A Letter to My Patients with Textured Silicone Breast Implants
You may have heard recent media reports regarding textured breast implants and an uncommon form of cancer called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). On July 27th, the breast implant manufacturer Allergan issued a voluntary withdrawal of its Biocell textured breast implants and tissue expanders from the market based on FDA recommendations.
BIA-ALCL is not breast cancer. It is an uncommon-but-treatable type of non-Hodgkin’s lymphoma that can develop around breast implants. To date, there have been no confirmed cases of BIA-ALCL in women who have had only “smooth surface” breast implants or tissue expanders.
Due to the low risk of developing BIA-ALCL, the FDA does NOT recommend for women with textured breast implants to have them removed unless they are experiencing symptoms. The most common symptom is a collection of fluid around the implant or swelling, but symptoms may also include pain, a lump in the breast or lymph node in the armpit, rash, fever, weight-loss or unexpected changes in breast shape, including asymmetry.
If you are experiencing any of these symptoms, I encourage you to call Angela at my office to set up a consultation. I will perform an evaluation and order the appropriate tests to determine if any treatment is indicated. Your health and safety will always be my top priority.
Women who develop BIA-ALCL are usually cured by removing the implant and the scar tissue surrounding it. Some patients may require additional treatment (such as radiation or chemotherapy). If you test positive for ALCL we will go over all options.
For additional information about BIA-ALCL, the website of the American Society of Plastic Surgeons (PlasticSurgery.org/ALCL) offers a great deal of information for patients.
Of course, please do not hesitate to call the office so we can personally address your questions or concerns. 480-767-1900
I appreciate the trust you placed in me when you selected me to be your plastic surgeon. I will continue to monitor any developments, and I will keep updated this page to keep you informed of any new information.
Lawrence W. Shaw, MD
FDA takes action to protect patients from risk of certain textured breast implants; requests Allergan voluntarily recall certain breast implants and tissue expanders from market
The U.S. Food and Drug Administration today took significant action to protect women from breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) by requesting that Allergan, the manufacturer of a specific type of textured implant, recall specific models of its textured breast implants from the U.S. market due to the risk of BIA-ALCL. Following the agency’s request, Allergan has notified the FDA that it is moving forward with a worldwide recall of their BIOCELL textured breast implant products, including: Natrelle Saline-Filled breast implants, Natrelle Silicone-Filled breast implants, Natrelle Inspira Silicone-Filled breast implants, and Natrelle 410 Highly Cohesive Anatomically Shaped Silicone-Filled breast implants. The recall also includes tissue expanders used by patients prior to breast augmentation or reconstruction, including Natrelle 133 Plus Tissue Expander and Natrelle 133 Tissue Expander with Suture Tabs. The recall helps ensure that unused products are removed from suppliers and doctors’ offices. The agency also issued a safety communication today for patients with breast implants, patients considering breast implants and their health care professionals outlining the known risks and what steps patients should consider when monitoring for symptoms of BIA-ALCL, including swelling and pain in their breasts. The safety communication also lists information about all models and style numbers included in the recall.
“Although the overall incidence of BIA-ALCL appears to be relatively low, once the evidence indicated that a specific manufacturer’s product appeared to be directly linked to significant patient harm, including death, the FDA took action to alert the firm to new evidence indicating a recall is warranted to protect women’s health,” said FDA Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D. “The FDA has been diligently monitoring this issue since we first identified the possible association between breast implants and ALCL in 2011 and, at that time, communicated to patients and providers that there is a risk for women with breast implants, more frequently occurring in women with textured implants, for developing this disease. Since that time, we have worked to increase awareness and encourage reporting of all cases to the FDA so that we could continue to monitor this potential safety signal. As this issue and the science have continued to develop, we have been monitoring the reports in databases, including external patient registries, and in scientific literature. Based on new data, our team concluded that action is necessary at this time to protect the public health. We will continue to monitor the incidence of BIA-ALCL across other textured and smooth breast implants and tissue expanders as well as other devices intended for use in the breast. If action is needed in the future, we will not hesitate to do what is necessary to protect patients.”
