Implant Reconstruction Risks and Complications

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If you’ve had or are considering breast reconstruction with implants, it’s important to know about the possible risks and maintenance required over time.

Breast implants usually don’t last a lifetime. It’s common for women who have implant reconstruction to have one or more additional surgeries at some point, either to address a complication or improve how their breasts look and feel. The longer you have implants, the greater your risk of having a complication. However, implants don’t have an expiration date and there’s no need to replace them unless you have a problem.

Breast implant reconstruction surgery carries many of the same risks as a mastectomy or other breast surgeries, such as:

bleeding
problems with anesthesia
infection in the area of the surgery
wound healing problems like hematoma (blood collecting in a surgical wound) or seroma (clear fluid collecting in a surgical wound)
unexpected scarring

Other risks are unique to breast implants, such as:

implant rupture
implant displacement
capsular contracture
breast implant illness

Before you decide whether to have breast implant reconstruction, you should talk with your medical team about the risks and benefits, and other options such as autologous (“flap”) reconstruction or no reconstruction (“going flat” or aesthetic flat closure).

If you have implant reconstruction, keep in mind that about once a year you’ll need to see a healthcare professional (such as a breast surgeon or plastic surgeon) who can check your implants for rupture and other problems.

Learn more about the following risks of breast reconstruction with implants:

Infection after breast implant reconstruction
Breast skin necrosis
Capsular contracture
Dynamic distortion
Breast implant displacement
Breast implant rupture
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
Breast implant illness

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Infection after breast implant reconstruction

Sometimes a bacterial infection can develop in the tissue around a breast implant or tissue expander days or weeks after the reconstruction surgery.

Symptoms of an infection can include a high fever and breast pain, redness, and swelling. You should tell your surgeon if you experience any of these symptoms.

Your surgeon may prescribe antibiotics, but may determine that antibiotics alone won’t clear the infection. Then they may need to perform surgery to clean out the infected tissue and either replace or remove the implant or tissue expander. After this surgery, you will need to continue taking oral or IV (intravenous) antibiotics. If the infection has completely cleared after a few months to a year (depending in your surgeon’s recommendation), you can usually have surgery to reconstruct the breast again.

You may be at greater risk for developing an infection around a breast implant or tissue expander if you:

have had radiation therapy to the breast in the past
smoke
have diabetes
are obese
have high blood pressure (hypertension)
had axillary lymph nodes removed during the same surgery as the mastectomy and reconstruction

Breast skin necrosis

When breast reconstruction with implants or tissue expanders takes place at the same time as the mastectomy, the breast skin doesn’t always heal properly. Sometimes the blood vessels that supply blood to the tissue are damaged, often because the skin was thinned too much when tissue was removed during the mastectomy. When there isn’t enough blood flow to the skin, areas of the skin on one or both breasts can wither and scab. This breakdown and eventual death of tissue is called “necrosis.”

Signs that you might be developing necrosis of the breast skin include the skin turning dark blue or black and developing scabs and/or open wounds. You also may get a fever or feel sick. It’s important to work with your care team to make sure you get prompt and proper treatment if you develop necrosis.

If you only have a small amount of skin compromised skin, your doctor may trim away some of the dead tissue and/or treat the area with basic wound care. If you have a larger area of skin necrosis that is not healing, you will usually need to have surgery to remove the dead tissue. Your plastic surgeon may have to replace some of the skin using a skin graft (skin taken from another place on your body). If the breast tissue has become infected, your surgeon may also need to remove your tissue expanders or implants during this surgery.

A few months later, after the skin has healed and the infection has cleared, you could have another surgery to correct any distortion to the breasts caused by the skin necrosis. For example, your plastic surgeon might recommend:

redoing your reconstruction if you had to have your expanders or implants removed
getting your nipples reconstructed if they were affected by the necrosis
transplanting a flap of tissue from another part of your body to fill in an area of the breast where you lost some skin and tissue

You may be at greater risk for developing breast skin necrosis if your surgeon inserted too large an implant that puts too much pressure on the fragile skin. Also, if you smoke, are obese, or have diabetes, your skin may be less likely to heal well after a mastectomy.

Capsular contracture

Once a breast implant is in place, scar tissue forms around it, creating a tissue capsule. The body forms a protective capsule like this around any implanted object it recognizes as foreign. The tissue capsule is usually soft or slightly firm, not noticeable, and helps to keep the implant in place.

