Cosmetic breast augmentation in Australia: a cost of complication study

Abstract

Background: Treatment of complications from cosmetic breast augmentation is subsidised by government funding in Australia.

Aim: We aimed to estimate the total cost to the Australian public health system of the treatment of complications following cosmetic breast augmentation.

Method: Using the PRISMA 2009 statement, a systematic review was conducted to find articles reporting on complications following cosmetic breast augmentation. A quantitative analysis was performed to calculate overall complication rates.

An economic cost analysis was performed on data from procedures performed in Australia between 2000-01 and 2014-15. We modelled costs to the public health system for this period and projected costs to the year 2030.

Results: Thirty-nine articles were identified for inclusion in the quantitative analysis of complication rates following cosmetic breast augmentation. Economic modelling showed an estimated cost of over A10millionjustforsurgeons’andsurgicalassistants’feestotreatcomplicationsbetween2000and2015.WeforecastoverA10 million just for surgeons’ and surgical assistants’ fees to treat complications between 2000 and 2015. We forecast over A50 million for this cost over the subsequent fifteen years. Total health spending on complications is estimated to have been almost A$200 million between 2000 and 2015.

Conclusion: This study illustrates the significant economic cost to the Australian health system created by complications following cosmetic breast augmentation. We believe this study reinforces the importance of the Australian breast device registry (ABDR) to further guide regulation, economic policy and health policy.

Full text

Australasian Journal of Plastic Surgery Volume 1 Number 2 2018
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AJOPS | ORIGINAL ARTICLE
PUBLISHED: 24-09-2018
1 Department of Plastic, Reconstructive and Hand Surgery
Peninsula Health
Frankston, Victoria, AUSTRALIA
2 Peninsula Clinical School
Central Clinical School
Monash University
The Alfred Centre
Melbourne, Victoria, AUSTRALIA
3 School of Public Health
Curtin University
Perth, Western Australia, AUSTRALIA
4 CCRE Therapeutics
School of Public Health and Preventive Medicine
Monash University
Melbourne, Victoria
AUSTRALIA
OPEN ACCESS
Correspondence
Name: George S Miller
Address: Department of Plastic and Reconstructive Surgery
Frankston Hospital
Peninsula Health
2 Hastings Road,
Frankston, Victoria, 3199
AUSTRALIA
Email: gsmiller87@gmail.com
Phone: +61 400 177 292
Citation: Miller GS, Robinson S, Reid CM, Hunter-Smith
DJ. Cosmetic breast augmentation in Australia: a cost of
complication study. Aust J Plast Surg. 2018;1(2):51–64.
https://doi.org/10.34239/ajops.v1i2.120
Accepted for publication: 9 April 2018
Copyright © 2018. Authors retain their copyright in the
article. This is an open access article distributed under
the Creative Commons Attribution Licence which permits
unrestricted use, distribution and reproduction in any
medium, provided the original work is properly cited.
Section: Breast
Cosmetic breast augmentation in Australia: a cost of
complication study
George S Miller BMedSc MBBS,1,2 Suzanne Robinson PhD,3 Christopher M Reid PhD MSc
FESC,3,4 David J Hunter-Smith MBBS MPH FRACS1,2
Abstract
Background: Treatment of complications from
cosmetic breast augmentation is subsidised by
government funding in Australia.
Aim: We aimed to estimate the total cost to the
Australian public health system of the treatment
of complications following cosmetic breast
augmentation.
Method: Using the PRISMA 2009 statement, a
systematic review was conducted to find articles
reporting on complications following cosmetic
breast augmentation. A quantitative analysis was
performed to calculate overall complication rates.
An economic cost analysis was performed on data
from procedures performed in Australia between
2000-01 and 2014-15. We modelled costs to the public
health system for this period and projected costs to
the year 2030.
Results: Thirty-nine articles were identified for
inclusion in the quantitative analysis of complication
rates following cosmetic breast augmentation.
Economic modelling showed an estimated cost
of over A$10 million just for surgeons’ and surgical
assistants’ fees to treat complications between 2000
and 2015. We forecast over A$50 million for this
cost over the subsequent fifteen years. Total health
spending on complications is estimated to have been
almost A$200 million between 2000 and 2015.
Conclusion: This study illustrates the significant
economic cost to the Australian health system
created by complications following cosmetic breast
augmentation. We believe this study reinforces the
importance of the Australian breast device registry
(ABDR) to further guide regulation, economic policy
and health policy.
Keywords: costs and cost analysis, mammaplasty, breast,
economic models, health policy
Br

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Introduction
With increased pressure on health care budgets,
we are seeing more focus on the clinical and cost
effectiveness of interventions provided by health
systems globally. The ‘Choosing Wisely’ campaign
recently adopted in a number of countries,
including Australia, focuses on encouraging
patients and clinicians to ‘discuss inappropriate
and potentially harmful tests, treatments and
procedures.’1 While the Australian campaign
is seeing the development and identication of
procedures that may be harmful to patients, there
is a paucity of robust clinical studies that clearly
dene the benet of cosmetic breast augmentation
in non-pathological female breasts. Despite this,
the number of cosmetic breast augmentations
performed in Australia each year is increasing
rapidly, with numbers of procedures more than
doubling over the past decade according to the
most recently documented Australian Institute of
Health and Welfare (AIHW) statistics.2 In addition,
there is an increasing popularity of ‘cosmetic
tourism’ by Australians for such procedures.
The process of having cosmetic breast augmentation
surgery in Australia involves a completely private
arrangement (and transactions) between a
surgeon, anaesthetist, hospital and patient, with no
funding or rebates available through the Medicare-
based public health system. The procedure is not
limited to Royal Australasian College of Surgeons
(RACS) accredited surgeons and, in many instances,
the doctor performing the surgery is a cosmetic
proceduralist. Further, the Australian Society of
Plastic Surgeons’ Breast Implant Registry does not
capture data related to non-specialist surgeons
who perform the procedures.
The most commonly documented complications
that arise from cosmetic breast augmentation
surgery are capsular contracture, implant
rupture, infection, seroma formation, haematoma,
deation, mal-positioning and/or rotation of the
implant, nipple and breast pain or sensation
changes.3-13 While the severity and implications of
complications vary widely according to individuals’
circumstances, they often require further
outpatient and inpatient surgical treatment.
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
Government subsidies cover part or all of the
surgical and medical costs associated with the
subsequent treatment of complications, even
though this ‘burden of disease’ is created entirely
from non-essential cosmetic operations. The
management of these complications therefore
places some level of burden on the health care
system. Hanefeld et al14 suggested that the economic
burden to the United Kingdom’s National Health
Service (NHS) from complications arising from
cosmetic tourism was £8.2 million per annum.
Methods
Using the PRISMA 2009 statement we conducted
a systematic review to nd articles reporting
complication rates following cosmetic breast
augmentation using breast implants (Figure 1).
A literature review of PubMed, Ovid Medline and
the Cochrane (Central) database was performed to
identify relevant articles using the following search
terms: ‘breast augmentation’, ‘cosmetic breast
surgery’, ‘breast implants’, ‘breast prosthesis’,
‘augmentation mammoplasty’, and ‘cosmetic
breast augmentation’. Additional terms included
‘complication’, ‘revision’, ‘capsular contracture’,
‘cost’, and ‘explantation’.
The inclusion criteria were:
• English language
• explicit documentation of complication rates
following cosmetic breast augmentation
• publication later than 1 January 2000
• mean follow-up greater than one year.
Exclusion criteria were:
• studies involving Poly Implant Prothese (PIP)
implants
• studies published prior to 1 January 2000
• mean follow-up less than one year
• revision augmentations and cosmetic augmentation
performed overseas.
No restrictions were placed on the type of article,
however, special consideration was needed
for statistical analyses appearing in multiple
publications arising from the same long-term
studies. In this circumstance, duplication was