In a table updated today on the agency’s BIA-ALCL webpage, the FDA provides the new total of 573 unique cases globally of BIA-ALCL and 33 patient deaths, which reflect a significant increase in known cases of BIA-ALCL since the agency’s last update earlier this year —an increase of 116 new unique cases and 24 deaths. Specifically, of the 573 unique cases of BIA-ALCL, 481 are attributed to Allergan implants. Of the 33 patient deaths the FDA is reporting today, 12 of the 13 patients for which the manufacturer of the implant is known, are confirmed to have an Allergan breast implant at the time of their BIA-ALCL diagnosis. These cases include new data reported to the agency since the public advisory committee meeting in March. Based on the currently available information, including the newly submitted data, our analysis demonstrates that the risk of BIA-ALCL with Allergan BIOCELL textured implants is approximately six times the risk of BIA-ALCL with textured implants from other manufacturers marketing in the U.S.
The table on the FDA’s website summarizes the cases, along with a breakdown of important information such as breast implant surface texture, patient’s age at diagnosis, time from last implant to diagnosis, and other details to give patients and health care professionals the most complete information possible about the known factors impacting these unique cases and deaths. The FDA is continuing to evaluate these additional case reports and will make this information available on its database of adverse event reports within the next few weeks.
The FDA has taken multiple steps to better understand the safety and risks of breast implants and to help strengthen the evidence generated to help inform its regulatory actions in this area, including sharing updates with the public (as recently as February2019 and via a public advisory committee meeting in March) and encouraging patients and health care professionals to report adverse events to the agency. This voluntary recall is a direct result of the agency’s comprehensive efforts to improve the quality of data collected and analyzed, and the FDA’s ongoing work to evaluate all available safety information.
“We understand that today’s news may be alarming to some patients with breast implants. In the safety communication issued today, we’re providing actionable information for individuals with specific breast implants and their health care professionals. The FDA does not recommend removal for patients without symptoms due to potential risks, but we provide helpful information for patients and providers to consider when discussing next steps,” said Jeff Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health. “Moving forward, we are committed to continuing to share updates with patients about this issue. We will continually evaluate any new information and may, as a result, take action regarding other breast implants, if warranted. In addition, we are continuing our assessment to determine whether the risk of developing BIA-ALCL is limited to specific models of textured, or all textured breast implants. We continue to advise women and health care professionals that the use of breast implants is associated with a risk of developing BIA-ALCL and that the risk is greater with textured implants.”
Textured breast implants overall are less common in the U.S. compared to other countries and specifically, macro-textured implants (the type of textured implant that Allergan manufactures) represent less than 5% of all breast implants sold in the U.S. Although this type of textured breast implant may represent a small proportion of the U.S. market, the continued availability of Allergan BIOCELL textured breast implants pose a public health risk to patients. Today’s action by the FDA is similar to other actions initiated by France, Canada and Australia, where the use of textured implants is much higher, sometimes as high as 80% of their market share. These countries have also initiated or taken actions to prompt the recall or removal of certain textured breast implants (including certain breast implants sold by Allergan) from the market.
In addition to the voluntary recall announced today, the FDA is initiating other actions to ensure that all women who consider breast implants have the information they need to have thoughtful and balanced discussions with their health care professional on the benefits and risks of breast implants based on clear information reflecting the most current understanding of their safety. For example, as previously discussed, the agency is considering recommendations for changes to the labeling of breast implants, which could include a boxed warning and a patient decision checklist to help women consider the benefits and risks of breast implants.
The FDA will continue to focus on gathering available evidence to help inform future regulatory actions and assure that women and health care professionals are informed of the risk of BIA-ALCL as they consider breast implants. To this end, the agency has requested that all breast implant manufacturers provide quarterly trending analyses of adverse events, including BIA-ALCL, and require reporting individual events in the adverse event database for devices and in existing registries. The FDA will continue to analyze all available information regarding risks associated with breast implants, routinely update the BIA-ALCL analysis published on our website and take additional actions when and where necessary.
The FDA is committed to protecting the health of women and providing as much information as possible to ensure they and their health care professionals know the benefits and risks of these devices, and that women have the most complete information available to make these important decisions about their health care.
Link to FDA Recall
The FDA Takes Action to Protect Patients from Risk of Certain Textured Breast Implants; Requests Allergan Voluntarily Recall Certain Breast Implants and Tissue Expanders from the Market: FDA Safety Communication
To protect individuals from the increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), associated with Allergan BIOCELL textured breast implants, the Food and Drug Administration (FDA) requested that Allergan recall its BIOCELL textured breast implants and tissue expanders. Allergan agreed and is removing these products from the global market. The FDA requested that Allergan recall all BIOCELL textured breast implants and tissue expanders marketed in the U.S. based on newly submitted Medical Device Reports (MDRs) reporting worldwide cases of BIA-ALCL and BIA-ALCL-related deaths associated with these devices. Allergan has notified the FDA that it will recall its BIOCELL textured breast implants and tissue expanders from the global market.
