The ailments listed on Nikki Carruthers’ medical chart read as follows: blackouts, memory loss, fainting, vomiting, thyroid problems, angina, hypertension, heart palpitations, high-blood pressure, migraines, chest pain, ulcers, depression, anxiety and exhaustion that keeps her in bed for at least 18 hours a day.
Carruthers, 29, had barely seen the inside of a doctor’s office until 2013 when she decided to get breast implants. The cascading health issues that followed have triggered dozens of hospital and doctor visits.
“My entire body was shutting down,” says the Winnipeger, who has been unable to work since July. “My throat is burning and hurts to swallow. It feels like someone is sitting on my chest when I try to breathe.”
The promotional machine driving the $1-billion international breast implant industry runs on tastefully lit, aspirational images of perfect bodies, glowing testimonials and inspirations from celebrities — but provides little mention of the potential risks, a Toronto Star/CBC Marketplace investigation, in partnership with the International Consortium of Investigative Journalists, has found.
Carruthers is among the increasing number of women across Canada who suffer health complications they believe are associated with their breast implants. They also believe they were misled by surgeons who reassured them that the health concerns of the 1990s were addressed more than a decade ago.
Breast implants are the most popular cosmetic surgery in the world with 10 million women opting for the devices during the past decade. Most have not reported adverse health issues and some studies point to high satisfaction rates.
There remains no straight line, cause-and-effect linking breast implants directly to auto-immune illness, known as breast implant illness. Recent research, published in respected medical journals and conducted over the past decade, is raising concerns that information about autoimmune illnesses is often not communicated to women considering the procedure.
The Star has interviewed nearly two dozen women who have health issues they attribute to their breast implants, including three with a rare cancer known as BIA-ALCL. All of them said their surgeons provided few warnings about the known risks.
Read More from The Implant Files:
A review of 25 websites belonging to plastic surgeons in the Toronto area show plenty of alluring images but little detail on the adverse outcomes proven to be associated with breast augmentation.
Undercover visits to three Toronto plastic surgeons by a CBC Marketplace researcher who posed as a prospective patient revealed sales techniques, some of which a leading medical ethicist called “very problematic.”
Since Monday, the ICIJ has heard from more than 540 women responding to an online callout for responses to the global series of stories on breast implant health issues. Among the 45 Canadians are women complaining of infections, hair loss, body inflammation, muscle weakness, trouble breathing, neurological issues, suicidal thoughts, autommune symptoms and implant rupture.
A recent Penn State survey of 824 North American plastic surgeons found that while 87 per cent discussed BIA-ALCL with their patients, 30 per cent did not include it as a risk on consent forms.
“It’s really disappointing,” said Dr. Donald Mackay, associate chair of surgery at Penn State Hershey. “There are clear guidelines as to the potential risks. Maybe you could write it off to lack of knowledge. But by now they really should know. The warnings are out there.”
At age 23, unhappy with her body image, Carruthers came up with $6,300 — financed through a line of credit — for breast augmentation.
It seemed safe and easy. Her doctors said little about medical risks beyond the standard warnings associated with any surgery.
“It was made to seem like getting a haircut,” she said. “He told me there were only very minor cosmetic risks which he would fix in a touch up procedure should something go wrong. He told me the new implants were lifetime devices, you could cut them in half with a knife, and the silicone material would not spill out and these implants rarely ever rupture.”
The message on the plastic surgery websites she visited were full of promises of confidence and perfection.
“I was like, ‘okay…I just need the confidence….You have to look like that or you’re nothing…Most plastic surgeons, they’re feeding on our insecurities. They’re feeding on our vulnerabilities,” she said.
Any excitement about her new body was soon undermined by health problems, said Carruthers.
She had the implant surgery in 2013 and just more than a year later she had a second surgery to relieve the severe pain in her chest. The implants had bottomed out and dropped too low on her chest.
“I was completely convinced that it was the best thing that I could have done for myself,” she says. “I thought, ‘I am fixing a problem that’s fixable.’ Safe. Everybody who’s famous is doing it…They have everything in the world they could possibly want. They have every guy wanting them.”
There is no standard script plastic surgeons use to inform patients of the risks. And each physician has their own approach.
They can vary widely.
The researcher sent by CBC Marketplace, who posed as a prospective patient, asked about recovery time at the three clinics she visited and the answers ranged from 24 hours to six weeks.
“We can get you out to dinner the night after surgery, we can get you to the beach the next day,” Dr. Mahmood Kara told the journalist who recorded with a hidden camera.
How? “You don’t have to understand, just need to know that I can deliver, and I’ve done it on thousands of patients.”
University of Toronto bioethicist Kerry Bowman says that response fails to provide the understanding necessary for the patient to have informed consent.
“That would worry me, because you do need to understand,” said Bowman. “Ethically and legally…you have to have a capable patient and she needs to fully understand and appreciate all of the risks.
The presentation of medical risks associated with breast implants are also a matter of concern.
During the consultation, Kara gave a detailed explanation of known health risks associated with the procedure, including rupture and potential hardening of the implants.
On his website, Kara calls it a “myth” that implants leak into the body if they are ruptured.
“In the unlikely event that the implant breaks, the silicone would not in fact leak into your body. The silicone would remain together in a mass,” it reads. “Despite some reports of illness resulting from implants, the science has proven that these are anecdotal at best and that there is no link between implants and autoimmune diseases and no increase in breast cancer as a result of breast augmentation.”
