A doctor who has performed over 6,000 breast surgeries answers your questions

board certified plastic surgeon dr. lori saltz
Board certified plastic surgeon Dr. Lori Saltz has more than 30 years of experience in breast surgery.

I’m Dr. Lori Saltz, an award-winning board certified plastic surgeon in San Diego, and I’ve specialized in breast surgery for almost 30 years. I’m writing today to help women understand the subject of BIA-ALCL, or breast implant associated anaplastic large cell lymphoma. Below, I’ve answered some of the most common questions about the subject.

What is BIA-ALCL?

BIA-ALCL, or breast implant associated anaplastic large cell lymphoma, is a type of lymphoma (not breast cancer) that is suspected of being linked to breast implants. It is a disease of the immune system, and occurs in the capsule, or scar tissue, surrounding the implant. BIA-ALCL is rare and usually fully treatable.

How risky are breast implants when it comes to BIA-ALCL?

Between 2011 and 2019, approximately 457 unique cases have been reported to the FDA. The majority of these cases have been reported in cases where the patient had textured breast implants at some point in her life prior to diagnosis.

To put these numbers into perspective, over 1.5 million women worldwide had breast augmentation in 2017 alone, a number that has held steady for many years. Moreover, plastic surgeons estimate that more than 35 million women currently have or have had textured breast implants.

The current lifetime risk of developing BIA-ALCL is estimated to be between 1 in 30,000 and 1 in 3817, and that’s only if you have textured implants. The risk of dying in a car accident in a lifetime is 1 in 645. The risk of developing some kind of cancer, of any type, in your lifetime is about 1 in 3 (according to the American Cancer Society).

BIA-ALCL differences between breast implant types and manufacturers

BIA-ALCL is seen most often with textured implants, but reviewing all the cases reported, it was found that the type of implant was not noted in a high number of cases.

It is important to know that the incidence varies greatly between the manufacturers with Allergan (Biocell) being 1 in 3,705, Mentor (Siltex) 1 in 60,631 and Sientra 1 in 200,000—which is why I only use Sientra implants when a patient’s case calls for textured implants.

The media and some doctors have played up BIA-ALCL risks without presenting all of these facts. Additionally, many surgeons simply don’t have complete knowledge or experience in using textured implants—which some women prefer for very specific reasons—nor have they differentiated among the risks between textured implant brands and techniques.

Surgical choices matter: I use Betadine plus triple antibiotic solution during surgery to reduce risk of both BIA-ALCL and capsular contracture.

Surgeons outside the U.S. actually favor textured implants because they feel BIA-ALCL risks are very low, and many of their patients want the specific advantages offered by textured implants.

In my practice, I offer my patients the pros and cons of all potentially suitable breast implant types (or alternative procedures when relevant, such as breast lift) and let them make a truly informed decision.

Why do some surgeons still use textured breast implants for some cases?

Textured implants offer some unique and important benefits to patients regardless of whether or not they are shaped:

  • Textured implants stay in place. For instance, it is much more difficult to push a textured implant out of position with pectoral muscle contractions. When muscles are flexed (i.e., when doing push-ups), textured implants won’t slide outward (known as “animation deformity”) nearly as much as smooth implants. For this reason, many athletic or very active women prefer textured implants.
  • Textured implants have lower rates of certain complications. When implants are placed over the muscle, we see a lower rate of capsular contracture with textured vs. smooth implants. Additionally, because they stay in place so well, the reoperation rate for malpositioned implants is much lower with textured implants.
  • Textured implants provide a more natural overall feel. Because the breast tissue grips the surrounding tissue, the breast will feel more like “a whole breast” with a textured implant, vs. a breast with an implant moving around underneath it.
  • A patient’s anatomy may call for a textured implant for a natural-looking result. After breast augmentation, the pectoralis muscle pushes on the implant in an outward and sideways direction. It is especially important that the implant stay where it needs to be if your chest is either caved in (pectus excavatum) or high in the center (pectus carinatum). A textured implant will ensure that the breast maintains a natural, aesthetically pleasing shape and position.

Why does BIA-ALCL happen to a small percent of women but not others?

There is scientific evidence that surgical techniques, geography, and genetics may play a role.