These products have the same BIOCELL textured surface (shell), which is a unique surface used only by Allergan. A list of Allergan’s BIOCELL textured devices marketed in the U.S. that will be voluntarily recalled can be found at the end of this communication.
The FDA’s analysis was attributed to a new worldwide reported total of 573 unique BIA-ALCL cases including 33 patient deaths. Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan breast implants at the time of diagnosis. In addition, 12 of 13 deaths occurring in patients with BIA-ALCL where the manufacturer was known occurred in patients implanted with an Allergan breast implant at the time of their BIA-ALCL diagnosis. The manufacturer and/or texture is unknown for the remaining 20 reported deaths from BIA-ALCL.
Based on the currently available information, including the newly submitted data, our analysis demonstrates that the risk of BIA-ALCL with Allergan BIOCELL textured implants is approximately 6 times the risk of BIA-ALCL with textured implants from other manufacturers marketing in the U.S. and continued distribution of Allergan’s Biocell BIOCELL textured breast implants would likely cause serious, adverse health consequences and potentially death from BIA-ALCL.
The FDA will continue to evaluate any new information and may, as a result, take action regarding other breast implants, if warranted. Although most cases of BIA-ALCL are associated with the use of textured breast implants, particularly macro-textured implants – such as those made by Allergan, we are continuing our assessment to determine whether the risk of developing BIA-ALCL is limited to specific models of textured, or all textured breast implants. Therefore, at the present time, we believe all individuals who are considering a breast implant of any type be informed of the risk of developing BIA-ALCL.
BIA-ALCL is not breast cancer – it is a type of non-Hodgkin’s lymphoma (cancer of the immune system). In most cases, BIA-ALCL is found in the scar tissue and fluid near the implant, but in some cases, it can spread throughout the body. At this time, the overall incidence of developing BIA-ALCL is considered to be low; however, a BIA-ALCL diagnosis is serious and can lead to death, especially if not diagnosed early or promptly treated. In most patients, BIA-ALCL is treated successfully with surgery to remove the implant and the scar tissue surrounding the implant; however, some patients may require treatment with chemotherapy and/or radiation therapy.
Patients: Important Recommendations If You Have Allergan BIOCELL Breast Implants
- If you have no symptoms, we are not recommending the removal of these or other types of breast implants due to the low risk of developing BIA-ALCL. However, if you have any questions, talk to your health care provider.
- Know the symptoms of BIA-ALCL – primarily persistent swelling or pain near the breast implant – and monitor the area around your breast implants for any changes.
- If you experience any of these symptoms or other changes, talk to your health care provider regarding the need for further evaluation. Evaluation for BIA-ALCL typically involves a physical exam, imaging, and/or assessment of the fluid or tissue around the breast implant. It is important to undergo an evaluation to diagnose BIA-ALCL since a confirmed BIA-ALCL diagnosis may change the type of operation that should be performed.
- Based on discussions with your health care provider, patients with confirmed BIA-ALCL should undergo implant removal and removal of the surrounding scar capsule, which is a more extensive operation than implant removal alone.
- As with any implanted device, it is good to keep a record of the device manufacturer, unique device identifier, and implant model name. You may have received this information on a patient device card from your surgeon. If you would like to obtain any of this information, consider asking your surgeon or obtaining the record of your surgery (operative notes) from the facility where it was performed.
- Understand that most cases of BIA-ALCL occur many years after breast implant placement. Talk to your surgeon about your risk of developing BIA-ALCL.
- If you are considering breast implants, please see these important recommendations.