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AJOPS | ORIGINAL ARTICLE
avoided by including only the most recent
publication regarding the study.
Data extracted from each study included author,
year of publication, level of evidence, type of study,
number of patients, follow up, type of prosthesis
used and indication, and outcomes measured. We
extracted data regarding all reported complications,
however, analysis was performed only on more
common short-term complications involving
infection, haematoma and seroma and long-term
complications involving capsular contracture,
rupture and re-operation rates. We attempted
to report complications on a ‘per-patient’ basis
rather that ‘per-implant’. Articles that reported
complications by implant were converted to a
gure according to their overall study population
to allow analysis. Our gures may therefore show
slight discrepancies when compared with original
published data. Incidence of breast augmentation
procedures was extracted from publicly available
data from AIHW.2
Using a top-down costing approach, we calculated
the direct cost of surgical fees for complications. We
then modelled the cost over specic periods for re-
operations arising from breast augmentation. Our
analysis required specic population and surgical
assumptions to enable the calculations, including:
• that all procedures performed are primary
augmentations (so as to not over-report
complication rates if we over-estimated the rate of
revision augmentations)
• the ratio of saline to silicone implants in Australia
is 5 per cent saline and 95 per cent silicone (to
prevent over-estimation of higher complication rates
associated with saline implant data)
• complication rates identied by current literature
worldwide apply to the Australian population.
Operations required for the treatment of
complications or for revision following breast
augmentation were matched to appropriate
Medicare procedure codes including:
• exchange of implant procedures (with or without
capsulectomy)
• explantation of prosthesis
• mastopexy
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
• other miscellaneous operations such as drainage of
haematoma or seroma, or debridement of infected
surgical wound.
Procedure codes used in our cost analysis are
documented in Appendix 1 with the overall
Medicare benet attributable to each (including
surgeon and assistant fees). For cost analysis
we modelled the ratio of procedure codes
proportionally for each cause of re-operation. The
ratios reect the common reasons for re-operation
and an approximate rate that these occur. Our
model is designed to reect the complications
according to the proportions demonstrated in the
literature.3-12
Figure 1: PRISMA article selection process
Results
The literature search was conducted in September
2017. The search and selection process is
summarised in Figure 1. Of the 267 articles assessed
for eligibility, 73 matched inclusion criteria and
were reviewed. Of these, 39 studies suciently
reported outcome data suitable for inclusion in
a quantitative analysis of complication rates.
Appendix 2 provides details of the 39 studies used
in the quantitative analysis.

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On the reported complications arising from 39,738
breast augmentation patients, meta-analysis
revealed:
• 2,462 primary saline augmentations (from six
studies)
• 32,838 primary silicone augmentations (from 31
studies)
• 4,438 revision silicone augmentations (from 11
studies).
Where implant type or indication was not explicitly
reported, studies were excluded. Tables 1–3 show
the complication rates identied. No articles
reporting on complications specic to revision
augmentation with saline prostheses met the
criteria for inclusion in the analysis.
Primary augmentation with saline prostheses
Only six articles reported the outcomes of saline
prostheses following primary augmentation. Table
1 summarises rates of complications reported in
each study.
Infection, seroma and haematoma complications
were poorly reported in these studies. Only one
study reported haematoma rates in a study of 20
patients15. No studies reported seroma rates, and
two studies reported infection rates.15,16 The overall
capsular contracture rate was 15.6 per cent (10-
year rate 21.6 per cent). Rupture (or ‘deation’)
was reported in three studies at an overall rate of 6
per cent (10-year rate 7.4 per cent).15-17 Re-operation
occurred in 31.8 per cent of the 1,793 cases (10-year
rate 44.1 per cent).
Swanson et al18 reported re-operation rates of
10.7 per cent for augmentation alone and 20.5 per
cent for augmentation with mastopexy based on
average follow-up periods of 8.3 months and 8.4
months respectively. Given the follow-up periods
in this study were shorter than 12 months, it was
not included for quantitative analysis.
In ve-year reported complication rates by
Walker et al,17 other signicant complications
such as asymmetry, breast pain and malposition
were noted in 12.2 per cent, 17.0 per cent and 9.2
per cent of patients respectively. Swanson et al18
reported asymmetry in 3.8 per cent and 3.4 per cent
respectively in the two groups described above.
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
A signicant positive correlation was detected
between the incidence of complications and patient
age but the correlation was weak (r = 0.10, p <
0.01). Swanson et al also showed that smoking was
associated with increased complication incidence,
as was revision breast surgery (p < 0.01).
Primary augmentation with silicone
prostheses
Thirty-one articles report on outcomes following
primary breast augmentation with silicone
implants and met the criteria for inclusion in
the quantitative analysis. Signicant Food and
Drug Administration (FDA) pre-approval studies
following a 1992 moratorium on silicone implants
in the USA provide most of the long-term data for
these types of prostheses. Core studies included
in this analysis6,7,9 provide prospective, long-
term analysis of silicone implants and associated
complications. Table 1 shows the categorical data
for each included study.
The 31 articles showed an overall re-operation
rate of 11.4 per cent (10-year rate 23.8 per cent)
following primary augmentation with silicone.
This is signicantly lower than reported rates from
all of the FDA studies conducted prospectively over
10 years.6,7,9 Araco et al19 report a comparatively
very low rate of re-operation in one of the largest
cohorts included in this analysis involving 3,002
patients. Caplin,9 Maxwell6 and Spear7 all report re-
operation rates greater than 25 per cent at 10 years.
Asymmetry and rippling were commonly reported
complications not analysed for overall occurrence.
Reported rates of asymmetry ranged from 0.8 per
cent to 7 per cent, while malposition was reported
in as many as 5.3 per cent of cases (range 0.8 to
5.3 per cent). Rippling was sparsely reported, but
documented rates were low (range 0.7 to 2.0 per
cent). Other complications such as nipple sensation
change, breast pain and palpable implant edges
were less commonly reported.

