BIA-SCC and BIA-ALCL

Breast implant associated squamous cell carcinoma and breast implant associated anaplastic large cell lymphoma are very rare. In fact, the incidence of these disease processes is not measured in annual rates. They are so rare that the case count is measured by the number of cases that have ever occurred in history. Understanding personal risk is important when recognizing this low incidence.

According to the American Society of Plastic Surgeons, there are 16 cases reported in the literature for BIA-SCC ever. In regards to BIA-ALCL, there are approximately 400 confirmed cases in the United States and a total of 1,227 worldwide as of August 2022.

BIA-SCC is a very rare but potentially aggressive tumor that appears to be associated with the scar that forms around any type of implant (knee implant, breast implant, etc), and in the case of breast implants, from the breast implant capsule. Because there are so few cases, it is not possible to determine what factors increase patient risk for BIA-SCC prior to their breast augmentation.

BIA-ALCL is a lymphoma or lymphoproliferative disease process. More information is available here. Below you can review a comparison of these two entities based on an overview from the American Society of Plastic Surgeons. Some information may be technical and more appropriate for your healthcare provider but it also offers the consumer insight into the language you may need to understand the full scope of these disease processes.

What is it?

BIA-SCC
Breast implant-associated squamous cell carcinoma (BIA-SCC) is a very rare but potentially aggressive, epithelial-based tumor that appears to emanate from the breast implant capsule. Pathology shows sheets of squamous cells lining the capsule in nests and bundles. BIA-SCC can exhibit highly invasive properties including spread to lymph nodes, local tissues and distant sites, such as muscle and bone.

BIA-SCC is not a cancer of the breast tissue itself.

BIA-ALCL
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and treatable type of T-cell lymphoma that can develop around breast implants. BIA-ALCL can exhibit highly invasive properties, including spread to lymph nodes, local tissues and distant sites.

BIA-ALCL is not a cancer of the breast tissue itself.

Lifetime Risk

BIA-SCC
Unknown.

BIA-ALCL
The current lifetime risk of BIA-ALCL varies widely (e.g., estimates of 1:2,207-1:86,029 based upon variable risk with different manufacturer types of textured implants. More recently, cumulative risk over 20 years in breast reconstruction patients implanted with Biocell devices was estimated at 1:100 (Cordeiro et al, 2020).

Age at presentation

BIA-SCC
55.8 years (range 40-81)

BIA-ALCL
55.3 years (range 28-84)

Average length since initial implantation

BIA-SCC
Average length since initial implantation 22.74 years (range 11-40 years)

BIA-ALCL
10.32 years (range 0.08-41 years)

Implant Surface

BIA-SCC
In case reports, BIA-SCC has been reported in patients who have had smooth and/or textured implants.

BIA-ALCL
No cases of BIA-ALCL have been confirmed in patients who have only had smooth implants in case series, case reports or registries. However, it is not possible to exclude the appearance of BIA-ALCL in association with smooth implants at this time. The FDA states that all confirmed cases worldwide either have a history of a textured device or an incomplete clinical history available for review.

Implant Type

BIA-SCC
BIA-SCC has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients.

BIA-ALCL
BIA-ALCL has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients.

Presentation

BIA-SCC
Delayed seroma (fluid collection), unilateral swelling, pain, erythema, often capsular contracture

BIA-ALCL
Delayed seroma, unilateral swelling, pain, erythema, sometimes capsular contracture

Extracapsular spread at presentation

BIA-SCC
80% at presentation

BIA-ALCL
28% at presentation

Typical Pathology

BIA-SCC
Squamous cells in sheets with varying degrees of atypia and metaplasia and at least one focus of SCC.

BIA-ALCL
Lymphoma with mass confined to single area on capsule.

Diagnostic Assessment

BIA-SCC
Send fluid collection sample to lab for testing of CK 5/6+ protein; p63+; Flow cytometry + for squamous cells and keratin

BIA-ALCL
Send fluid collection sample to lab for testing of CD30+ protein; ALK-; Flow cytometry + for T-cells

Imaging

BIA-SCC
Ultrasound to evaluate for fluid around the implant +/- aspiration; MRI with and without contrast to evaluate capsule to rule out mass; PET-CT for extent of disease, if present.

BIA-ALCL
Ultrasound to evaluate for fluid around the implant +/- aspiration; PET‐CT is performed following a positive diagnosis. Mammograms are not helpful for evaluating lymphoma but are important for the evaluation of breast cancer.

Treatment

BIA-SCC
Official treatment recommendations will need to be based on emerging data. At present, it appears that explantation with complete (en bloc) capsulectomy will provide the best outcomes.

Based on existing case reports, it appears that incomplete resection of BIA-SCC can result in early and/or aggressive recurrence.