Allergan Natrelle Saline-Filled Breast Implants (formerly McGhan RTV Saline-Filled Mammary Implant) approved under P990074. The following are the textured styles:
- Style 163 – BIOCELL Textured Shaped Full Height, Full Projection Saline Breast Implants
- Style 168 – BIOCELL Textured Round Moderate Profile Saline Breast Implants, also referred to as 168MP (168 Moderate Profile)
- Style 363 – BIOCELL Textured Shaped Moderate Height, Full Projection Saline Breast Implants, Allergan catalog includes 363LF, or 363 Low Height Full Projection
- Style 468 – BIOCELL Textured Shaped Full Height Moderate Projection Saline Breast Implants
Allergan Natrelle Silicone-Filled Textured Breast Implants (formerly Inamed Silicone-Filled Breast Implants) approved under P020056. The following are the textured styles:
- Style 110 – BIOCELL Textured Round Moderate Projection Gel Filled Breast Implants
- Style 115 – BIOCELL Textured Round Midrange Projection Gel Filled Breast Implants
- Style 120 – BIOCELL Textured Round High Projection Gel Filled Breast Implants
- Style TRL – Natrelle Inspira BIOCELL Textured Responsive Silicone-Filled Breast Implants
- Style TRLP – Natrelle Inspira BIOCELL Textured Responsive Silicone-Filled Breast Implants
- Style TRM – Natrelle Inspira BIOCELL Textured Responsive Silicone-Filled Breast Implants
- Style TRF – Natrelle Inspira BIOCELL Textured Responsive Silicone-Filled Breast Implants
- Style TRX – Natrelle Inspira BIOCELL Textured Responsive Silicone-Filled Breast Implants
- Style TCL – Natrelle Inspira BIOCELL Textured Cohesive Silicone-Filled Breast Implants
- Style TCLP – Natrelle Inspira BIOCELL Textured Cohesive Silicone-Filled Breast Implants
- Style TCM – Natrelle Inspira BIOCELL Textured Cohesive Silicone-Filled Breast Implants
- Style TCF – Natrelle Inspira BIOCELL Textured Cohesive Silicone-Filled Breast Implants
- Style TCX – Natrelle Inspira BIOCELL Textured Cohesive Silicone-Filled Breast Implants
- Style TSL – Natrelle BIOCELL Textured Soft Touch Silicone-Filled Breast Implants
- Style TSLP – Natrelle BIOCELL Textured Soft Touch Silicone-Filled Breast Implants
- Style TSM – Natrelle BIOCELL Textured Soft Touch Silicone-Filled Breast Implants
- Style TSF – Natrelle BIOCELL Textured Soft Touch Silicone-Filled Breast Implants
- Style TSX – Natrelle BIOCELL Textured Soft Touch Silicone-Filled Breast Implants
Natrelle 410 Highly Cohesive Anatomically Shaped Silicone Filled Breast Implants approved under P040046. The following are the textured styles:
- Style 410FM
- Style 410FF
- Style 410MM
- Style 410 MF
- Style 410 FL
- Style 410 ML
- Style 410 LL
- Style 410 LM
- Style 410 LF
- Style 410 FX
- Style 410 MX
- Style 410 LX
Allergan tissue expanders for the breast that have BIOCELL texturing originally cleared as:
- Natrelle 133 Plus Tissue Expander (K143354)
- Natrelle 133 Tissue Expander with Suture Tabs (K102806)
Breast Implant Illness (BII) – Frequently Asked Questions
Q: What is Breast Implant Illness (BII)?
A: There are women with breast implants who self-identify and present with various systemic symptoms and believe that these are related to their breast implants. They refer to these symptoms as Breast Implant Illness (BII).
Breast Implant Illness (BII) is a term used by women who have breast implants and who self-identify and describe a variety of symptoms including (but not limited to) fatigue, chest pain, hair loss, headaches, chills, photosensitivity, chronic pain, rash, body odor, anxiety, brain fog, sleep disturbance, depression, neurologic issues and hormonal issues that they feel are directly connected to their saline or silicone, textured or smooth breast implants.
The recent increase in patients reporting Breast Implant Illness (BII) symptoms appears to be related to social media. There is one Facebook group alone with more than 70,000 members, all of whom report Breast Implant Illness (BII) symptoms. This is not to say that social media is the cause of Breast Implant Illness (BII) however, it may account for the rapid increases in patient reporting. BII is not an official medical diagnosis.
Q: Is there a link between medical grade silicone implants and any disease?
A: Silicone is an element that exists in nature as crystalline silica, which has been shown to activate the immune system in conditions such as systemic sclerosis which has been seen in stone masons. Silicone used in breast implants is different and to date has not been proven to cause any disease. This silicone does not exist is nature, it is created by hydroxylating silica to form polydimethylsiloxane. Medical grade silicone has had antioxidants, dyes, and plasticizers removed during processing.
Q: Are there any tests that would indicate a connection between breast implants and symptoms that are being labelled Breast Implant Illness (BII)?
A: There is no diagnostic testing specifically for Breast Implant Illness (BII). This is one of the current areas of focus for the Aesthetic Surgery Education and Research Foundation, the research arm of the American Society for Aesthetic Plastic Surgery. There are tests for autoimmune diseases that can be performed to evaluate for potential causes of a patient’s symptoms. There are patients who have symptoms they attribute to Breast Implant Illness (BII) with positive immune testing and others with all laboratory tests which show no abnormalities.