AJOPS | ORIGINAL ARTICLE
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication st
Table 1: Results of meta-analysis
Primary saline augmentation
Author Year Patients (n) Follow up Haematoma Haematoma Seroma Seroma Infection Infection CC† CC† Rupture Rupture Re-operation Re-operation
(years) count rate count rate count rate count rate count rate count rate
Blount16 2013 402 1.2 NR NR NR NR 6 1.50% 17 4. 30% NR NR 87 21.70%
Fagrell15 2001 20 7.5 1 5% NR NR 0 0% 4 20% NR NR NR NR
Levi20 2008 325 6.04 NR NR NR NR NR NR NR NR 15 4.95% NR NR
Stevens21 2005 324 5 NR NR NR NR NR NR NR NR 17 5.30% NR NR
Walker17 2009 876 10 NR NR NR NR NR NR 182 20.80% 59 6. 80% 320 36.50%
Somogyi22 2015 515 1.5 1.5 NR NR NR NR NR NR NR NR NR 65 12.60%
Total events 1 6 203 91 407
Total patients 2462 20 422 1298 1525 1793
Overall rate 5% 1.42% 15.64% 5.97% 31.80%
Ten-year rate 5% 1.42% 21.60% 7.37% 44.10%
Primary slicone augmentation
Author Year Patients (n) Follow up Haematoma Haematoma Seroma Seroma Infection Infection CC† CC† Rupture Rupture Re-operation Re-operation
(years) count rate count rate count rate count rate count rate count rate
Araco19 2007 3002 6.1 NR NR NR NR NR NR 14 0.50% NR NR 47 1.57%
Basile23 2005 288 2 NR NR NR NR 16 5.56% NR NR NR NR NR NR
Blount16 2013 856 1.2 8 0.90% 2 0.20% 6 0.70% 11 1.30% 32 3.70% 65 7.60%
Brown24 2005 118 1.75 1 0.85% NR NR NR NR 2 1.70% NR NR NR NR
Collis25 2000 53 10 NR NR NR NR NR NR 7 14% NR NR 13 24.50%
Dancey26 2012 1400 6 NR NR NR NR NR NR 376 26.90% NR NR NR NR
Giordano27 2013 330 2 NR NR NR NR NR NR 11 6% NR NR NR NR
Haws28 2014 321 1 NR NR NR NR 4 1.40% 12 3.90% 1 0.40% NR NR
Hvilsom3 2009 5373 3.8 80 1.50% 10 0.20% 102 1.90% 226 4.20% NR NR 260 4.80%
Holmich29 2007 190 19 NR NR NR NR NR NR 117 62% NR NR 74 39%
Kjoller4 2002 754 7 17 2.30% 1 0.20% 15 2.00% 86 11.40% 3 0.50% 84 11.14%
Namnoum5 2013 4412 3 NR NR NR NR NR NR 317 7.10% NR NR 774 17.50%
Maxwell6 2015 492 10 6 1.30% 7 1.60% 8 1.70% 45 9.20% 50 10.20% 146 29.70%
Spear7 2014 455 10 NR NR 8 1.80% NR NR 86 18.90% 42 9.30% 164 36.1%
Lista8 2013 440 1.2 NR NR 15 3.40% NR NR 3 0.70% NR NR 41 10.70%
Niechajev30 2007 80 5 2 2% 2 2% NR NR NR NR 0 0 2 2.50%
Pfeiffer31 2009 436 2 NR NR 12 2.90% 58 6.70% 26 5.90% NR NR NR NR
Sevin32 2006 210 8 NR NR NR NR 0 0% 17 8% 8 4% 21 10%
Caplin9 2014 1124 9 NR NR NR NR 14 1.2% 81 7.2% NR 3.8-10.3% 317 28%
Henriksen10 2003 971 1.3 NR NR NR NR NR NR 45 4.10% NR NR 65 6%
Stevens11 2016 1116 9 NR NR 13 1.20% 10 0.90% 134 11.20% 48 4.30% 248 22.20%
Stevens33 2010 211 2.4 NR NR 2 0.95% 2 0.95% 3 1.20% NR NR 11 5.20%
Benito-Ruiz12 2016 373 5 NR NR 3 0.80% 3 0.80% 13 3.40% 4 1.10% 33 8.90%
Doren34 2015 384 5.3 1 0.26% NR NR NR NR 18 4.70% 3 0.80% 34 8.90%
Doshier35 2016 178 1.25 NR 0.84% NR NR 0 0.00% 0 0.00% 0 0.00% NR 7.97%
Drinane36 2016 55 2 .6 NR NR NR NR NR NR 4 7.28% NR NR NR NR
Flugstad37 2015 2797 1 NR NR NR NR NR NR 57 2.04% NR NR NR NR
Keramidas38 2016 180 1 0 0.00% NR NR 1 0.55% 0 0.00% NR NR NR NR
Kerfant39 2017 156 1.85 2 1.28% NR NR 2 1.28% 6 3.80% NR NR NR 9.94%
McGuire40 2017 5059 4.1 NR NR NR 0.06% NR NR 234 2.30% NR NR NR NR
Somogyi22 2015 1024 1.5 NR NR NR NR NR NR NR NR NR NR 53 5.18%
Total events 117 75 241 1951 191 2452
Total patients 31814 8393 10586 12441 31446 5219 21520
Overall rate 1.39% 0.71% 1.94% 6.20% 3.66% 11.39%
Ten-year rate 1.39% 0.71% 1.94% 14 .39% 6.30% 23.70%
Revision silicone augmentation
Author Year Patients (n) Follow up Haematoma Haematoma Seroma Seroma Infection Infection CC† CC† Rupture Rupture Re-operation Re-operation
(years) count rate count rate count rate count rate count rate count rate
Caplin9 2014 269 9 NR NR NR NR 4 1.40% 54 20.10% NR NR 101 37.50%
Henriksen10 2003 119 1.3 4 3.40% NR NR 4 3.40% 6 5.00% NR NR 65 6%
Maxwell6 2015 156 10 3 2% 5 3.20% 3 2.10% 18 11.90% 8 5.20% 74 47.30%
Spear7 2014 147 10 NR NR 9 6.00% NR NR 42 28 .70% 8 5.40% 67 46.00%
Stevens11 2016 363 9 NR NR 6 1.60% 5 1.50% 47 13.00% 12 3.30% 133 36.60%
Stevens33 2010 141 2.4 NR NR 1 0.70% 1 0.70% 2 1.70% NR NR 10 6.80%
Castello41 2011 49 2 NR NR NR NR NR NR 33 67% NR NR NR NR
Forster42 2012 230 6.1 NR NR NR NR NR NR NR NR NR NR 58 25%
Grewal43 2013 134 1 NR NR NR NR NR NR 39 29% NR NR NR NR
Doren34 2015 198 5.3 0 0 NR NR NR NR 17 8.60% 2 1.00% 38 19%
McGuire40 2017 2632 2.6 NR NR NR 0.15 NR NR 212 4.10% NR NR NR NR
Total events 7 21 17 470 30 546
Total patients 4438 473 807 1048 4208 864 1623
Overall rate 1.48% 2.60% 1.62% 11.17% 3.47% 33.64%
Ten-year rate 1.48% 2.60% 1.62% 27.60% 4.40% 47.60%
CC † = Capsular contracture (Baker III/IV) | NR = Not reported

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Table 2: Total cosmetic breast augmentations since 2000–01 by financial year
Year Bilateral augmentation Unilateral augmentation Total augmentations
2000/01 3105 269 33 74
2001/02 3496 242 3738
2002/03 3564 232 3796
2003/04 4691 247 4938
2004/05 5877 292 6169
2005/06 6370 331 6701
2006/07 7089 318 7407
2007/08 7753 367 8120
2008/09 7239 369 7608
2009/10 7643 394 8037
2010/11 7696 351 8047
2011/12 7405 421 78 26
2012/13 7607 408 8015
2013/14 7880 41 9 8299
2014/15 10383 417 10800
Total 97798 5077 102875
Prevalence 0.84%
Frequency of breast augmentation in the Australian female population 1 every 118 females
Total female population (n=11,614,645)*
* source Australian Bureau of Statistics population data June 2014
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
Figure 2: Bilateral augmentation forecast by year until 2030.
X= number of bilateral augmentations Y= number of years
Cost analysis
Table 2 shows the gures for breast augmentation
procedures performed in Australia per year from
2000-01 to 2014-15.2 These gures do not distinguish
between primary or revision procedures, nor types
of implant used. Using these gures we estimate
the current rate of cosmetic breast augmentation
to be 0.8 per cent of the female population.44 This
equates to 1 in every 118 females in Australia.
We performed modelling to predict the complication
rates occurring at one year and 10 years from the
augmentations performed in 2014-15 alone. From
this single year’s breast augmentations, we predict
a further 2,613 re-operations would be required
over the subsequent 10 years.
Figure 2 shows projected future incidence of
cosmetic breast augmentation in Australia. Based
on the recent trend, we have projected the rate of
breast augmentation in Australian to reach over 2
Revision augmentation with silicone
prostheses
Eleven articles reporting on outcomes following
revision augmentations using silicone prostheses
were used in the quantitative analysis. Seven of
these articles prospectively studied the outcomes
of patients undergoing revision augmentation.
Indications for revision augmentation are
sporadically reported throughout the studies.
Table 1 shows the complication rates for each of
the studies.
Although fewer patients were studied following
revision augmentation, long-term complication
rates are signicantly higher than primary
augmentation. Complications such as haematoma,
seroma and infection are comparable to primary
silicone augmentation—overall rates are 1.5 per
cent, 2.6 per cent, and 1.6 per cent respectively.
Capsular contracture was higher in revision
augmentation with an overall rate of 11.2 per cent
(10-year rate 27.1 per cent). Interestingly, the overall
rate of rupture in revision silicone augmentation
was trending slightly towards a lower rate than in
primary augmentation at 3.5 per cent (10-year rate
4.1 per cent).
The most signicant measure of complications
following augmentation is the re-operation rate.
The overall rate of re-operation following revision
augmentation was calculated to be 33.6 per cent
(ten-year rate 46.7 per cent)—signicantly higher
than the corresponding rate following primary
augmentation (23.7 per cent).