BIA-ALCL
In the majority of cases, explantation with complete (en bloc) capsulectomy is curative. Incomplete capsular resection has been associated with both recurrence and significantly lower survival. Rare patients will present with more advanced disease and may require radiotherapy and chemotherapy. Treatment approach should follow international guidelines established by the National Comprehensive Cancer Network (NCCN) for BIA-ALCL. Current treatment recommendation is for bilateral complete capsulectomy and implant removal, as a small number of women have had contralateral disease found incidentally.

Chemotherapy / Radiation Therapy

BIA-SCC
Patients treated within these cases did not appear to respond.

BIA-ALCL
Responds to Brentuximab plus CT.

Reporting

BIA-SCC
The FDA recommends that any suspected or confirmed cases of SCC, lymphomas, or any other cancers around the breast implant be reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov.

BIA-ALCL
The FDA recommends that any suspected or confirmed cases of BIA‐ALCL be reported to the PROFILE registry, the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov. To report a case to PROFILE, go to ThePSF.org/PROFILE.

Patient Counseling and Informed Consent

BIA-SCC
BIA‐SCC should be discussed with any patient considering breast implants as part of the informed-consent process.

BIA-ALCL
BIA‐ALCL should continue to be discussed with any patient considering breast implants as part of the informed-consent process.

American Society of Plastic Surgeon/Plastic Surgery Foundation Recommendations

Prior to implantation of any breast implant, plastic surgeons should provide patients with the manufacturer’s patient labeling, the FDA-required patient decision checklist and any other educational material to best discuss the benefits and risks of breast implants.

Preoperative workup is essential. All patients presenting with a late seroma should have fine needle aspiration (FNA) and cytology testing. Specimens should be sent for immunohistochemistry including CD30, ALK, CK 5/6, p63 and flow cytometry to look for T-cells, squamous cells and keratin.

All patients presenting with a late seroma should undergo a breast ultrasound and MRI with and without contrast. If disease is confirmed, a PET-CT should be considered prior to surgical intervention. A thorough preoperative work-up allows for potentially the most appropriately planned, single-stage surgery with the greatest chance of success for cure.

Consider the possibility of BIA-ALCL, BIA-SCC and other lymphomas when treating a patient with late-onset, peri-implant changes. If you have a patient with suspected BIA-ALCL or BIA-SCC, refer them to experts familiar with the diagnosis and treatment of BIA-ALCL and BIA-SCC.

At surgery, collect fresh seroma fluid, representative portions of the capsule, and specific pathology requests to rule out both BIA-ALCL and BIA-SCC.

Diagnostic evaluation should include cytological evaluation of seroma fluid or mass with Wright Giemsa stained smears and cell block immunohistochemistry/flow cytometry testing for cluster of differentiation (CD30) and Anaplastic Lymphoma Kinase (ALK) markers, as well as Cytokeratin 5/6 (CK 5/6) and p63.

Flow cytometry should include instructions to look for T cells, squamous cells, and keratin.

All confirmed or suspected BIA-SCC data should be entered into the PROFILE Registry (Data entry mechanism forthcoming).

Data for all patients with seroma should be entered into the National Breast Implant Registry (NBIR).

Click here for the original blog post written by Dr. Jonathan Kaplan for BuildMyHealth.

The post Update on Breast Implants first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Dr. Bae:
I’m good. I’m good. All is well, all is well.

The big news on textured breast implants

Greg:
Well, I’m happy to hear that. I’ve been seeing a little bit in the news lately, these textured silicone breast implants that I think were done, you can correct me if I’m wrong, done years ago. I don’t know that they do them anymore. Maybe they do, but there is some concern about them and a lot of people who have those are wondering, do I need to go and get those replaced? Or, what do I do, because everybody wants to stay as healthy as they possibly can.

Dr. Bae:
Right. Well, I’m glad you asked me about that, because I just happened to have some breasts implants with me right here.

Greg:
Oh, wow. Look at that, props.

Why textured breast implants are textured

Dr. Bae:
What are the chances? So I guess the first thing we should talk about is just kind of some baseline knowledge, fundamental knowledge that there’s the difference between round implants, which are kind of the typical round silicone implants you always think of, versus these teardrop or shaped implants. You can see it’s fuller at the bottom. And so, when you have a round implant, if it spins in the breast tissue, like in the breast pocket, inside the patient’s breast, if it spins, no problem. It’s still a round implant. But if this spins, then you’ve got sort of a sideways boob. So what they do is, they now texture-

Greg:
Nobody wants a sideways boob, Dr. Bae.

