BIA-ALCL and Textured Breast Implants: What You Need to Know
Picture 1. A smooth (S) vs a textured (T) breast implant.
If you are having a breast implant surgery either for breast reconstruction after mastectomy or for breast augmentation (enlargement), a very important conversation that you will inevitably have with your surgeon will be around the choice between smooth vs textured breast implants (Picture 1). This is specially driven by the increasing recent awareness regarding the association of textured breast implants with Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).
What is BIA-ALCL?
BIA-ALCL is a rare type of lymphoma (cancer of lymphatic cells) that may occur around textured breast implants. No case has been reported in association with smooth breast implants. The incidence is related to the degree of surface texturing of the implant; the rougher the surface texture the higher the risk of development of BIA-ALCL. Table 1 summarises the findings of the largest study on the epidemiology of BIA-ALCL in Australia and New Zealand published in 2019. The macrotextured implants were removed from the Australian market in 2019, while Mentor microtextured implants with the calculated risk of one ALCL case per 86,029 implants inserted have kept their TGA (Therapeutic Goods Administration) approval. In most cases BIA-ALCL can be cured with removal of breast implant and its surrounding capsule, however 4 deaths have been reported in Australia out of 112 cases of confirmed BIA-ALCL. Therefore, the estimated risk of death from Mentor microtextured implants is roughly 1 in 2,000,000. To put this risk in context, the risk of death from a road accident is 1 in 1000-10,000, and the risk of death from an accident at work is 1 in 10,000-100,000!
Table 1. Number of breast implants inserted per each confirmed ALCL case based on the sales data. Macrotextured implants had much higher rate of ALCL compared to Mentor microtextured implants and were removed from the Australian market in 2019.
How is BIA-ALCL diagnosed?
The most common presentation of BIA-ALCLA is breast swelling due to accumulation of fluid between the implant and its surrounding capsule (delayed seroma). It takes an average of 7-10 years after implant insertion before it develops. The diagnosis is confirmed by aspiration and pathological examination of the seroma fluid.
For more information on BIA-ALCL follow the link below from TGA website:
Do textured implants offer any advantage over smooth implants?
Texturing of the surface of the implant brings in some unique advantages. Therefore, despite the small associated risk of BIA-ALCL, textured implants accounted for about 50% of implants inserted in Australia in 2020. These advantages include:
Picture 2. A round (left) vs an anatomical or teardrop (right) implant.
Prevent rotation of anatomical implants: Breast implants are either round or teardrop shaped (anatomical, picture 2). Anatomical implants were developed to give the reconstructed breast a more natural shape (Picture 3). All the anatomical implants currently in the market are manufactured with surface texturing to reduce the chance of implant rotation.
Reduce capsular contracture: One of the most common reasons for revisional surgery after implant insertion is capsular contracture, which is formation of a thick, contracted capsule around the implant. This in return can cause implant displacement, contour deformity, pain, and overall dissatisfaction. Texturing of the surface of the implant has been shown to reduce the rate of capsular contracture to about a third.
Picture 3. Breast shape by implant type. (Left) Breast reconstructed with round, smooth implant; (right) breast reconstructed with anatomical implant. Both implants have the same silicone gel fill. Note the convex, augmented upper pole with the round implant compared to the straight, more natural upper pole with the anatomical implant. (Adapted from Gabriel A, Maxwell GP. PRS. Jul 2019)
Picture 4. Right breast rippling following reconstruction with a silicone gel implant with low form stability. (Adapted from Nahabedian M. PRS. Jul 2019)
Increased form stability: Texturing of implant surface is one of the factors that increases its form stability. This in turn can reduce the so called “rippling” in the upper pole (picture 4).
Disadvantages of textured implants
Association with BIA-ALCL: As already discussed in the current blog
More difficult insertion: Often a larger incision is required to insert a textured implants compared to the same size smooth implant.
Increased implant palpability: Although texture anatomical implants are designed to offer a more natural look, this may be at the cost of less natural feel with increased implant palpability!
In summary there are many factors that must be considered when choosing your breast implant. This is not a one-size-fits-all scenario! Individualised decision making is required based on a thorough discussion of your desires and wishes in conjunction with your surgeon’s skillset and experience to achieve the best outcome for you.