion caused by an implant may make the mammographic stereotactic procedure impossible. The risk of damage to the implant may cause reluctance on the part of the radiologist to perform a needle biopsy technique. Because up to 80 percent of breast biopsies yield benign pathology, the patient with implants may well undergo an open biopsy procedure with resulting scar for a benign cause. Mastectomy rather than lumpectomy is often recommended for the breast cancer patient with implants. Surgical treatment of breast cancer by lumpectomy with preservation of the breast can be achieved in two-thirds to three-fourths of our patients today. When the breast can be preserved, providing normally sensate tissue and symmetry with the contralateral breast, the result for the patient is superior to the best reconstruction. There are problems encountered, however, with the lumpectomy approach in a patient with implants. The achievement of a normal tissue margin about the tumor in a lumpectomy procedure in a patient with subglandular implants may be difficult because of capsule formation and distortion of the tissue. Radiation treatment of the remaining breast tissue to lower the risk of local recurrence represents the standard of care after lumpectomy. Radiation will frequently cause the development of a firm capsule about the implant, whether above or below the muscle, resulting in asymmetry, discomfort, or both. Handel et al. reported complete follow-up data on 26 patients with augmentation who were treated with breast conservation surgery.9 Seventeen patients developed significant capsular contracture and eight required corrective surgery. We have observed the development of capsular firmness in all patients after radiation treatment. For these reasons, mastectomy is often recommended rather than lumpectomy, even for small tumors in the implant patient. The surgical approach for implant placement may adversely affect our ability to perform lymphatic mapping and sentinel node biopsy should breast cancer develop in the augmented patient. The technique of sentinel node biopsy has eliminated the necessity of complete axillary node dissection in the 70 percent of our patients with breast cancer who are sentinel node negative and have no axillary metastases. We have followed 971 patients who had a negative sentinel node biopsy with no further axillary dissection. In a median follow-up of 24 months, there have been no axillary recurrences. Forty-one patients in this group with invasive breast cancers have been followed for 4.0 to 5.7 years (median, 4.2 years) with no axillary recurrences.10 We have also shown that sentinel node biopsy alone without complete axillary dissection eliminates the risk of lymphedema and the postmastectomy pain syndrome in node-negative patients.11 Successful lymphatic mapping and axillary sentinel node identification depends on a normal, unscarred, high upper outer quadrant breast and axillary anatomy. We do not believe that we can rely on the technique to identify the true sentinel node in patients who have undergone transaxillary augmentation because of the disruption of the fine lymphatic channels in the lower axilla. Therefore, we believe a complete axillary dissection with its attendant risks is required in patients with breast cancer who have had implants placed through transaxillary incisions. The importance of the subareolar lymphatics in the lymphatic drainage pattern of the breast has been demonstrated by Kern and Rosenberg.12 The use of a subareolar dye injection rather than a peritumoral intraparenchymal injection yielded an improved rate of sentinel node identification. This is consistent with the anatomical concept that breast lymphatic flow coalesces in the subareolar area then flows to the axillary nodes. This finding suggests the possibility that a periareolar incision for implant placement may interfere with lymphatic flow from the central breast to subareolar lymphatics and then through superficial channels to the axilla. We believe the inframammary and transumbilical approaches for implant placement are least likely to compromise normal lymphatic anatomy and should not interfere with lymphatic mapping and sentinel node identification.