In some women, a tissue capsule forms that is unusually hard and dense. The capsule tightens around and squeezes the implant. This condition, called capsular contracture, can cause chronic pain, distort the shape of the breast, and raise the implant higher on the chest.

Signs of capsular contracture, such as increasing firmness or tightness in the breast, can start to appear as early as a few months after implant reconstruction surgery or years later. Capsular contracture can affect one or both implants.

If you’ve had radiation therapy at any time in the past — and particularly if you had it after your initial breast reconstruction surgery — that can greatly increase your risk of developing capsular contracture. But overall, the reasons why some people develop capsular contracture while others do not are not well understood. Other factors that may raise the risk of capsular contracture include:

rupture of an implant
hematoma (a build-up of blood where tissue was removed during surgery)
developing a layer of bacteria (called a biofilm) on an implant
a genetic predisposition to forming more scar tissue than normal

If capsular contracture is causing chronic pain and/or changes in the position and shape of the breast, you may want to consider surgery to treat it. Your plastic surgeon might recommend:

a capsulectomy: surgery to remove the existing implant and the surrounding tissue capsule and then insert a new implant that is wrapped in a sheet of acellular dermal matrix material (a soft-tissue substitute made from human or animal skin)
an open capsulotomy: surgery to cut open the tissue capsule around the implant by making small incisions, possibly removing some of the capsule, and possibly adding a small piece of acellular dermal matrix material over the parts of the capsule that have been cut open. The existing implant may be replaced with a new one.

However, there is a significant risk of capsular contracture coming back if you continue to have breast implants. The only ways to ensure that you won’t have capsular contracture again in the future are to remove the implants and have your breasts reconstructed with a flap of tissue taken from another place on your body (“autologous reconstruction”) or to go flat.

Physical therapy is another option if you have a milder case of capsular contracture or would prefer not to get surgery to treat it. Seeing a physical therapist who specializes in capsular contracture can help ease the discomfort and tightness and loosen the scar tissue.

Dynamic distortion

In most breast implant reconstruction surgeries, the plastic surgeon places the implants under part or all of the chest (pectoralis) muscle. This is known as under-the-muscle or subpectoral implant placement. Since breast tissue was removed during the mastectomy, the skin is now in closer contact with the underlying chest muscle. As the tissues heal, the skin tends to stick to the chest muscle. When you flex your chest muscle, your breasts may move in unnatural looking ways. For example, they may appear to pop upward and outward or to shift down. Plastic surgeons call this problem “dynamic distortion” or “animation deformity.” Some women find that it causes pain or that it makes them feel self-conscious.

There are two main types of surgery that can correct dynamic distortion:

Prepectoral revision: Removing the implants from under the chest muscle and placing new implants directly under the skin on top of the chest muscle (called over-the-muscle or prepectoral implant placement). To provide support for the implants and prevent them from showing through the skin, the surgeon may wrap or cover them in acellular dermal matrix (a soft tissue substitute made from human or animal skin).
Explant and autologous (“flap”) reconstruction: Removing the implants and replacing them with your own tissue transplanted from another place on your body, such as the belly, buttocks, or thigh. A tissue flap provides a layer of living tissue between the skin and the chest muscle, eliminating dynamic distortion.

Breast implant displacement

There’s a small risk that breast implants will shift over time so that they’re not in the correct position in the breast. This can happen to one or both implants and can be the result of many different factors, such as an error in the initial placement of the implants, gravity, damage to the tissue from radiation therapy, and problems with the breast skin. Here are some examples of the ways breast implants can become displaced:

The implants can settle too low on the chest: Sometimes implants drop too low, slipping beneath the bottom fold of the breast. This can happen, for instance, if the surgeon created too large a pocket in the chest to hold the implant, or the weight of larger implants stretches the breast tissue over time.
The implants can settle too far apart and away from the middle of the chest: This is called “lateral displacement” and it’s another problem that can develop if the surgeon created implant pockets that are too large or if the pockets stretched out over time. When a woman who is experiencing lateral displacement lies on her back, her reconstructed breast(s) may shift too far to the sides.
The implants can come together in the middle of the chest: In rare cases, the skin and muscle between the breasts can detach. This can cause the implants to come together and create the appearance of a “uniboob.” This is called symmastia and it can occur, for example, if too much tissue was removed too close to the breastbone during the mastectomy.
The implants can flip from front to back or rotate around like a wheel within the implant pocket, causing distortion in the shape of the breast and/or pain. This can happen if the pocket around the implant is larger than the implant or if there is trauma to the chest.