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AJOPS | ORIGINAL ARTICLE
per cent of the entire Australian female population
by the year 2030, equating to 1 of every 38 females
in Australia.
Table 3 shows the estimated cumulative
complications from all augmentations performed
between 2000 and 2015 and the associated cost
for re-operations during this period. The number
of re-operations is estimated to have been 15,251
between July 2000 and June 2015.
If cosmetic breast augmentation rates were to
increase at the current rate until 2030, the cost to
the Australian health system for surgical fees alone
would be in excess of another A$50 million from
now until 2030.
Table 4 shows the total cumulative surgical
reimbursement cost directly attributable to re-
operations performed from 2000-01 to 2029-2030.
Discussion
Many articles have investigated complications
following the insertion of breast prostheses and
compared the performance of different implant
types. Most of these investigate a sole complication
such as infection or capsular contracture. In
2013, an extremely thorough report by Gurgasz
et al45 was performed on behalf of the Australian
safety and ecacy register of new interventional
procedures—surgical. The results of this review
support the statistical ndings of our analysis.
Reviews by Schaub et al,46 Wong et al47 and many
others13, 48-53 also produced results similar to ours.
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
Table 3: Total estimated cost from complications arising f rom augmentations performed from 2000–01 – 2014–15 (A$)
Total augmentation n=10,800 Number of events from 2000–2015
Haematoma 1713.4
Seroma 684.1
Infection 2125.4
Capsular contracture 9405.3
Rupture 4319.9
Re-operation 15251.1
Complications—procedures
and healthcare interventions
(ACH 8th edition) Australia
Proportion of cases
predicted
Number of cases
predicted
Total cost predicted
30024 8% 1221 $338,107.05
31551 8% 1221 $264,651.75
45548 6% 914 $252,995.20
45551 15% 2287 $1,014,741.90
45552 15% 2287 $1,752,711.06
45553 15% 2287 $1,752,711.06
45554 15% 2287 $1,919,570.58
45555 2% 305 $233,745.90
45557 8% 1221 $1,122,416.46
45558 8% 1221 $1,683,441.54
Total 100% 15251 $10,395,092.50
Table 4: Total estimated and forecast cost of complications arising from augmentations performed f rom 2000–01
to 2029–30 (A$)
Total augmentation n=302,82 Number of events from 2000–2030
Haematoma 5039.5
Seroma 2012.2
Infection 6251.3
Capsular contracture 56153.2
Rupture 26345.4
Re-operation 93011.4
Complications—procedures
and healthcare interventions
(ACH 8th edition) Australia
Proportion of cases
predicted
Number of cases
predicted
Total cost predicted
30024 8% 7440 $2,425,812.00
31551 8% 7440 $1,612,620.00
45548 6% 5580 $1,544,544.00
45551 15% 13952 $6,190,502.40
45552 15% 13952 $10,692,533.76
45553 15% 13952 $10,692,533.76
45554 15% 13952 $11,710,471.68
45555 2% 1861 $1,426,233.18
45557 8% 7441 $6,840,213.66
45558 8% 7441 $10,259,204.34
Total 100% 93011 $63,394,668.78

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AJOPS | ORIGINAL ARTICLE
Benefits
Alderman et al54 describe the improvement
in women’s short- and long-term satisfaction
and psychosocial wellbeing following breast
augmentation using the Breast-Q outcome
measure. Their study concludes that breast
implants are effective in improving quality of life.
Their results are supported by other studies.55,56
Our study does not contradict the ndings of these
studies—we analysed the costs without factoring in
these benets. The literature is evolving regarding
the long-term outcomes and benets following
cosmetic breast augmentation.
Cost burden
From the data we have extracted from AIHW
we have demonstrated a signicant nancial
and resource burden on the Australian health
system.2 Our analysis only shows surgeons’ and
surgical assistants’ Medicare rebates. We did not
include complications arising from augmentations
performed prior to 2000, or revision augmentations
and cosmetic augmentation performed
overseas. Our results are therefore a signicant
understatement of the real cost to the public
health system and wider economy. If nothing else,
this economic analysis provides a perspective
regarding the use of resources and the future
challenges to the Australian health sector from a
growing population.
The overall re-operation rate calculated in our
analysis includes 3,002 patients from a series by
Araco et al19 which reported disproportionately
lower re-operation rates than other studies. If we
removed this single article our results show even
higher costs.
Livingston57 reported the cost of cosmetic tourism
on a single health service over 12 months. For
each patient presenting with complications from
cosmetic tourism the associated cost of treatment
averaged A$12,600. This study is reinforced by
the ndings of Miyagi58 who reported similar
costs for treatment of cosmetic tourists in the
United Kingdom. Adabi59 showed costs for treating
complications from cosmetic tourism in the USA
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study
averaged US$18,211 per complication, equating to
a cost of over US$1.3 billion on the US economy and
health system.
If we attempted to calculate the total economic
cost of these complications to Australia’s health
system, we could apply the rates determined by
Livingston and Adabi to our calculated incidence
of re-operations from 2000–2015, as follows:
• 15,251 re-operations at A$12,600 (Livingston) implies
a total cost of A$192 million
• 15,251 re-operations at US$18,200 (Adabi) implies
a total cost of US$278 million (or A$358 million at
recent exchange rates).
These gures are clearly signicant. While the
applicability of the results of Livingston and Adabi to
Australia must be considered, these large monetary
gures do illustrate the potentially greater cost of
these complications than the gures we estimated.
The cost of the wide range of resources involved in
surgical management of complications could easily
escalate the real cost to something similar to the
hypothetical gures above.
For the future it is important to capture more
detailed data on the cost and medical impact of
cosmetic tourism, including the cost of managing
complications in the public health system. This
needs to be part of a wider discussion relating
to the ‘movement of patients, quality assurance
and standards of care, and procedures for legal
responsibility’.14
We acknowledge that our study has several
limitations. The rst is the lack of high-quality
evidence in the literature. There are no randomised
trials in the meta-analysis. This paper relies
heavily on retrospective and case series data.
We also note that our calculations are estimates
and do not represent gures from a registry or
prospective dataset. Future data collected by the
Australian breast device registry (ABDR) will
enable more accurate modelling and calculation of
the burden of disease created by cosmetic breast
augmentation. The ABDR also allows tracking of
device performance and complication proles. This
is of particular importance regarding conditions
such as anaplastic large cell lymphoma (ALCL).

