Richard V. Dowden, M.D., C.M., F.A.C.S.

Certified by the American Board of Plastic Surgery

Cosmetic and Plastic Surgery, Inc.
6770 Mayfield Road, Suite 410
(Mayfield Heights) Cleveland, Ohio 44124
(440) 449-7470


Answers to Frequently Asked Questions about
breast enlargement:

Can implants slosh, gurgle, or make other sounds?

Yes, but usually this is only in the first few weeks or months after operation. OK, here it is, more than you probably ever imagined you wanted to know about noises emanating from breasts! If you are interested in the definitive article, the reference is: "Bourdonnement and other benign temporary breast implant sounds", Annals of Plastic Surgery, Vol 43 p589, 1999.

A wide variety of sounds can emanate from the implant-augmented breast in the early postoperative period. Some of the sounds can be avoided or minimized by intraoperative techniques. These sounds are virtually always benign, and temporary. Nevertheless, they can be worrisome to patients, and the plastic surgeon needs to be able to reassure the patients about the fact that these sounds do not signify a leaking implant or other problems.

These sounds can include a wide variety: popping, crackling or crepitation, swishing, sloshing or gurgling, and squeaking, rubbing, humming or vibrating. None of them are obvious and all require quiet conditions to hear. Some are difficult to describe adequately using English vocabulary. Due to their totally benign nature, the source of these sounds has not been anatomically clarified, but reasonable conjecture is probably enough for such conditions that do not require treatment. Nevertheless, patients are understandably alarmed by sounds emanating from their breasts, and it is helpful for the surgeon to be able to discuss them, and to reassure the patient of the lack of long term significance of the phenomenon.

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Popping:

Popping is caused by residual air in the pocket adjacent to the implant. With pressure or certain movements, or even deep breathing, popping is felt and heard by the patient. This seems to be due to an air 'bubble' adjacent to the implant being forced to move from one area to another, through a tight zone. Patients may worry that they have popped a stitch or broken the implant. Popping can be minimized by evacuating all air from around the implant by using a temporary catheter just prior to closure. If present, popping will disappear in a few days as the air is absorbed. (Another type of popping is that which occurs with a closed capsulotomy, a harsh sound signifying separation of the fibrous scar capsule. This is occasionally heard during forceful compression massage by the patient, and is of course transitory, not continuous, and requires strong pressure to elicit.)
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Crackling or crepitation:

Crackling or crepitation occurs immediately post operatively, and often is detectable in the operating room. It is basically just subcutaneous air caused by the implant or expander having forced some air from the developing pocket out into the surrounding tissues. It is a painless crackling sensation mostly felt by palpation, but it can also be heard under quiet conditions. For some reason, patients imagine that this signifies leaking of the implant, which it does not. Crepitation can be minimized by using a small temporary catheter to permit air escape from the pocket during inflation, although that may not always be practical. In the absence of other concomitant signs, crepitation alone does not signify infection nor pneumothorax, and will be gone in several days as the air absorbs. Crepitation alone does not signify the need for a chest xray. Of course it is theoretically possible that any operation could result in subcutaneous infections that produce crepitation, but this extraordinarily rare event would take time to develop, and would be accompanied by signs of severe illness.
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Swishing, sloshing or gurgling:

Swishing, sloshing or gurgling requires an air/fluid interface. For some reason patients worry that it signals their implants are leaking, which it does not. Sloshing can originate from either outside or inside the implant.

Outside the implant, sloshing originates from an air-fluid level in the pocket external to the implant. This of course requires the presence of both residual air, and fluid such as seroma, and is likely to be somewhat position-dependent. Obviously this necessitates a pocket somewhat larger than the implant. Using suction just prior to closure can minimize this type of sloshing. This sound should disappear within a few weeks as the seroma and air are absorbed.

Sloshing from within the implant is limited to saline-filled implants, and means that not all air was removed from with the implant. This is likely to be position-independent and will be absorbed within a few weeks to months depending upon the amount of air, since oxygen and nitrogen can transfer through the silicone rubber membrane. Residual air within the implant can be minimized by adding some saline to the empty implant before evacuating the air and saline while rolling the implant for insertion as previously described for certain insertion methods. The saline displaces the tiny amount of air that would inevitably remain inside the implant. Since adopting this practice in 1992, I have had no patients with such sloshing. Pre-filled implants would of course not be subject to internal air, but they have their own disadvantages. With both the internal and external sloshing, the small amount of air is of no concern regarding air travel or scuba diving and do not indicate the need to restrict either activity.

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Squeaking, rubbing, humming or vibrating:

Squeaking, rubbing, humming or vibrating, which I have termed "Bourdonnement" is alarming to patients and apparently not uncommon, and is reported often on implant-related Internet discussion forums. This strange sound-sensation is difficult to describe using English vocabulary. Patients tend to use combinations of words such as "a buzzing hum" or " a squeaking-rubbing" or "sort of a noisy feeling". A number of medical terms have been taken from other languages when English lacked the precise word. At a meeting in 1997, a group of French-speaking surgeons suggested that the word "bourdonnement" best describes this sound-sensation phenomenon, and is the word I use in discussion with patients.

Bourdonnement is elicited by moving the implant slowly from side to side, and is dependent upon how strongly one presses the implant against the ribs, as it is absent if the pressure is either too great or too little. The sound, reminiscent of a squeaking door hinge, is quite faint and may require a stethoscope for the surgeon to hear. Usually the surgeon and patient can feel a faint vibration, like a hum, as the sound is produced.

Up to June 1999 I had encountered this phenomenon in 11 breasts, usually unilateral, sometimes bilateral (not necessarily synchronous), and may have missed other unreported or brief episodes. Furthermore, I have been tabulating statistics on this only since mid 1996 when it was first brought to my attention. Onset ranged from postoperative day four to day 30. Duration varied from one to nine weeks.

I use both smooth and textured implants, in both prepectoral and subpectoral planes, inserting them through all four standard incision sites (inframammary, areolar, umbilical, and axillary). I have found bourdonnement only with subpectoral smooth saline implants, but it appears to be independent of implant manufacturer, valve style, and size; the frequencies are proportionate to my use of the various types of smooth implants. Most of my subpectoral implants have been textured, so only a small number have been smooth, specifically 108 between June 1996 and June 1999. The 11 instances of bourdonnement from the group of 108 smooth subpectoral implants placed during the three-year period in question indicate about 10% incidence.

Bourdonnement has not been encountered with inadequately filled implants, but I usually fill to the optimum (i.e. with overfill as required to minimize wrinkling). It is reasonable to infer that the phenomenon requires the firmness of an optimally filled implant. It should be noted that in my practice, smooth sub-pectoral implants contain no steroids, antibiotics, or antibacterials, nor are any of these substances placed within the pocket; perhaps doing so might prevent the occurrence. I rarely use drains in this setting, and none of the patients experiencing bourdonnement had drains used. There was neither positive nor negative association with Mondor's cords.

One can only guess at the precise source of the sound. One patient said the sound was similar to "squeaky clean hair", and that may be an excellent analogy, as one can readily visualize the fresh implant surface rubbing against the recently exposed clean firm surface. Presumably the phenonomen disappears only after a sufficiently slick serous exudate begins to form to reduce friction between the surfaces. There has been no noticeable capsular contracture in patients who exhibit this transient phenomenon, but the numbers are too small to justify any conclusion in that connection.

Not knowing the cause makes prevention elusive. One might expect, however, that irrigating the pocket with a slippery substance such as an iodophor or other such antibacterial might make local conditions unfavorable for the occurrence of bourdonnement. I would be pleased to hear from others who have encountered this phenomenon.


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