Most breast augmentation procedures go smoothly, with only rare complications or side effects. However, patients should be aware of these unlikely risks.

According to the American Society of Plastic Surgeons (ASPS), the potential complications of breast augmentation include infection, bleeding, issues with anesthesia, hematoma, rippling, and abnormal scarring.

There are other complications as well. According to the experts that we spoke with, some of the most common are “Snoopy deformity,” capsular contracture, rippling, and “bottoming out.”

It should be noted that, despite the attention it’s received in the media, a form of breast cancer called anaplastic large cell lymphoma (ALCL), which may be associated with breast augmentation, remains extremely rare and is generally associated with textured implants.

Capsular contracture

Capsular contracture is one of the most prevalent breast implant complications. “Capsular contracture is quite common, with clinically significant rates reported at 15-45%,”says Dr. Constance M Chen, a board-certified plastic surgeon based in New York City.

The capsule is a pocket comprised of scar tissue that forms around all breast implants. However, when the scar tissue begins to constrict the capsule, it hardens and its shape may become distorted. This is capsular contracture, an unpleasant complication that can cause severe discomfort and breast pain.

Beverly Hills plastic surgeon Dr. Suzanne Trott says that the incidence of capsular contracture that actually affects the aesthetic result or causes pain is low – about 3-9% over a ten year period. Still, it’s a complication that’s dreaded by plastic surgeons.

“Once it happens, it can be difficult to fix,” Trott says. “If it isn’t treated correctly, the recurrence rate can be up to 80-100%.”

Chen says that clinically significant capsular contracture is addressed by removing the implant and performing a complete capsulectomy with or without replacement of the implant.

It should be noted that saline implants have a lower rate of capsular contracture than silicone gel-filled implants, and that the risk of capsular contracture is much lower when the implants are placed under the pectoralis muscle as opposed to directly under the breast tissue.

Snoopy deformity

According to Trott, Snoopy deformity, also called a “double bubble,” is the most common of all breast augmentation complications that she sees.

This issue happens when the implant sits too high on the chest wall and the breast tissue falls below. This may be caused by capsular contracture, or poor decision-making on the part of the surgeon and patient.

For instance, a patient that needs a breast lift in addition to implants may decide to forego the lift procedure because she doesn’t want the scar. This would cause the implant to sit too high on the chest, with the saggy skin remaining below.

Over the years and through pregnancies, the breast tissue starts to sag but the implant stays in the same place.“This is a problem that a lot of women develop over time, even if they started out with perfect implant position,” says Trott.

To treat Snoopy deformity, Trott usually removes the implants and replaces them. Typically, a lollipop incision breast lift is performed.

If capsular contracture is the main culprit, many women with Snoopy deformity won’t need a lift at all. “In such cases, removing the capsule and replacing the implants is often all that is required,” Trott says.

A rare form of “double bubble” occurs when a breast implant falls below the inframammary crease instead of projecting forward. This creates a line across the lower portion of the breast. Luckily, this issue is highly uncommon.

“This deformity can be corrected in many ways,” says Chen. “This includes releasing the underlying capsule around the implant and creating a new breast pocket for the implant. For example, the implant can be moved above the pectoralis muscle if it was previously below it, and vice versa.”

Implant rippling

Breast implant rippling refers to noticeable ripples on the surface of a breast implant. This occurs when the tissue overlying the implant sticks to the implant, usually on the lateral and inner (cleavage area) portions of the breasts.

Insufficient tissue coverage, as well as overfilling or underfilling the implant, are factors that can lead to breast implant rippling. It is more common in patients with saline breast implants and in those with subglandular implant placement (over the muscle).

According to Chen, rippling after breast augmentation surgery is very common especially with textured implants, saline implants, and in women with very thin breast skin or little breast tissue. In either case, breast implant revision surgery is the best solution.

“Rippling can be addressed by changing the implant — often with a larger implant, switching to silicone or to a smooth implant, or adding acellular dermal matrix,” says Chen. “Rippling can also be improved with fat grafting to make the irregularities less noticeable.”