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AJOPS | ORIGINAL ARTICLE
Social and psychological burden
The burden of disease created by cosmetic
breast augmentation extends beyond monetary
considerations; medical, social, lifestyle and
psychological risks are associated with cosmetic
surgery. Boulton et al60 illustrated hidden risks—
including medical, social and lifestyle factors—
associated with cosmetic surgery, particularly in
a medical system becoming increasingly market-
based. A recent review by Brunton61 highlighted
the negative psychological impacts of cosmetic
surgery on some patients and described the various
motivating factors linked to poor psychological
outcomes.
Alderman62 reported a signicant improvement in
satisfaction with breasts, psychosocial wellbeing
and sexual wellbeing in a study of 611 patients
following breast augmentation. However, physical
wellbeing was signicantly below baseline
scores both at six weeks and six months. From a
prospective, multi-centre study Murphy55 reported
a 95 per cent rate of satisfaction six years after
augmentation and signicant improvement in body
image, however, he did not nd any improvement
in overall physical health following breast
augmentation. Despite many articles describing the
positive psychological impact following cosmetic
breast augmentation, both Figueroa-Haas63 and
Lipworth64 documented increased suicide risk and
a trebled risk of death from alcoholism and the
abuse of prescription and recreational drugs in
women with breast augmentation.
Medical burden of breast augmentation
Complications following cosmetic breast
augmentation are common. In the short-term,
complications such as infection, seroma, and
haematoma are expected in a low percentage of
patients but become more prevalent over a longer
period. Our results show that women undergoing
cosmetic breast augmentation should be prepared
for at least a 20 per cent rate of re-operation
within ten years, with an increased risk with each
year they have the implant in-situ. These results
are comparable to other systematic reviews and
meta-analyses.13,45-53,65,66 For patients undergoing
revision augmentation, the risk of needing further
surgery is even greater and expected sooner. We
have found that about half of patients will require
a further operation within ten years of revision
augmentation.
Rarer types of complications following cosmetic
breast augmentation were not taken into
account such as brachial plexus impingement,67
silicone lymphadenopathy,68 chronic/late onset
haematoma,69 pneumothorax and cardiac
tamponade70 and recently an increased rate of
ALCL detection.71, 72 Many of these rare events have
signicant negative health effects for the patients
involved and treatment commonly requires
considerable time and resources.
Conclusion
This review presents complication rates following
cosmetic breast augmentation with saline and
silicone prostheses. While we recognise the
potential benet some women gain from cosmetic
breast augmentation, we believe the medical,
social, lifestyle and psychological risks are not fully
appreciated in this minimally regulated market.
Our analysis demonstrates that the economic
costs of complications following cosmetic breast
augmentation are signicant, reinforcing the
important role of the Australian Breast Device
Registry and suggesting a need for increased
regulation.73
Further investigation and more detailed economic
modelling that captures the entire health care cost
of complications following breast augmentation
is needed. A wider discussion around the rights
of patients and the responsibilities of public
health systems is also required focusing on how
we can modify current practices and regulations
to improve patients’ awareness of the potentially
signicant complications as well as who should bear
the nancial burden. The increasing popularity of
cosmetic tourism adds another signicant hurdle
in steps towards fuller regulation.
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study

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60
AJOPS | ORIGINAL ARTICLE
Acknowledgements
Vicky Tobin PhD, Monash University Plastic and
Reconstructive Surgery Group (Peninsula Clinical
School), Peninsula Health, Frankston, Victoria,
Australia, for contribution to the study design and
critical analysis.
Disclosure
The authors have no nancial or commercial
conicts of interest to disclose.
References
1 Bhatia RS, Levinson W, Shortt S, Pendrith C, Fric-Shamji E,
Kallewaard M, Peul W, Veillard J, Elshaug A, Forde I, Kerr
EA. Measuring the effect of choosing wisely: an integrated
framework to assess campaign impact on low-value care.
BMJ Qual Saf. 2015; 24(8): 523–31. https://doi.org/10.1136/
bmjqs-2015-004070 PMid:26092165
2 Australian Institute of Health and Welfare. Procedures and
healthcare interventions (ACHI 2nd–8th editions), Austra-
lia, 2000–01 to 2014–15 [web report]. Canberra: Australian
Government [Updated 5 July 2018; cited 1 September,
2017]. Available from: https://www.aihw.gov.au/reports/
hospitals/procedures-data-cubes/contents/data-cubes.
3 Hvilsom GB, Holmich LR, Henriksen TF, Lipworth L,
McLaughlin JK, Friis S. Local complications after cosmetic
breast augmentation: results from the Danish registry
for plastic surgery of the breast. Plast Reconstr Surg.
2009;124(3):919–25. PMid:19730312
4 Kjoller K, Holmich LR, Jacobsen PH, Friis S, Fryzek J,
McLaughlin JK, Lipworth L, Henrikson TF, Jorgensen S,
Bittmann S, Olsen JH. Epidemiological investigation of
local complications after cosmetic breast implant surgery
in Denmark. Ann Plast Surg. 2002;48(3):229–37. https://doi.
org/10.1097/00000637-200203000-00001 PMid:11862025
5 Namnoum JD, Largent J, Kaplan HM, Oefelein MG, Brown
MH. Primary breast augmentation clinical trial outcomes
stratied by surgical incision, anatomical placement and
implant device type. J Plast Reconstr Aes. 2013;66(9):1165–
172. https://doi.org/10.1016/j.bjps.2013.04.046
PMid:23664574
6 Maxwell GP, Van Natta BW, Bengtson BP, Murphy DK. Ten-
year results from the Natrelle 410 anatomical form-stable
silicone breast implant core study. Aesthet Plast Surg.
2015;35(2):145–55. https://doi.org/10.1093/asj/sju084
PMid:25717116 PMCid:PMC4399443
7 Spear SL, Murphy DK. Natrelle round silicone breast
implants: core study results at 10 years. Plast Recon-
str Surg. 2014;133(6):1354–361. https://doi.org/10.1097/
PRS.0000000000000021 PMid:24867717 PMCid:PMC4819531
8 Lista F, Tutino R, Khan A, Ahmad J. Subglandular breast
augmentation with textured, anatomic, cohesive silicone
implants: a review of 440 consecutive patients. Plast
Reconstr Surg. 2013;132(2):295–303. https://doi.org/10.1097/
PRS.0b013e3182958a6d PMid:23584627
9 Caplin DA. Indications for the use of MemoryShape breast
implants in aesthetic and reconstructive breast surgery:
long-term clinical outcomes of shaped versus round sili-
cone breast implants. Plast Reconstr Surg. 2014;134 Suppl
3:27s–37s. https://doi.org/10.1097/PRS.0000000000000609
PMid:25158767
10 Henriksen TF, Holmich LR, Fryzek JP, Friis S, McLaughlin
JK, Høyer AP, Kjøller K, Olsen JH. Incidence and severity
of short-term complications after breast augmentation:
results from a nationwide breast implant registry. Ann
Plast Surg. 2003;51(6):531–39. https://doi.org/10.1097/01.
sap.0000096446.44082.60 PMid:14646643
11 Stevens WG, Calobrace MB, Harrington J, Alizadeh K,
Zeidler KR, d’Incelli RC. Nine-year core study data for
sientra’s FDA-approved round and shaped implants with
high-strength cohesive silicone gel. Aesthet Plast Surg.
2016;36(4):404–16. https://doi.org/10.1093/asj/sjw015
PMid:26961987
12 Benito-Ruiz J, Manzano ML, Salvador-Miranda L. Five-
year outcomes of breast augmentation with form-stable
implants: periareolar vs transaxillary. Aesthet Plast
Surg. 2017;37(1):46–56. https://doi.org/10.1093/asj/sjw154
PMid:27694448
13 Nava MB, Rancati A, Angrigiani C, Catanuto G, Rocco N.
How to prevent complications in breast augmentation.
Gland Surg. 2017;6(2):210–17. https://doi.org/10.21037/
gs.2017.04.02 PMid:28497025 PMCid:PMC5409896
14 Hanefeld J, Horsfall D, Lunt N, Smith R. Medical tourism:
a cost or benet to the NHS? PLoS One. 2013;8(10):e70406.
https://doi.org/10.1371/journal.pone.0070406
PMid:24204556 PMCid:PMC3812100
15 Fagrell D, Berggren A, Tarpila E. Capsular contrac-
ture around saline-lled ne textured and smooth
mammary implants: a prospective 7.5-year follow-up.
Plast Reconstr Surg. 2001;108(7):2108–112. https://doi.
org/10.1097/00006534-200112000-00047 PMid:11743411
16 Blount AL, Martin MD, Lineberry KD, Kettaneh N,
Alfonso DR. Capsular contracture rate in a low-risk
population after primary augmentation mammaplas-
ty. Aesthet Plast Surg. 2013;33(4):516–21. https://doi.
org/10.1177/1090820X13484465 PMid:23636624
17 Walker PS, Walls B, Murphy DK. Natrelle saline-lled breast
implants: a prospective 10-year study. Aesthet Plast Surg.
2009;29(1):19–25. https://doi.org/10.1016/j.asj.2008.10.001
PMid:19233001
18 Swanson E. Prospective comparative clinical evaluation of
784 consecutive cases of breast augmentation and vertical
mammaplasty, performed individually and in combina-
tion. Plast Reconstr Surg. 2013;132(1):30e–45e. https://doi.
org/10.1097/PRS.0b013e3182910b2e PMid:23806952
19 Araco A, Gravante G, Araco F, Delogu D, Cervelli V, Walgen-
bach K. A retrospective analysis of 3,000 primary aesthetic
breast augmentations: postoperative complications and
associated factors. Aesthet Plast Surg. 2007;31(5):532–39.
https://doi.org/10.1007/s00266-007-0162-8 PMid:17659411
20 Levi B, Rademaker AW, Fine NA, Mustoe TA. Comparison of
breast implant deation for mentor anterior and posterior
valve designs in aesthetic and reconstructive patients. Plast
Reconstr Surg. 2008;122(3):685–92. https://doi.org/10.1097/
PRS.0b013e318182378e PMid:18766029
21 Stevens WG, Stoker DA, Fellows DR, Hirsch EM. Accel-
eration of textured saline breast implant deation rate:
results and analysis of 645 implants. Aesthet Plast Surg.
2005;25(1):37–39. https://doi.org/10.1016/j.asj.2004.11.005
PMid:19338785
22 Somogyi RB, Brown MH. Outcomes in primary breast aug-
mentation: a single surgeon’s review of 1539 consecutive
cases. Plast Reconstr Surg. 2015;135(1):87–97. https://doi.
org/10.1097/PRS.0000000000000773 PMid:25539298
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study