Q. Is there any scientific data showing causation between implants and these symptoms or any disease entity?
A: In 1999, The Institute of Medicine Committee on the Safety of Silicone conducted an extensive review of the available literature and concluded there was no demonstrated clear link between silicone implants and any systemic illness. There have been studies of many different sizes and design to look at the safety of breast implants themselves. These have looked at specific autoimmune disorders and diseases. In aggregate, these studies show little to no links between breast implants and any disease. Studies of patients who have symptoms that they have related to their breast implants have not shown consistent laboratory abnormalities to define a distinct syndrome. To-date, there has been very little in the way of research into this entity that has been labelled Breast Implant Illness (BII) by women with breast implants.
Q: Does implant removal improve patient’s symptoms or cure a patient who has a medically diagnosed disease entity like an autoimmune disease?
A: Various studies show different degrees of improvement in patient symptoms after removal of their breast implants, some of which are temporary, and some showing permanent resolution of symptoms. There are no studies which specifically show which symptoms may or may not improve with implant removal with or without capsulectomy.
There is no current definitive epidemiological evidence to support a direct link between breast implants and any specific disease process. However, this does not mean further research is not indicated. In rare and unusual disease processes, it can take years to come to a scientific conclusion. There are many factors that can affect the interaction between a patient and her breast implants. Further study is required to determine the best way to potentially screen patients prior to breast implant surgery and to determine which of the multitude of reported symptoms might improve with implant and capsule removal.
A lack of a direct, proven scientific link does not mean that the symptoms experienced by these patients are not real. Some patients have legitimate concerns about a potential link between breast implants and symptoms, so it deserves our attention and further scientific research to better determine what symptoms may improve with explanation of implants.
Q. What are ASAPS and ASERF doing to better understand this group of systemic symptoms being called Breast Implant Illness (BII)?
A. Because there are many women that self-identify as having Breast Implant Illness (BII), we are listening. ASAPS and ASERF are developing a new scientific study to examine this entity. We are also providing our members with a questionnaire to use to collect a record of complaints from patients with implants, as well as one to utilize for post-explantation. We cannot yet define BII and therefore cannot say with any certainty that it exists, because we do not have any tests we can run to prove or disprove its existence. However, we can listen to and partner with our patients to determine what is the best course of action to address their complaints, be it explantation or otherwise.
Q: What should a physician do when a patient complains of Breast Implant Illness (BII) symptoms?
A: Do not ignore your patient’s concerns. Their symptoms are real and whether or not they can or cannot be attributed to their implants isn’t relevant since there is simply no existing way to prove nor disprove causation or association.
Options can include: further medical work up with or without the consultation of a rheumatologist, observation without medical work up, implant removal without capsulectomy, exchange with or without capsulectomy, removal with total capsulectomy, or removal with en bloc capsulectomy.
Patients who present with concerns of Breast Implant Illness (BII) have real symptoms that often cannot be categorized into any specific know disease entity. This does not mean their symptoms are not real and they deserve a full evaluation. The various options need to be discussed and hopefully, with further research, we may be able to determine which patients may see symptom improvement or resolution with removal of their implants and which may not see any change.
Q: What is the risk of developing Breast Implant Illness (BII)?
A: As there is no definitive link between the often subjective and divergent list of symptoms, and no means for testing, there is no ‘known’ risk. Many of the symptoms described by breast implant patients are experienced by the general public on a regular basis with or without implants. That isn’t to write-off a potential connection, but no connection has been established to-date.
Patients should however be informed of the risks that can be associated with breast implants, including (but not limited to) BIA-ALCL, a rare spectrum of disorders that can range from a benign accumulation of fluids around the breast (seroma) to an extremely rare lymphoma. They should know that BIA-ALCL is not a cancer of the breast tissue itself and that when caught early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.
Q: If after the discussion of risks and the possibility of no improvement of symptoms post-explantation is discussed with a patient, what should be done if the patient demands an “en bloc” or “total” capsulectomy with their explantation?
A: There are many medical inaccuracies perpetuated by the internet. BII patients tend to believe that a total capsulectomy is necessary to remove all causative agents and they prefer it en bloc, oftentimes without having a full understanding of what size incision is necessary for en bloc. Rather than react, first discuss the reasons you would perform a total capsulectomy with any patient. Not all plastic surgeons routinely perform a capsulectomy with explant, but some do.