Dr. Bae:
I think a lot of people gave that up for their New Year’s resolution, right? So the thing is, the reason they texture these implants, as opposed to being smooth like the other implant I showed you, they texture these-

Greg:
So they don’t move.
Dr. Bae:

So they don’t move, exactly. So, what the … you’re pretty smart. Producer, check out the big brain on Greg.

Greg:
Maybe I’ll go to medical school.

Dr. Bae:
Maybe so, and I’ll go back to being … I’ll be a radio host.

Greg:
We better keep what we’re doing.

Dr. Bae:
So, the thing is, that texturing has become an issue over the last couple years, that people have noticed an issue with it. And what it is, is that there’s something called anaplastic large cell lymphoma, which is kind of like cancer, but not really. And what it is, is that after a few years, two years to 28 years they found, after getting textured implants, what they found is that the scar tissue that naturally forms around breast implants, whether they’re saline, silicone, round, shaped, your body naturally formed scar tissue. But in some cases, specifically with a certain type of textured implant, that scar tissue could get really thick and starts secreting some fluid. And the patients would have this huge seroma or fluid collection that would form around their breast implant. Like I said, two years or 28 years after.

Anaplastic large cell lymphoma (ALCL)

Dr. Bae:
And that was caused by this lymphoma, or this thickened scar tissue. So the way to treat it is you go in, you take out the breast implant, you take out the scar tissue and typically a hundred percent of the time people would be cured if you found that early enough. So that’s anaplastic large cell lymphoma, ALCL, that’s associated with textured implants. But not just any textured implant, specifically one that was made by Allergan, and that one’s been taken off the market. So statistically speaking, is a very low risk for people to get this problem if they have textured implants. If you have smooth implants, there’s really been no evidence that smooth implants cause that problem. And the reason it’s been in the news lately, and also which, I should say, the reason I’ve been thinking about this lately because it’s been in the news, I’ve had patients reach out to me saying, “Hey, I’ve got this brand of a MENTOR silicone textured implant. Does that mean I need to come back in?”

Dr. Bae:
And the FDA says, just like I told this patient, that because they took the main offender off the market and because the risk is so low, that if you have textured implants and it’s not that Allergan product, if it’s MENTOR or Sientra and you’re not having any problems, your breast isn’t blowing up with a bunch of fluid, if you’re not having problems, you don’t have to do anything. You don’t have to go in and get them changed out. So just FYI, the more you know, public service announcement, that if you’re happy with your breast implants, you don’t need to do anything with them. You don’t have to get them taken out every 10 years like some people mistakenly think. So again, just keep going, get your mammograms, get your checkups from your doctor. And as long as you’re happy with your breast implants, you don’t have to do anything else about them.

Greg:
But, if somebody has a question, if somebody has a question about their implants, or if they just want you to examine their breasts and check out where they are, they can reach out to you on social media.

Dr. Bae:
Absolutely. They can reach out to us. Instagram, TikTok, Snapchat @realdrbae. R-E-A-L-D-R-B-A-E, not B-A-Y. And check us out on our website, realdrbae.com, where they can check pricing, all that good stuff. But yeah, people message us all the time. All my surgical patients, they always have my email address and my phone number. So they’re able to reach out to me afterwards if they’re worried. So, there’s no excuse. You can absolutely get in touch with this doctor.

Greg:
And if you’re not a previous patient of Dr. Bae’s, and you’ve never even spoken to him before, if you Instagram him with a question, DM, he will answer you. Right, Dr. Bae?

Dr. Bae:
That’s absolutely true. Yeah. As long as you’re not saying anything mean, I will respond to you.

Greg:
That’s my policy on social media, too. All right. Well, thanks Dr. Bae. Appreciate it.

Dr. Bae:
My pleasure. My pleasure.

The post What you need to know about textured breast implants [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Chrissy Teigen becomes the latest famous person to open up about getting a boob job. She joins the ranks of Kaley Cuoco, Victoria Beckham and Anna Faris. For what it’s worth, does it really matter anymore? It’s not shocking and that’s a good thing.

Chrissy Teigen and her boob job

As time passes, the news of someone getting a boob job has lost its sheen as “big news!” The truth is, it’s no longer taboo to get a boob job. This is partly due to the #metoo movement. Obviously the #metoo movement is about someone abusing their position of power in how they treat women. But in a #metoo-adjacent sense, if anyone comes off as sexist or treating a woman differently for feeling “feminine,” they’re very quickly shut down. Plus, being critical of what someone else does with their body is just ridiculous. Who cares what you think about so-and-so’s choices?!

As far as Chrissy Teigen is concerned, she got a boob job a little over a decade ago. She says that she got implants to make her breasts perkier when modeling bathing suits. Many women feel this way. They want implants simply to help fill out clothes, so they fit better.

