Position Statement: Breast augmentation and reduction mammoplasty
procedures
Background
Breast augmentation procedures, performed by plastic, cosmetic and general breast surgeons, have
become increasingly popular in recent years. There is a trend for increasing cosmetic surgery tourism,
including breast procedures, especially to South-east Asia. The American Society of Aesthetic Plastic
Surgery reports a rapid increase in the number of breast implant procedures, with 316,848 cases in
2011 [1]. Breast enlargement surgery is the most commonly performed cosmetic operation in the UK
[2] where in 2001, 77% of the 13,000 breast implant operations were estimated to have been
performed for cosmetic purposes [3].
Reasons for concern
The growing incidence of breast augmentation procedures is of concern to BreastSurgANZ for two
reasons. Firstly, women with breast implants may be reluctant to participate in the BreastScreen
Program because of anxiety about damaging the implants. Secondly, implants may impair early
detection of breast cancer.
A woman with breast implants presents specific challenges for breast imaging. Breast implants are
radio-opaque, and restrict the visualisation of breast tissue with mammography [4]. The implant can
also compress the breast tissue and hence limit the detection of subtle findings such as architectural
distortion and microcalcifications. The lower sensitivity of mammography in women with implants
may lead to delayed diagnosis.
In addition to concerns about augmentation, other breast aesthetic procedures and breast reduction
mammoplasty procedures are often performed on women in the age group where the risk of breast
cancer is increasing. If these women have not had recent screening, it is prudent to do so preoperatively.
Benefits of pre-augmentation / reduction mammoplasty imaging
All patients considering breast augmentation or breast reduction mammoplasty surgery require a
comprehensive assessment of underlying breast cancer risk and thorough clinical examination to
exclude obvious abnormalities that would need to be fully evaluated. In addition to basic history and
examination, some confirmatory breast imaging would be indicated in many cases. While the early
detection of breast cancer is the major indication for pre-operative breast imaging, baseline imaging
also has other benefits. These include documentation and appropriate investigation of pre-existing
parenchymal abnormalities in the breast so as to aid radiological assessment in the setting of future
breast cancer screening. The imaging may also be of documentary importance when malignancy
occurs in the previously augmented breast [5]. Appropriate imaging may vary depending on the
woman’s age, risk factors for breast cancer, breast density and clinical examination findings, but
would usually involve mammography, possibly ultrasound and sometimes an MRI (see Table 1).
BreastSurgANZ recommendations
1) Surgeons performing breast augmentation or reduction mammoplasty should perform
comprehensive risk assessment, thorough clinical examination and appropriate imaging.
2) General practitioners who are aware that patients are planning to have these procedures
performed overseas, or by surgeons who have not met these standards of pre-operative
assessment, should complete these assessments themselves, or refer women to an
appropriate specialist or breast assessment clinic.
3) National societies of plastics and cosmetic surgeons should consider endorsing and promoting
these pre-operative requirements for their members who perform breast augmentation and
reduction mammoplasty surgery.
BreastSurgANZ suggests the following investigations should be considered prior to breast
augmentation or breast reduction procedures:
Table 1: Appropriate pre-augmentation or breast reduction investigations according to women’s
age, risk status and clinical examination
Clinical
examinationa
Mammography
Ultrasound
MRIb
Age < 40

average risk
Yes
Consider
Consider
No

increased riskc
Yes
Yes
Yes
Consider

difficult to
clinically assessd
Yes
Consider
Yes
No
Age 40+

average risk
Yes
Yes
Consider
No

increased riskc
Yes
Yes
Yes
Consider

difficult to
clinically assessd
Yes
Yes
Yes
Consider
a. Significant clinical findings including abnormal clinical examination or symptoms. Such
findings need full assessment by a breast physician or breast surgeon and may require a biopsy
depending on the nature of the problem.
b. MRI is specifically indicated only if recommended by a breast specialist. It is only claimable on
Medicare for patients within Cancer Australia’s Risk Category 3 [6].
c. Defined as:
i. Significant family history (Cancer Australia Risk Category 2 or 3) [6];
ii. Previous clinical history (e.g. prior biopsies showing proliferative breast disease such as
LCIS, ADH, ALH, multiple papillomatosis etc.); or
d. Defined as suspicious or inconclusive findings or situations where an assessment is difficult
due to anatomical features such as dense breasts.
References
[1] American Society of Aesthetic Plastic Surgery. www.surgery.org/consumers/plastic-surgerynewsbriefs
[2] British Association of Plastic, Reconstructive and Aesthetic Surgeons. Breast enlargement –
patient information guide.
http://www.bapras.org.uk/resources/plastic_surgery_information_guides/breast_enlargement
[3] McIntosh SA, Horgan K. Augmentation mammoplasty: effect on diagnosis of breast cancer. J Plast
Reconstr Aesthet Surg. 2008;61(2):124-9. Epub 2007 Nov 26.
[4] Lavigne E, Holowaty EJ, Pan SY et al. Breast cancer detection and survival among women with
cosmetic breast implants: systematic review and meta-analysis of observational studies. BMJ. 2013
Apr 29;346:f2399. doi: 10.1136/bmj.f2399.
[5] Stöblen F, Rezai M, Kümmel, S. Imaging in patients with breast implants – results of the First
International Breast (Implant) Conference 2009. Insights Imaging (2010);1:93-97.
[6] Cancer Australia. Assessment algorithm. FRA-BOC [Familial risk assessment – breast and ovarian
cancer]. Assertion definitions. Evaluation categories. http://canceraustralia.gov.au/clinical-bestpractice/gynaecological-cancers/familial-risk-assessment-fra-boc/what-fra-bocassesses/assessment-algorithm