If your implant flips or rotates, your surgeon may be able to show you how to push it back into place with your hands. But if it flips repeatedly, you may want to consider surgery to reposition the implant, adjust the implant pocket, and/or replace the implant with a different type, size, or shape to improve its position and prevent it from moving around as much.

Breast implant rupture

All breast implants — including silicone gel-filled and saline-filled implants — have an outer silicone shell that can potentially develop a tear or hole called a rupture. Saline-filled implants also have a valve that can fail and leak (though this is rare compared to leaks caused by tears in the shell). The chance that your implant will rupture or leak increases over time.

Implant rupture can happen because of normal aging of the implant, damage caused by surgical instruments during the initial implant surgery, a needle insertion during a biopsy, or other factors.

When a saline-filled implant ruptures, the saline leaks out quickly — typically over the course of a few days — and the breast appears somewhat deflated, so you know that it’s ruptured. The saline (salt water) is generally harmless and absorbed by the body.

When a silicone gel-filled implant ruptures, it’s harder to recognize because the implant will often maintain its shape. It may take you longer to realize that the implant has ruptured, or you may not realize it at all. If the silicone gel comes out of the implant, it can stay in the body and spread to nearby tissues or to other parts of the body such as the lymph nodes or the lungs. Signs that your silicone gel-filled implant has ruptured can include changes in breast shape and size, and increasing pain, firmness, and swelling over a period of weeks. Rupture can also cause capsular contracture. Silicone gel-filled implant rupture that doesn’t cause any noticeable symptoms is known as “silent rupture.”

If at any time you think your implant may have ruptured, have your plastic surgeon check it. Your doctor will not be able to confirm a silent rupture of a silicone gel-filled implant by physical examination alone. An imaging test, such as an ultrasound or MRI, can help determine whether an implant is leaking. An MRI (with equipment designed specifically for imaging the breast) is widely considered the most accurate imaging test for this purpose. However, as with any imaging test, there’s some risk that the results will not be accurate — a rupture may not show up, or an intact implant may appear to be ruptured on an MRI.

The FDA recommends that people with silicone gel-filled implants have periodic imaging (with ultrasound or MRI) to screen for implant rupture even if they have no symptoms. This screening should begin 5 to 6 years after the implants are placed and then be repeated every 2 to 3 years after.^{1 Getting health insurance to cover imaging tests to screen for breast implant rupture can be challenging. Your plastic surgeon may be able to help you work with your insurance company to get coverage approved for these tests in advance.}

If a breast implant ruptures, it is usually surgically removed as long as you are healthy enough for surgery. If you have a health condition that makes surgery unsafe, it is generally OK to leave a ruptured saline-filled implant in place. Ruptured silicone-filled implants have greater health risks and should be removed if possible. If silicone gel has leaked past the scar tissue capsule around the ruptured implant, your plastic surgeon will try to remove as much of it as they can.

Usually if you’ve decided that you want new implants, your surgeon can insert them during the same surgery. In some cases, your surgeon may recommend that you switch to a different type of implant. Another option may be to have your breast(s) reconstructed with a flap of tissue taken from another place on your body (“autologous reconstruction”) rather than getting new implants.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

BIA-ALCL is a rare form of T-cell lymphoma (cancer of the immune system) that can develop in the scar tissue and fluid surrounding a breast implant. BIA-ALCL is not breast cancer. BIA-ALCL can occur around saline-filled or silicone gel-filled breast implants. In some cases, it can spread throughout the body. BIA-ALCL is curable in most patients if it’s diagnosed early and treated appropriately, but a small number of women have died from the illness.

So far, all the confirmed cases of BIA-ALCL have been in women who had breast implants with a textured surface or whose implant surface type was not known. As of November 16, 2020, the American Society of Plastic Surgeons said there were 982 cases of BIA-ALCL worldwide.²

In July 2019, Allergan announced a global recall of its Biocell textured breast implants and tissue expanders. The U.S. Food and Drug Administration (FDA) requested the recall because it found that 91 percent of the confirmed cases of BIA-ALCL at that time (481 of 573 cases) were attributed to textured implants made by Allergan. Some other types of textured implants and tissue expanders are still available in the United States. Many plastic surgeons are no longer using textured breast implants.

The most common symptoms of BIA-ALCL are swelling (due to fluid build-up) or pain in the area of the breast implant. Some patients have had a lump next to the implant surface or in the armpit. The symptoms may occur years after the implant is placed. BIA-ALCL can be diagnosed with a biopsy of the fluid or lump.