Bottoming out

“Bottoming out” is when a breast implant starts to descend toward the lower pole of the breast, stretching out the distance between the nipple and inframammary crease. “The nipple starts looking too high on the breast and the upper pole becomes very flat — all of the implant’s fullness is in the lower pole,” says Trott.

Patients with poor skin elasticity are most at risk of encountering this issue. This problem is only further complicated by the fact that it is often accompanied by rippling. Placement of excessively large implants also significantly increases the risk of bottoming out.

Poor skin elasticity can stem from pregnancy, breast-feeding, dramatic weight loss from bariatric surgery, large amounts of breast fat, medications, and other factors. “Like most of the other complications of implant malposition, bottoming out is usually treated with a surgical procedure. Internal suturing is done along the bottom of the pocket horizontally to shorten the nipple-to-inframammary crease distance,” says Trott. “This is sometimes reinforced with Strattice porcine cadaveric tissue as well.”

Compared to most breast implant problems, bottoming out is relatively uncommon.

Implant rupture

Implant rupture means that the silicone shell of an implant breaks. It can happen with both saline and silicone implants.

If your saline implant ruptures, you will most certainly notice. All of the saline will leak out and the implant will go flat. “You could go to sleep with your breasts looking normal, and wake up with one deflated,” says Trott. She says that while this can look scary, it isn’t an emergency.

“Obviously the implants will need to be replaced,” she says. “If you don’t have time to deal with having a surgery immediately, the other implant can be deflated [for the purposes of symmetry] in your plastic surgeon’s office with a needle through the skin under local anesthetic until you are ready to have them changed.”

While the rupture of a saline implant is obvious, when it comes to the rupture of silicone implant detection is not so simple.

As the silicone filling is more viscous and is not immediately absorbed by the body, a rupture can go unnoticed. “It might just show up on a mammogram,” Trott explains.

“If the rupture stays ‘intracapsular’ — inside the wall of scar tissue around the implant — and you don’t get a capsular contracture, it may not feel any different,” says Trott. Usually, evaluation by MRI is necessary to determine if a silicone implant is ruptured.

“You could go to sleep with your breasts looking normal and wake up with one deflated.”

-Dr. Trott

A ruptured silicone gel breast implant can be painful and result in changes to the shape of the breast. However, as Trott explains, implant ruptures are not dangerous, regardless of whether the implant is filled with saline or silicone.

“The silicone will not leak all over your body and the saline will just be absorbed normally,” Trott says. “It isn’t an emergency to fix, but it is recommended to have the implant removed, the pocket cleaned out and the implant replaced.”

Chen agrees that it’s important to remove ruptured implants, and also notes that ruptured silicone can be difficult to remove completely. “A new breast pocket provides a fresh clean field for the implant to reduce the risk of further problems such as infection or capsular contracture,” she says.

Symmastia

Symmastia, also called “uniboob,” occurs when one or both implants end up too close to the midline over the sternum, and may even touch each other. This happens if the capsules that naturally form around the implants are too close to the midline.

There are two things that predispose a patient to the development of a symmastia: when implants are too big or too wide for the patient, and when the chest wall is indented (pectus excavatum). In either case, symmastia is usually the result of over-dissection in the inner portion of the implant pocket by the operating surgeon.

While it’s not particularly painful or as common as some of the other breast implant complications, symmastia can be difficult to fix.

Trott explains that, “it will require another surgery, and while it doesn’t usually require a new big scar, like with a double bubble deformity, internal sutures [called capsulorrhaphy] need to be placed to separate the pockets, and the implants need to be downsized as the pocket sizes are being made smaller.”

In these situations, the capsules are often very thin and the tissue isn’t strong enough to hold the sutures. “Because of this, some surgeons prefer to create a new pocket, or use Strattice cadaveric porcine skin to help reinforce the capsulorrhaphy,” says Trott.

Avoiding complications

Regardless of the precautions take, all surgery comes with its share of risks. Choosing the right board-certified plastic surgeon is the best way to minimize any potential issues.

Breast augmentation is by far the most performed cosmetic surgery procedure, with over 290,000 performed in the United States in 2016 according to the ASPS. This means that you have your pick of many qualified and experienced surgeons.

It is important to speak with your surgeon about your concerns, and to follow their advice to limit the risk of complications.

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