If you wish to perform capsulectomy on a patient, it is important to explain that it is not always possible to remove all of the capsule. Sometimes a portion of the capsule must be left behind or is disintegrated with the use of electrocautery to prevent significant damage to muscle, rib or lung. Explain what size incision is necessary for an en bloc (as many may not be aware of how large an incision may be necessary). If they had an axillary approach or periareolar approach for breast implant placement, it must be explained to them that they cannot have the procedure done through those incisions. It is recommended to reinforce that there are increased surgical risks associated with en bloc capsulectomy which requires a complete dissection of all the tissues surrounding the breast implant and, that we do not have enough collective data to guarantee any improvement in their symptoms they have labelled Breast Implant Illness (BII).
BIA-ALCL FAQs as of February, 2019
Q: What is BIA-ALCL?
A: BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma) is a rare spectrum of disease that can range from an indolent accumulation of fluids around the breast (seroma) to a potentially metastatic lymphoma especially when there are delays in diagnosis. It is a disease that ranges from indolent to full-blown metastatic disease when not caught early. BIA-ALCL is not a cancer of the breast tissue itself. When diagnosed early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required.
BIA-ALCL is currently classified as a lymphoma. Many experts believe that it behaves clinically as a lymphoproliferative disorder (LPD) that encompasses the spectrum of disease from benign CD30+ seromas, to CD30+ malignant seromas, to invasive capsular disease, and finally metastatic disease. Current ASERF research is underway to further understand the proper classification of this disorder. Similar to LPDs, BIA-ALCL is a highly treatable disease with high cure rates.
Q: Have there been any deaths due to BIA-ALCL?
A: There have been 17 confirmed deaths globally, (9 in the United States), attributed to BIA-ALCL since the disease was first reported nearly 20 years ago.
Q: What are the symptoms of BIA-ALCL?
A: The first symptom of BIA-ALCL is usually a swelling of the breast between 2 to 28 years after the insertion of breast implants, with an average of about 8 years after implantation. The swelling is due to a collection of fluid surrounding the implant. This fluid can cause the breast to enlarge significantly over a period of days or weeks. It can also present as a lump in the breast or armpit, firmness of the breast, or pain. It is usually easily and completely treated if patients see their doctor at the first symptom.
Q: What is the risk of developing BIA-ALCL?
A: The FDA reports that it is 1:3,817 to 1:30,000 in their latest statement. These risk assessments are changing on an ongoing basis, but this is the most accurate information currently available.
Based on current data, the risk can be further explained by the texture grade of the implants as follows:
- Grade 1 (Smooth only) – In global databases, there has not been a confirmed case of smooth only. In the Feb 2019 FDA statement, it was reported that “there have been reports of BIA-ALCL in patients with smooth-surfaced implants and many reports do not include the surface texture of the implant at the time of diagnosis.” At the time of this publication it is known that a single case of smooth only BIA-ALCL was originally reported to the FDA; however, it was later determined that this was not accurate and the case was a mixed implant case, and the report to the FDA was amended.
- Grade 2 (e.g. Microtexture, Siltex and similar) – 1:82,000
- Grade 3 (e.g. Macrotexture, Biocell and similar) – 1:3,200
- Grade 4 (e.g. Polyurethane) – 1:2,800*
*Based on data form an Australian study – however this was 100% Silimed PU implants that had a manufacturing defect and have since been taken off the market.
Loch-Wilkinson, A., et al. (2017). “Breast Implant-Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk.” Plast Reconstr Surg 140(4): 645-654
Q: If a breast implant patient sees a plastic surgeon when she develops a first symptom, will she be cured?
A: That answer is not known and is a very important piece of information for patients and plastic surgeons. Most of the time patients see their plastic surgeon right away when they develop significant swelling of the breast. In these cases, the disease is almost always caught early and cured with a straightforward operation. Some women with advanced disease ignored earlier symptoms or saw a doctor who did not properly diagnose them. There are a few patients who presented with advanced disease who said that they never had earlier symptoms.
Q: Can you explain the differences in implant texture and what role that factor plays in the research?
A: Although it is rare, BIA-ALCL appears to currently develop exclusively in women with textured implants. To date there has not been a case of BIA-ALCL in a patient with only smooth implants. There are several theories which attempt to explain the higher rate for textured implant patients: many believe that the increased surface area of textured implants allows a higher number of bacteria around the implant, which forms a biofilm in some patients, and can result in chronic inflammation, ultimately leading to a proliferation of lymphocytes. Less accepted theories are that textured implants create greater inflammation because of chronic mechanical irritation, and another postulates that microscopic shedding of silicone from the textured wall induces inflammation.