Dr. Jan Willem Cohen Tervaert, director of the rheumatology at the University of Alberta’s medical school and a co-author of several studies detailing connections between breast implants and autoimmune illnesses, says that advice is challenged by research.
“There are plenty publications demonstrating leaking of silicone with new implants,” he says. “Patients have a specific pattern of complaints and complications not dissimilar from fibromyalgia (commonly described as feeling pain throughout the body)…We demonstrated that fibromyalgia-like symptoms disappeared or ameliorated after explantation.”
Kara declined repeated interview requests.
At the clinic of plastic surgeon Dr. Martin Jugenburg — known as Dr.6ix on his website — the journalist asked for a copy of the consent form she had to sign before making the decision and providing a $2,000 deposit to book the surgery.
“I don’t think I’m allowed to do that for some reason,” a clinic nurse said who later provided the consent form.
“I’m amazed that there’s so much push back on getting the consent forms,” Bowman said after reviewing the footage. “I think asking to pay in advance is very problematic from an ethical point of view.”
In a written response, Jugenburg said his clinic does not require patients to pay in order to view or receive consent forms.
“This was not clear during your researcher’s visit, and as a result of your feedback, I made sure in the future there will be no confusion.”
The overwhelming majority of plastic surgeons’ websites contain testimonials and “before and after” images that appear to breach provincial legislation and Ontario College of Physicians and Surgeons policies.
“Where we have been alerted to the use of before and after photos in the past, we have held that they constitute testimonials in contravention of the regulation,” said college spokesperson Shae Greenfield.
Among the physicians cited by the college for advertising breaches are Kara and Jugenburg.
Last year, the college cautioned Kara for using before-and-after photos in a magazine advertisement.
“Given his repeated breaches of advertising policy and regulation, the (college complaints) committee was not satisfied that he would change his behaviour without further guidance,” the decision reads.
But prominently featured on his website today are more than 260 before-and-after photos of plastic surgery procedures.
Jugenburg is currently facing a disciplinary hearing before the college which alleges he committed professional misconduct for advertising methods, including permitting a film crew into a surgical procedure without the patient’s consent, making “improper” use of her images and posting “pre and post-operative images of her on his social media accounts without her consent,” along with “pressuring her to follow and contribute to his social media accounts.”
In a written response, Jugenburg said the allegations are “denied and being defended.”
The use of before-and-after photos is “widespread” in medicine, he wrote, adding the images provide, “pertinent information to the public, as patients increasingly perform their own research on the Internet, demand more transparency … and more self-directed decision-making ability.”
Jugenburg’s website currently has more than 250 before-and-after images for a variety of plastic surgery procedures.
Some plastic surgeons shun the practice of posting before-and-after images.
Toronto plastic surgeon Dr. Leila Kasrai explains on her website why she does doesn’t: “Due to the advertising regulations of the College of Physicians and Surgeons of Ontario imposed on all doctors in Ontario, we cannot display photos and testimonials of our patients,” it reads.
At a third Toronto clinic, Dr. Sean Rice provided a detailed explanation of health risks and cited medical evidence.
Later, his assistant offered the journalist a surgical date for the next day.
“Next week is fine, you can also do tomorrow if you want,” the woman said.
Bowman, who reviewed the exchange, called that “way too fast.”
“You percolate as we all do as human beings with any major decision in our life,” he says. “A patient (is) thinking through these types of things and I found it interesting that — just emerged out of nowhere — there’s an opening tomorrow.”
In a written response, Rice said the journalist “requested breast implant surgery the next day. I did not pro-actively offer surgery the next day.
“I want to ensure all patients fully understand risks associated with their surgical procedure. I offer an opportunity to discuss the consent form after review to allow any follow-up questions before surgery. Patients deserve time to evaluate and question a consent from before endorsing.”
Worsening symptoms eventually led Nikki Carruthers to undergo a third breast surgery in September: This time, to have them removed — against the advice of her surgeon.
“(He) said there’s no proof implants can make you sick as he chuckled in his office,” Carruthers said. “I feel like I have been through World War Three with my own body, fighting with these professionals to believe me.”
When they came out, a discovery: The right implant had ruptured and both implants showed capsular contracture — the formation of hard, often painful scar tissue around the implants, according to an analysis of the removed implants by Pierre Blais, a former Health Canada senior advisor and chemist who runs an Ottawa company that tests the devices.
“This type of rupture is common and indicates…material fatigue,” the report reads. “It is not the outcome of trauma or accidental…damage.”
While the left implant was not ruptured, it showed “errors in fabrication and/or formulation of the shell material.”
In an interview, Blais said Carruthers’ right implant rupture (which “broke into four parts”) is hardly unique.
“When you look at the instructions for use for a product like this, and all the competitors, it says a rupture may happen,” says Blais. “It’s not really right. They should say a rupture will happen. It depends how long you have it.”
Carruthers said the findings were a vindication.
“My instincts were correct. I was not going insane.”
A liver tumour has shrunk since the explant. But she has yet to return to work due to pain and fatigue, cognitive impairment, tremors and auto-immune illnesses.
“I can only imagine how many women are out there right now…having no idea what’s wrong, feeling hopeless and crazy…The whole thing makes me sick to my stomach every time I think about it.”
With files from Makda Ghebreslassie, CBC Marketplace and Sasha Chavkin, ICIJ
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