Australasian Journal of Plastic Surgery Volume 1 Number 2 2018
61
AJOPS | ORIGINAL ARTICLE
23 Basile AR, Basile F, Basile AV. Late infection following
breast augmentation with textured silicone gel-lled
implants. Aesthet Plast Surg. 2005;25(3):249–54. https://doi.
org/10.1016/j.asj.2005.02.006 PMid:19338816
24 Brown MH, Shenker R, Silver SA. Cohesive silicone gel
breast implants in aesthetic and reconstructive breast
surgery. Plast Reconstr Surg. 2005;116(3):768–79. https://doi.
org/10.1097/01.prs.0000176259.66948.e7 PMid:16141814
25 Collis N, Coleman D, Foo IT, Sharpe DT. Ten-year review
of a prospective randomized controlled trial of textured
versus smooth subglandular silicone gel breast implants.
Plast Reconstr Surg. 2000;106(4):786–91. https://doi.
org/10.1097/00006534-200009020-00005 PMid:11007389
26 Dancey A, Nassimizadeh A, Levick P. Capsular contrac-
ture—what are the risk factors? A 14-year series of
1400 consecutive augmentations. J Plast Reconstr Aes.
2012;65(2):213–18. https://doi.org/10.1016/j.bjps.2011.09.011
PMid:21930448
27 Giordano S, Peltoniemi H, Lilius P, Salmi A. Povidone-io-
dine combined with antibiotic topical irrigation to reduce
capsular contracture in cosmetic breast augmentation: a
comparative study. Aesthet Plast Surg. 2013;33(5):675–80.
https://doi.org/10.1177/1090820X13491490 PMid:23757043
28 Haws MJ, Schwartz MR, Berger LH, Daulton KL. Sientra
portfolio of Silimed brand shaped implants with high-
strength silicone gel: a 5-year primary augmentation clini-
cal study experience and a postapproval experience-results
from a single-surgeon 108-patient series. Plast Reconstr
Surg. 2014;134 Suppl 1:38s–46s. https://doi.org/10.1097/
PRS.0000000000000346 PMid:25057747
29 Holmich LR, Breiting VB, Fryzek JP, Brandt B, Wolthers
MS, Kjøller K, McLaughlin JK, Friis S. Long-term cos-
metic outcome after breast implantation. Ann Plast
Surg. 2007;59(6):597–604. https://doi.org/10.1097/SAP.
0b013e31803c7c78 PMid:18046137
30 Niechajev I, Jurell G, Lohjelm L. Prospective study com-
paring two brands of cohesive gel breast implants with
anatomic shape: 5-year follow-up evaluation. Aesthet Plast
Surg. 2007;31(6):697–710. https://doi.org/10.1007/s00266-
006-0057-0 PMid:17653683
31 Pfeiffer P, Jorgensen S, Kristiansen TB, Jorgensen A,
Holmich LR. Protective effect of topical antibiotics in
breast augmentation. Plast Reconstr Surg. 2009;124(2):629–
34. https://doi.org/10.1097/PRS.0b013e3181addc68
PMid:19644284
32 Sevin A, Sevin K, Senen D, Deren O, Adanali G, Erdogan
B. Augmentation mammaplasty: retrospective analysis of
210 cases. Aesthet Plast Surg. 2006;30(6):651–54. https://doi.
org/10.1007/s00266-006-0076-x PMid:17093874
33 Stevens WG, Hirsch EM, Tenenbaum MJ, Acevedo M. A
prospective study of 708 form-stable silicone gel breast
implants. Aesthet Plast Surg. 2010;30(5):693–701. https://doi.
org/10.1177/1090820X10381880 PMid:20884898
34 Doren EL, Pierpont YN, Shivers SC, Berger LH. Compari-
son of Allergan, Mentor, and Sientra contoured cohesive
gel breast implants: a single surgeon’s 10-year experi-
ence. Plast Reconstr Surg. 2015;136(5):957–66. https://doi.
org/10.1097/PRS.0000000000001675 PMid:26505700
35 Doshier LJ, Eagan SL, Shock LA, Henry SL, Colbert SH, Puck-
ett CL. The subtleties of success in simultaneous augmen-
tation-mastopexy. Plast Reconstr Surg. 2016;138(3):585–
92. https://doi.org/10.1097/PRS.0000000000002517
PMid:27556602
36 Drinane JJ, Kortes MJ, Bergman RS, Folkers BL. Evalu-
ation of antibiotic irrigation versus saline irrigation in
reducing the long-term incidence and severity of capsular
contraction after primary augmentation mammoplasty.
Ann Plast Surg. 2016;77(1):32–36. https://doi.org/10.1097/
SAP.0000000000000302 PMid:25144414
37 Flugstad NA, Pozner JN, Baxter RA, Creasman C, Egrari
S, Martin S, Messa CA, Oliva A, Schlesinger SL, Korte-
sis WG. Does implant insertion with a funnel decrease
capsular contracture? A preliminary report. Aesthet Plast
Surg. 2016;36(5):550–56. https://doi.org/10.1093/asj/sjv237
PMid:26672104
38 Keramidas E, Lymperopoulos NS, Rodopoulou S. Is antibi-
otic prophylaxis in breast augmentation necessary? A pro-
spective study. Plastic surgery (Oakv). 2016;24(3):195–98.
https://doi.org/10.1177/229255031602400310
39 Kerfant N, Henry AS, Hu W, Marchac A, Auclair E.
Subfascial primary breast augmentation with fat
grafting: a review of 156 cases. Plast Reconstr Surg.
2017;139(5):1080e–085e. https://doi.org/10.1097/
PRS.0000000000003299 PMid:28445355
40 McGuire P, Reisman NR, Murphy DK. Risk factor analysis
for capsular contracture, malposition, and late seroma in
subjects receiving natrelle 410 form-stable silicone breast
implants. Plast Reconstr Surg. 2017;139(1):1–9. https://doi.
org/10.1097/PRS.0000000000002837 PMid:27627058 PM-
Cid:PMC5201411
41 Castello MF, Lazzeri D, Silvestri A, Agostini T, Pascone C,
Marcelli C, Gigliotti D, D’Aniello C, Gasparotti M. Maximiz-
ing the use of precapsular space and the choice of implant
type in breast augmentation mammaplasty revisions: re-
view of 49 consecutive procedures and patient satisfaction
assessment. Aesthet Plast Surg. 2011;35(5):828–38. https://
doi.org/10.1007/s00266-011-9704-1 PMid:21455821
42 Forster NA, Kunzi W, Giovanoli P. The reoperation cascade
after breast augmentation with implants: what the patient
needs to know. J Plast Reconstr Aes. 2013;66(3):313–22.
https://doi.org/10.1016/j.bjps.2012.09.033 PMid:23102610
43 Grewal NS, Fisher J. Why do patients seek revisionary
breast surgery? Aesthet Surg J. 2013;33(2):237–44. https://
doi.org/10.1177/1090820X12472693 PMid:23388645
44 Australian Bureau of Statistics. Australian Demograph-
ic Statistics, June 2014. Canberra: Australian Govern-
ment [Released 18 December 2014; cited 1 September
2017]. Available from: http://www.abs.gov.au/AUSSTATS/
abs@.nsf/allprimarymainfeatures/54A5E977BB10644C-
CA257E1300775B9B?opendocument.
45 Gurgacz S, Lambert R, Vogan A, Cooter R, Mutimer K, Mad-
dern G. Rapid review: breast prosthesis implantation for
reconstructive and cosmetic surgery: Australian safety and
ecacy register of new interventional procedures-surgical.
ASERNIP-S report no. 82. Royal Australian College of Sur-
geons. Adelaide, South Australia, December 2013. [Updated
December 2013; cited 1 September 2018]. Available from:
https://www.surgeons.org/media/20844776/rpt_2014-02-
04_rr_breast_implantation__2_.pdf
46 Schaub TA, Ahmad J, Rohrich RJ. Capsular contracture
with breast implants in the cosmetic patient: saline versus
silicone—a systematic review of the literature. Plast Re-
constr Surg. 2010;126(6):2140–149. https://doi.org/10.1097/
PRS.0b013e3181f2b5a2 PMid:20661169
47 Wong CH, Samuel M, Tan BK, Song C. Capsular contracture
in subglandular breast augmentation with textured versus
smooth breast implants: a systematic review. Plast Reconstr
Surg. 2006;118(5):1224–236. https://doi.org/10.1097/01.
prs.0000237013.50283.d2 PMid:17016195
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study