Q: Is it a problem with Saline or Silicone implants?
A: Of the 457 unique cases of BIA-ALCL (FDA 2-2019) implants are both silicone and saline. It appears to purely be related to the surface of the implant and not to what the implant is filled with.
Q: How does this impact those with breast implants?
A: ASAPS and ASERF emphasize that the most important issue for women with breast implants is to screen for breast cancer with self-exam, a regular physician exam, and mammography/ultrasound/MRI as recommended by their physician. Regardless of BIA-ALCL, all women should see their plastic surgeon immediately if they note a change to the size, feel, or shape of their breasts.
Q: What about those considering breast implants?
A: Patients considering textured breast implants should discuss this issue with their plastic surgeon. Since our knowledge of this condition is continuing to evolve, thanks in large part to ASERF-sponsored research, patients should check surgery.org and the FDA website for any updates.
Q: What if a doctor is recommending textured implants to a patient?
A: The choice of implant type is ultimately a decision between an educated patient and her board certified plastic surgeon. There may be certain circumstances where a textured implant is recommended for particular patients.
All patients should have a detailed conversation with their surgeon about the risks associated with textured implants, beyond what is published online or in pamphlets. Ultimately, there are instances where textured implants are the best choice for them.
Q: How is BIA-ALCL diagnosed?
A: If a woman develops swelling in an augmented breast, she should undergo an ultrasound scan. If fluid is detected, it should be drained and tested for:
CD30 immunohistochemistry is not diagnostic for BIA-ALCL; however, it is a marker for activated T-Cells. If a patient’s seroma is CD30 positive, and the cytology is negative, this likely represents a precursor to BIA-ALCL, and should be treated with total capsulectomy. If the seroma test is CD30 negative with negative cytology, then it should be treated as a benign seroma using the individual surgeon’s protocol.
The majority of seromas seen clinically are benign seromas and not BIA-ALCL.
Management of all seromas should be by a board-certified plastic surgeon. Mammograms are not useful in diagnosing BIA-ALCL. In confirmed cases PET or MRI/CT scans may be used to help stage the disease.
If a patient wants to have their textured implants removed and replaced, the options are:
- Exchange to smooth implants
- Exchange to smooth implants with a capsulectomy
Q. How is BIA-ALCL treated and what is the prognosis?
A. Current recommendations for the treatment of BIA-ALCL call for bilateral capsulectomy (removing all the scar tissue) and removal of the old breast implants. This is a very common procedure performed by plastic surgeons, identical to what is done when an implant has ruptured or capsular contracture has developed. Smooth implants can be put back in or the patient can choose not to have implants. In all early stage cases, the disease has been fully resolved by this surgery alone. The majority of patients require no additional treatment. However, if the disease has spread to lymph nodes or grown into the adjacent tissues, chemotherapy and radiation may be necessary. These are very serious treatments with significant side effects.
Q: Are some patients at greater risk than others?
A: The rates of BIA-ALCL seem to have different rates throughout the world. This may be due to different reporting and registries, but there is likely to be a genetic predisposition that is not yet fully understood. For instance, as of this time there are very few cases in Asian patients. The risk is only with textured implants and not smooth implants; the rate is no different between silicone and saline; it occurs in both cosmetic and reconstructive patients. There is no test to determine whether one textured implant patient is at any more risk of developing this disorder than any other patients.
Q: Should patients have their implants removed because of BIA-ALCL?
A: For textured implant patients, neither the FDA nor any plastic surgery society currently recommends that women should preventatively remove textured breast implants to prevent BIA-ALCL. However, there are women who have been concerned enough about BIA-ALCL and have chosen to have their implants removed. There are some women who were already considering a breast implant revision, and the BIA-ALCL issue gave them one more reason to decide to proceed.
Breast implant patients should have ongoing follow up. Current FDA recommendations and ASAPS recommendations indicate that patients with textured implants with no issues should not do anything and implant removal is not recommended.
Q: Should women with breast implants be screened for BIA-ALCL?
A: There is no blood test to specifically screen for BIA-ALCL. The expert opinion is that asymptomatic women without breast changes do not require more than routine mammograms and breast exams. But if a patient experiences a change in her breasts – especially if there is swelling or a lump – she should undergo immediate examination, imaging, and consultation with a plastic surgeon. If there is fluid around the implant the fluid should be aspirated under ultrasound guidance and sent for analysis.
Q: What causes BIA-ALCL?