In the article above, she appears someone despondent that she wants them out and will have to get a lift now. For what its worth, she need not feel this way. She doesn’t need a lift only because she had implants. She’s had two children and that causes breasts to become pendulous. If she ever wants perky breasts again, implant or not, she would need a lift anyway. No need to blame herself.

And in a twisted sort of way, the fact that a celebrity getting a boob job isn’t as big as deal as it once was, shows society is maturing as a whole!

To check pricing on a boob job from Dr. Kaplan, click here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Chrissy Teigen Opens Up About Her Boob Job first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Breast asymmetry correction is one of the most complex breast procedures around. The complexity is due to the myriad of ways to fix the asymmetry. It’s not just a matter of size, but also of shape. And then you have to get the nipple in a symmetrical position!

Video of breast asymmetry correction

As the video shows, there are many steps to correcting breast asymmetry. First you must identify the problem. Is it only a size discrepancy or a ptotic (droop) issue. Based on the discrepancy, the surgical plan will proceed from there.

The key to success is ensuring a cohesive plan preoperatively. Having a range of breast implants available to improve size symmetry is important. But you may also need to use different techniques for the breast lift to improve symmetry between the nipple position.

This means a “donut” lift to reduce the size of one areola to match the other. It may mean a “lollipop” lift to shift the areola northward. Or it may mean a more extensive “anchor” lift to shorten the distance between the nipple to the inframammary fold. Again, there are many variables and steps to achieving success. Experience matters.

And while experience is key, obviously cost is a realistic matter to take into account. To check pricing on this procedure from Dr. Kaplan, click here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Breast asymmetry correction with implants and lift [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

What is ‘bottoming out’ in breast augmentation?

In an ideal situation, a breast implant sits behind the breasts in perfect symmetry. However, if the fold under the breast, the inframammary fold, is disturbed, the implant can bottom out. The fold is usually very adherent to the chest wall.

Bottoming out can occur if the fold is inadvertently released from the chest wall. This can occur if the implants are too large and put too much pressure on the fold, such that it pulls away from the chest wall. And sometimes the fold must be lowered to accommodate a larger implant. If that’s done, the fold will bottom out if the fold is not affixed back to the chest wall with a suture.

If bottoming out occurs, a new pocket for the implant must be created. However, two things are important when doing this. First, the implant should remain under the muscle so the implant continues to be camouflaged and look as natural as possible. Secondly, the pocket needs to be strong to minimize a recurrence of bottoming out.

That’s where the neosubpectoral pocket technique comes in. This is a confusing concept so the video below will help. But essentially, the physician uses the naturally occurring scar tissue around the implant (the capsule), to help make the new pocket. A new pocket is made between the muscle and the capsule and the implant is placed here. That way, the implant is still under the muscle and on top of the capsule.

The alternative, is to use sutures to tighten the pocket and eliminate the bottoming out. However, a new pocket made with this technique has a high chance of failing because the sutures can pull through.

Video: How to treat bottoming out of the breast

To check pricing on a breast augmentation revision, click here.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Bottoming out…in breast augmentation first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

What does a breast augmentation revision entail?

A breast augmentation revision can mean many things. First it depends on what the problem is. Did the implants bust or leak? Then a revision would mean an exchange of the old implants for the new implants. But then you have to decide, do you go up in size, switch from saline to silicone or silicone to saline? If you’re going down in size then you’ll need a lift to remove excess skin so the breasts don’t look deflated with the smaller implants.

In the video below, the patient was actually happy with the existing size of her implants (300cc). But she was unhappy about other things. As you’ll see in the video, she had a great deal of ptosis (droop) in the right breast. The other thing, which you can also see in the video, was rippling, a common undulation of the skin caused by saline implants.

Breast lift, capsulectomy, implant exchange

So when you review her concerns – droop of both breasts (right greater than left) and rippling – it’s clear what a revision means in her situation. She needs to remove excess breast skin to perform a breast lift to correct the droop. The rippling can be corrected by exchanging the saline implant with a silicone implant (but the same size implant).

She could also feel the implant on the undersurface of the left breast really easily. This was due to very little tissue between the skin and the implant. This was corrected during surgery by closing off the implant pocket with breast tissue so there’s more breast between the skin and the implant.

One additional issue that was apparent during the operation was the formation of thick scar tissue around the implant. This scar tissue is referred to as a capsule. When the scar is thick and can deform the breasts, that’s capsular contracture. The capsulectomy was included with her procedure as you’ll see below.

Video review of breast augmentation revision

To check pricing on breast augmentation revision from Dr. Kaplan, click here.

Click here for the original blog post written by Dr. Jonathan Kaplan for BuildMyBod.

The post Breast Augmentation Revision [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.