Australasian Journal of Plastic Surgery Volume 1 Number 2 2018
62
AJOPS | ORIGINAL ARTICLE
48 Liu X, Zhou L, Pan F, Gao Y, Yuan X, Fan D. Comparison of
the postoperative incidence rate of capsular contracture
among different breast implants: a cumulative meta-analy-
sis. PLoS One. 2015;10(2):e0116071. https://doi.org/10.1371/
journal.pone.0116071 PMid:25680100 PMCid:PMC4332657
49 Horsnell JD, Searle AE, Harris PA. Intra-operative tech-
niques to reduce the risk of capsular contracture in
patients undergoing aesthetic breast augmentation—a re-
view. Surgeon. 2017;15(5):282–89. https://doi.org/10.1016/j.
surge.2017.03.001 PMid:28476310
50 Gampper TJ, Khoury H, Gottlieb W, Morgan RF. Silicone gel
implants in breast augmentation and reconstruction. Ann
Plast Surg. 2007;59(5):581–90. https://doi.org/10.1097/01.
sap.0000258970.31562.5d PMid:17992156
51 Huang N, Liu M, Yu P, Wu J. Antibiotic prophylaxis in pros-
thesis-based mammoplasty: a systematic review. Int J Surg.
2015;15:31–37. https://doi.org/10.1016/j.ijsu.2015.01.020
PMid:25638736
52 Egeberg A, Sorensen JA. The impact of breast im-
plant location on the risk of capsular contraction. Ann
Plast Surg. 2016;77(2):255–59. https://doi.org/10.1097/
SAP.0000000000000227 PMid:25003431
53 Yalanis GC, Liu EW, Cheng HT. Ecacy and safety of
povidone-iodine irrigation in reducing the risk of cap-
sular contracture in aesthetic breast augmentation:
a systematic review and meta-analysis. Plast Recon-
str Surg. 2015;136(4):687–98. https://doi.org/10.1097/
PRS.0000000000001576 PMid:26397246
54 Alderman A, Pusic A, Murphy DK. Prospective analysis of
primary breast augmentation on body image using the
BREAST-Q: results from a nationwide study. Plast Recon-
str Surg. 2016;137(6):954e–60e. https://doi.org/10.1097/
PRS.0000000000002183 PMid:27219264 PMCid:PMC4879787
55 Murphy DK, Beckstrand M, Sarwer DB. A prospective,
multi-center study of psychosocial outcomes after aug-
mentation with natrelle silicone-lled breast implants.
Ann Plast Surg. 2009;62(2):118–21. https://doi.org/10.1097/
SAP.0b013e31817f01f8 PMid:19158517
56 McCarthy CM, Cano SJ, Klassen AF, Scott A, Van Laeken
N, Lennox PA, Cordeiro PG, Pusic AL. The magnitude of
effect of cosmetic breast augmentation on patient sat-
isfaction and health-related quality of life. Plast Recon-
str Surg. 2012;130(1):218–23. https://doi.org/10.1097/
PRS.0b013e318254b3bc PMid:22743886
57 Livingston R, Berlund P, Eccles-Smith J, Sawhney R. The
real cost of ‘cosmetic tourism’ cost analysis study of
‘cosmetic tourism’ complications presenting to a public
hospital. E-Plast. 2015;15:e34.
58 Miyagi K, Auberson D, Patel AJ, Malata CM. The unwritten
price of cosmetic tourism: an observational study and cost
analysis. J Plast Reconstr Aes. 2012;65(1):22–28. https://doi.
org/10.1016/j.bjps.2011.07.027 PMid:21865103
59 Adabi K, Stern CS, Weichman KE, Garfein ES, Pothula A,
Draper L, Tepper OM. Population health implications of
medical tourism. Plast Reconstr Surg. 2017;140(1):66–
74. https://doi.org/10.1097/PRS.0000000000003459
PMid:28654593
60 Boulton TN, Malacrida C. Women and cosmetic breast
surgery: weighing the medical, social, and lifestyle
risks. Qual Health Res. 2012;22(4):511–23. https://doi.
org/10.1177/1049732311421774 PMid:21908704
61 Brunton G, Paraskeva N, Caird J, Bird KS, Kavanagh J, Kwan
I, Stanseld C, Rumsey N, Thomas J. Psychosocial predic-
tors, assessment, and outcomes of cosmetic procedures: a
systematic rapid evidence assessment. Aesthet Plast Surg.
2014;38(5):1030–040. https://doi.org/10.1007/s00266-014-
0369-4 PMid:24962402
62 Alderman AK, Bauer J, Fardo D, Abrahamse P, Pusic A.
Understanding the effect of breast augmentation on quality
of life: prospective analysis using the BREAST-Q. Plast Re-
constr Surg. 2014;133(4):787–95. PMid:24675184
63 Lipworth L, Nyren O, Ye W, Fryzek JP, Tarone RE, McLaugh-
lin JK. Excess mortality from suicide and other external
causes of death among women with cosmetic breast
implants. Ann Plast Surg. 2007;59(2):119–123; discussion
124–15.
64 Figueroa-Haas CL. Effect of breast augmentation mam-
moplasty on self-esteem and sexuality: a quantitative
analysis. Plast Surg Nurs. 2007;27(1):16–36. https://doi.
org/10.1097/01.PSN.0000264159.30505.c9 PMid:17356451
65 Li S, Chen L, Liu W, Mu D, Luan J. Capsular contracture
rate after breast augmentation with periareolar versus
other two (inframammary and transaxillary) incisions: a
meta-analysis. Aesthet Plast Surg. 2018;42(1):32–37. https://
doi.org/10.1007/s00266-017-0965-1 PMid:28916908
66 Zelken J, Cheng MH. Asian breast augmentation:
a systematic review. Plast Reconstr Surg Glob-
al Open. 2015;3(11):e555. https://doi.org/10.1097/
GOX.0000000000000528 PMid:26893980 PMCid:P-
MC4727707
67 Berry MG, Stanek JJ. Brachial plexus impingement: an un-
usual complication of bilateral breast augmentation. Aes-
thet Plast Surg. 2008;32(2):381–82. https://doi.org/10.1007/
s00266-007-9055-0 PMid:18043961
68 Dragoumis DM, Assimaki AS, Vrizas TI, Tsiftsoglou AP.
Axillary silicone lymphadenopathy secondary to augmen-
tation mammaplasty. Indian J Plast Surg. 2010;43(2):206–09.
https://doi.org/10.4103/0970-0358.73453 PMid:21217983
PMCid:PMC3010785
69 Iorwerth A, Cochrane R, Webster DJ. Chronic haemato-
ma as a late complication of cosmetic breast augmen-
tation. Breast. 2000;9(3):158–60. https://doi.org/10.1054/
brst.1999.0117 PMid:14731841
70 Nagrani T, Neuman T, Baldari D, Zaher M, Lafferty J, Baglini
R, Kasabian A. Tamponade following breast augmentation.
Ann Plast Surg. 2010;64(2):141–43. https://doi.org/10.1097/
SAP.0b013e3181b0bb1f PMid:20098095
71 Johnson L, O’Donoghue JM, McLean N, Turton P, Khan
AA, Turner SD, Lennard A, Collis N, Butterworth M, Gui
G, Bristol J, Hurren J, Smith S, Grover K, Spyrou G, Krupa
K, Azmy IA, Young IE, Staiano JJ, Khalil H, MacNeill FA.
Breast implant associated anaplastic large cell lympho-
ma: the UK experience. Recommendations on its man-
agement and implications for informed consent. Eur J
Plast Surg. 2017;43(8):1393–401. https://doi.org/10.1016/j.
ejso.2017.05.004 PMID: 28596034
72 Srinivasa DR, Miranda RN, Kaura A, Francis AM, Cam-
panale A, Boldrini R, Alexander J, Deva AK, Gravina PR,
Medeiros LJ, Nast K, Butler CE, Clemens MW. Global ad-
verse event reports of breast implant-associated ALCL: an
international review of 40 government authority databas-
es. Plast Reconstr Surg. 2017;139(5):1029–039. https://doi.
org/10.1097/PRS.0000000000003233 PMid:28157770
73 Australian Breast Device Registry [website]. Canberra: Aus-
tralian Government, 2017 [Cited 1 January 2018]. Available
from: http://www.abdr.org.au.
Miller, Robinson, Reid, Hunter-Smith: Cosmetic breast augmentation in Australia: a cost of complication study