Interestingly, researchers have noticed that a different type of bacteria grows in the biofilm (a layer of microbial flora that exists in the capsule) of BIA-ALCL patients than in patients with normal, healthy capsules. This bacteria (R. pickettii) is killed by a specific antiseptic called Betadine, but not by other commonly-used antibiotics that plastic surgeons irrigate the breast pocket to reduce the types of bacteria that are associated with capsular contracture. This is why I use Betadine plus triple antibiotic solution during surgery: to reduce the risk of both BIA-ALCL and capsular contracture.

What can plastic surgeons do to reduce the risk of BIA-ALCL?

We can do several things to reduce risk of BIA-ALCL. First, we work to keep risk of any infection to a minimum, as we do believe that bacterial growth is a factor in BIA-ALCL risk. Best practices here include, but are not limited to:

  • Placing air- and water-tight occlusive dressings over the nipple to keep the bacteria in the milk ducts from being expressed onto the skin
  • Using a no-touch implant placement technique (i.e., using the Keller Funnel to insert silicone implants)
  • Applying Betadine and triple antibiotic solution during surgery to prevent growth of BIA-ALCL associated bacteria, R. pickettii

We can also only offer our breast implants with the lowest association with BIA-ALCL. In my practice, I use only Sientra textured implants—which have the lowest number of associated BIA-ALCL cases by far—as well as smooth, round implants from all three FDA-approved manufacturers.

Is BIA-ALCL breast cancer? What is the difference?

BIA-ALCL is not a type of breast cancer. Rather, it is a type of non-Hodgkin’s lymphoma, or cancer of the immune system. When present in patients with breast implants, the disease is found in the scar tissue capsule and fluid surrounding the breast implant, not in the breast tissue itself.

Anaplastic Large Cell Lymphoma can actually occur in other parts of the body that have nothing to do with breast implants. Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a specific type of ALCL.

Can BIA-ALCL be treated?

BIA-ALCL is not as aggressive as other types of lymphoma. When caught early, as is the case in 80% of patients, the disease can almost always be cured with removal of the implant and capsule alone (via en bloc capsulectomy or another explantation procedure). In a small number of cases, if the disease has progressed, chemotherapy and/or radiation in addition to explantation has been necessary to fully treat BIA-ALCL.

Of the very few deaths from BIA-ALCL that have been reported, the patients either were not diagnosed early or treated appropriately. This is a very rare disease that was not even on plastic surgeons’ radars until recently.

The risks associated with any additional surgery are statistically more likely to be a concern than your individual chances of getting BIA-ALCL. As such, it is not medically recommended that otherwise healthy women have their breast implants removed to avoid the remote chance of BIA-ALCL.

How does BIA-ALCL show up? When can it show up?

It usually presents as a seroma (fluid collection around the implant) a year or more after surgery. The mean time of presentation is eight years after surgery, but it can occur at any point after implantation.

Not all seromas are BIA-ALCL, but all should be checked by a qualified physician to rule out any issues.

Additionally, it’s worth mentioning that breast self-examination is important for every woman, regardless of whether or not she has breast implants—the risk of breast cancer (1 in 8) is much higher than the risk of BIA-ALCL. Knowing your breasts is the best way to catch any and all potential issues early.

Even if risks are low, should I remove my breast implants to prevent BIA-ALCL from showing up?

Not all women with BIA-ALCL have textured implants at the time of their diagnosis, but the evidence we have shows that nearly all have had textured implants at some point in the past. It therefore seems that removing textured implants or exchanging them for smooth implants would not lower the risk.

Basically, the risks associated with any additional surgery are statistically far more likely to be a concern than your individual chances of getting BIA-ALCL. As such, it is not medically recommended that women have their breast implants removed to avoid the remote statistical chance of BIA-ALCL, except in special cases.

That said, peace of mind is critical to your well being, and if you are worried, I want to help. We offer breast implant removal at LJCSC including the en-bloc implant removal technique. I am also highly experienced with breast implant replacement for women who want to change the type, shape, or size of implant they have for any reason.

I hope this post has answered some of your questions about BIA-ALCL, as well as helped you understand the facts. If you have more questions, or you are concerned about your breast implants, I encourage you to consult with an experienced, board certified plastic surgeon. If you are in the San Diego area, feel free to call my office at La Jolla Cosmetic Surgery Centre at 858-452-1981.

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