Treatment for BIA-ALCL involves an “en bloc capsulectomy” (surgery in which the implant and surrounding tissue capsule is removed in one piece). Some patients have also required radiation therapy, chemotherapy, and/or stem cell transplant therapy.

Researchers aren’t sure why BIA-ALCL develops around textured breast implants. One theory is that the rough, sandpaper-like surface of textured implants might cause chronic inflammation in some women that leads to lymphoma. Another theory is that the rough surface and the greater surface area of a textured implant traps more bacteria, creating what’s called a biofilm — a colony of microbes that stick to each other and to the surface of the implant — that causes inflammation and leads to lymphoma.

To learn more, read Breastcancer.org’s Special Report on Breast Implant Illness and BIA-ALCL.

Breast implant illness (BII)

Breast implant illness (BII) is a term that some women and doctors use to describe a wide range of symptoms that can occur after getting breast implants. BII can happen with any type of breast implant, including silicone gel-filled, saline-filled, smooth surface, or textured surface. Symptoms can include joint and muscle pain, chronic fatigue, memory and concentration problems, breathing problems, sleep disturbance, rashes and skin problems, dry mouth and dry eyes, anxiety, depression, headaches, hair loss, and gastrointestinal problems.

A lot of the symptoms of BII are associated with autoimmune and connective tissue disorders, such as lupus, rheumatoid arthritis, and scleroderma. Some people who have BII also get diagnosed with a specific autoimmune or connective tissue disorder, but many do not.

In many, but not all cases, surgery to remove the breast implants improves or completely resolves the BII symptoms.

Researchers don’t know why some women with breast implants develop BII. A leading theory, according to experts, is that some people are predisposed to having an immune reaction to the materials that are used to make breast implants, creating inflammation that leads to BII symptoms.

Some doctors who have treated many patients with BII say it is more likely to occur in people who have a personal or family history of autoimmune conditions, allergies, and conditions such as irritable bowel syndrome, migraines, chronic fatigue, or fibromyalgia. But some women who develop BII don’t have any of these risk factors.

BII is not currently recognized as an official medical diagnosis and it hasn’t been studied much as a unique condition. The FDA released a statement in 2019 saying that it is taking steps to better understand the condition and its risk factors.³ In 2020, the FDA included information about BII in the new labeling that it recommends implant manufacturers adopt.¹

To learn more, read Breastcancer.org’s Special Report on Breast Implant Illness and BIA-ALCL.

Written by: Jen Uscher, contributing writer

This page was developed with contributions from the following experts:

Sophie Bartsich, M.D., FACS, plastic surgeon in private practice in New York, NY, assistant clinical professor of surgery at New York-Presbyterian/Weill Cornell Medical Center

Constance M. Chen, M.D., MPH, FACS, plastic and reconstructive surgeon in private practice in New York, NY, assistant clinical professor of surgery at New York-Presbyterian/Weill Cornell Medical College

Minas Chrysopoulo, M.D., FACS, plastic surgeon, president of PRMA Plastic Surgery, Center for Advanced Breast Reconstruction in San Antonio, TX, and creator of the Breast Advocate App

Frank J. DellaCroce, M.D., FACS, plastic surgeon, founding partner of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans, LA

Ron Israeli, M.D., FACS, plastic surgeon, founding partner of New York Breast Reconstruction and Aesthetic Plastic Surgery in Great Neck, NY, clinical assistant professor at the Zucker School of Medicine at Hofstra/Northwell

Elisabeth Potter, M.D., plastic surgeon in private practice in Austin, TX, affiliate faculty member in the department of surgery and perioperative care at the University of Texas at Austin Dell Medical School

Smita Ramanadham, M.D., FACS, board-certified plastic surgeon at SR Plastic Surgery in East Brunswick, NJ

William L. Scarlett, DO, FACS, FACOS, FAACS, plastic surgeon, chief of surgery and director of surgical services at Holy Redeemer Hospital in Bensalem, PA

References

U.S. Food and Drug Administration. Breast Implant Labeling Recommendations. September 29, 2020. Available at https://www.fda.gov/media/131885/download (PDF)
American Society of Plastic Surgeons. 2019 Plastic Surgery Statistics. Available at
https://www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-physician-resources
U.S. Food and Drug Administration. Statement on Breast Implant Safety. May 2, 2019. Available at https://www.fda.gov/news-events/press-announcements/statement-fda-principal-deputy-commissioner-amy-abernethy-md-phd-and-jeff-shuren-md-jd-director-fdas