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AJOPS | ORIGINAL ARTICLE
Appendix 1
Code Description of procedure
Surgeon
Medicare
rebate ($AUD)
Surgical
assistant
rebate ($AUD)
30024 Wound of soft tissue, debridement of extensively infected post-surgical
incision
$326.05 $0.00
31551 Breast, haematoma, seroma or inflammatory condition including abscess,
granulomatous mastitis or similar, exploration and drainage of when
undertaken in the operating theatre of a hospital
$216.75 $0.00
45548 Breast prosthesis, removal of, as an independent procedure $276.80 $0.00
45551 Breast prosthesis, removal of, with excision of fibrous capsule $443.70 $0.00
45552 Breast prosthesis, removal of, with excision of fibrous capsule and
replacement of prosthesis
$638.65 $127.73
45553 Breast prosthesis, removal and replacement with another prosthesis
following medical complications (such as rupture, migration of the
prosthetic material, or capsule formation)
$638.65 $127.73
45554 Breast prosthesis, removal and replacement with another prosthesis,
following medical complications (such as rupture, migration of prosthetic
material, or capsule formation) where new pocket is formed including
excision of fibrous capsule
$699.45 $139.89
45555 Silicone breast prosthesis, removal of and replacement with prosthesis
other than silicone gel prosthesis
$638.65 $127.73
45557 Breast ptosis, correction of by mastopexy by any means (unilateral) $766.05 $153.21
45558 Breast ptosis, correction of by mastopexy by any means (bilateral) $1,148.95 $229.79
Author Year Patients (n) Calculated patient
years
Follow-up
years
Primary saline implants
Blount16 2013 402 482.4 1.2
Fagrell15 2001 20 150 7.5
Levi20 2008 325 1963 6.04
Stevens21 2005 324 1620 5
Walker17 2009 876 8760 10
Somogyi22 2015 515 772.5 1.5
Primary silicone implants
Araco19 2007 3002 18312.2 6.1
Basile23 2005 288 576 2
Blount16 2013 856 102 7.2 1.2
Brown24 2005 118 206.5 1.75
Caplin92014 1124 10116 9
Collis25 2000 53 530 10
Dancey26 2012 1400 8400 6
Giordano27 2013 330 660 2
Haws28 2014 321 321 1
Henriksen10 2003 971 1262.3 1.3
Holmich29 2007 190 3610 19
Hvilsom32009 5373 20417.4 3.8
Kjoller42002 754 5278 7
Appendix 2

Australasian Journal of Plastic Surgery Volume 1 Number 2 2018
64
AJOPS | ORIGINAL ARTICLE
Lista82013 440 528 1.2
Maxwell62015 492 4920 10
Namnoum52013 4412 14528 3
Niechajev30 2007 80 400 5
Pfeiffer31 2009 436 872 2
Sevin32 2006 210 1680 8
Spear72014 455 4550 10
Stevens11 2015 1116 8928 8
Stevens33 2010 211 506.4 2.4
Benito-Ruiz12 2016 373 1865 5
Doren34 2015 384 2035.2 5.3
Doshier35 2016 178 222.5 1.25
Drinane36 2016 55 143 2.6
Flugstad37 2015 2797 2797 1
Keramidas38 2016 180 180 1
Kerfant39 2017 156 288.6 1.85
McGuire40 2016 5059 20741.9 4.1
Somogyi22 2015 1024 1536 1.5
Revision silicone implants
Caplin92014 269 2421 9
Castello41 2011 49 98 2
Forster42 2012 230 1403 6.1
Grewal43 2013 134 134 1
Henriksen10 2003 119 154.7 1.3
Maxwell62015 156 1560 10
Spear72014 147 1470 10
Stevens11 2015 363 2904 8
Stevens33 2010 141 338.4 2.4
Doren34 2015 198 1049.4 5.3
McGuire40 2016 2632 6843.2 2.6
Author Year Patients (n) Calculated patient
years
Follow-up
years