A: ASAPS, ASERF, the FDA, and the implant manufacturers are intensely studying BIA-ALCL. To date, no specific causal factors have been identified. Implant texturing, bacteriologic contamination, and genetic factors have been implicated and are undergoing further study.
The best theory today is that a combination of four factors are required for the development of BIA-ALCL:
- Textured implants (surface area to sequester bacteria)
- Chronic bacterial-inflammation
- Genetic predisposition
The source of the chronic inflammation is thought to be bacteria that have been identified around the implants in affected breasts. Evidence is accumulating that a long-term inflammatory response to the presence of these bacteria is one of the factors that may cause BIA-ALCL. Research is ongoing and cases are being monitored.
Genetic factors may play a role. Some geographic areas have reported very few cases. Ongoing data collection worldwide will help to determine whether or not there are any genetic propensities for this disease.
Q: Does ASAPS recommend against the use of textured implants?
A: The available data does not support discontinuance of textured implants. The best practice is always for the physician to discuss with each patient the known risks and potential complications associated with any procedure. It is important for the patient and her doctor to frankly discuss all options available, and the risks involved.
Every plastic surgeon offers patients options regarding breast implants in terms of sizing, shape, and surface. Depending on a particular patient’s needs, a textured implant may be preferable. The plastic surgeon must provide a frank and transparent discussion regarding the benefits and risks of implants, both smooth and textured. The patient must then make an informed decision, based upon her own assessment of her needs and the risks involved.
Every plastic surgeon needs to help each individual patient make her own decision about which implant she prefers in a fully transparent manner. This involves weighing any possible increased risks against the advantages offered by a particular type of implant. It is critical that the patient makes a fully informed decision following a full discussion of the risks and benefits.
Q: What is the recommended clinical response to a patient presenting with symptoms that could be attributable to ALCL?
A: Detailed information can be found on the ASAPS website at:
Q: Where can I find more information on BIA-ALCL?
A: Additional information and resources on BIA-ALCL are available online at https://www.surgery.org/media/resources
Q: Is there any assistance available to the patient?
A: The Mollenkopf Aesthetic Breast Reconstruction Fund and the BIA-ALCL Patient Assistance Fund can offer financial assistance to patients. Additionally, Sientra offers to cover lab testing for any seromas associated with their implants.
- The Mollenkopf Aesthetic Breast Reconstruction Fund: http://www.aserf.org/attachments/223_mollenkopf-grant-request-form.pdf
- The Mollenkopf Aesthetic Breast Reconstruction Fund The Aesthetic Surgery Education and Research Foundation (ASERF) is pleased to announce available funding for breast reconstruction patients. The Mollenkopf Aesthetic Breast Reconstruction Fund provides grants to ASERF/ASAPS member surgeons, to financially assist patients in completing their aesthetic breast reconstruction journeys. These funds are intended to help underinsured or uninsured patients nationwide cover the associated costs with breast reconstruction. The goal of this fund is to provide women with limited financial means the opportunity to achieve the best possible aesthetic breast reconstruction result. In particular, the grant is focused on women who need a final surgery or revisional surgery to complete their aesthetic reconstruction. The goal is for ASERF/ASAPS members to help women feel good about themselves after their reconstruction and aid them in returning “back to me.”
- The BIA-ALCL Patient Assistance Fund: http://www.aserf.org/images/documents/bia-alcl-patient-fund-grant-request-form.pdf
- The American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS), in conjunction with the Aesthetic Surgery Education and Research Foundation (ASERF) and the Plastic Surgery Foundation (PSF), are pleased to announce funding for patients diagnosed with breast implant associated anaplastic large cell lymphoma (BIA-ALCL). These funds are intended to help underinsured or uninsured patients who are seeking surgical treatment of BIA-ALCL, total capsulectomy and explantation, and excision of associated mass with biopsy of suspicious node(s) and implant-based reconstruction, if indicated. The goal of this Fund is for ASAPS, ASPS, ASERF, and PSF members to help patients obtain treatment when insurance limitations would have otherwise restricted their ability to do so. The Fund is made possible by generous contributions from Allergan, Mentor Worldwide, LLC and Sientra, Inc.
- Sientra : http://sientra.com/Content/pdfs/LGL-0006%20R2-Sientra%20Warranty%20Terms%20and%20Conditions.pdfThe Sientra Platinum20™ Product Replacement and Limited Warranty Program for Sientra Opus™ Silicone Gel Breast Implants (Smooth and Textured Surface) offers assistance with patients presenting with late-forming seromas.