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Recently, a 29-year-old mother was declared dead in Johor Bahru from a breast augmentation procedure that went tragically south. The swift death of the victim shook the aesthetic industry. Understandably, a heightened sense of suspicion towards breast-enhancing procedures soon followed, with many questions raised following the victim’s death coverage. 

Here at Artisan Aesthetic and Plastic Surgery, we sought the opinion of our in-house specialist, Dr Andrew Cheah, to better understand how a seemingly harmless procedure could have led to such an untimely demise. Below are pivotal events that transpired before her death. These are highlighted to provide clarity on the series of choices that led to this fatal outcome.

• On the 29th of July, the victim underwent a breast augmentation procedure at a residential premise. Injectables containing hyaluronic acid were injected into her breasts during the procedure. 
• The victim initially experienced symptoms of dizziness and discomfort after the procedure.
• On the 30th of July, her symptoms progressed to debilitating levels of pain in her chest, followed by swelling. 
• The victim visited a general practitioner who stated that improper use of an anaesthetic dose worsened her condition. The doctor then directed the victim to be admitted to the hospital. 
• The victim’s condition worsened, and she was transferred to the intensive care unit (ICU) for treatment. 
• The victim was declared dead on the 2nd of August. 
• Post-mortem is currently being conducted. Officials stated it would take up to 3 months to determine the exact cause of death. 

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Can a boob job lead to fatality?

This question has been gnawing in many’s minds since the victim’s death was publicised in the media. Is it actually possible? Yes. Statistically, cosmetic breast surgery has a mortality risk of 1 in every 72,000 procedures (0.0014%) [1]. These numbers, however, are attributed to surgeries done on frail and comorbid patients. This often happens when surgeries are conducted on patients without the awareness of underlying health conditions. 

In the case of the victim, even though the cause of death is yet to be determined, many negligent practices have taken place, which could all have led to her death. In other words, it is not that “boob jobs are fatal”, but like all procedures, whether minor or major, if left in the wrong hands and setting, could lead to death for anyone. 

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‍How did a boob job lead to death?

As previously mentioned, several factors contributed to the fatality; let’s take a look at what they are.

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1. Unlicensed practitioner 

The most blatant red flag, in this case, is that an unlicensed beautician conducted the procedure using unorthodox methods. Breast enhancement, otherwise referred to as Breast Augmentation, is a safe surgical procedure only when performed by trained surgeons. In Singapore, only board-certified plastic surgeons [2] are qualified to perform breast augmentation and other medical-grade [3] procedures. 

In the victim's case, an array of mistakes could have occurred, from an unsterile environment, anaesthesia malpractice, improper filler administration (wrong injection technique), lack of patient eligibility for procedure, use of wrong implant material, etc. The list is endless. 

This is not to say that breast augmentation procedures are entirely risk-free. In the hands of qualified professionals, timely treatment would be administered to prevent fatalities due to the surgeon’s extensive knowledge, experience, and skills in risk management. Risks involved with implant-based breast augmentation procedures include:

• Infection
• Bleeding
• Pain and discomfort in chest and breast 
• Altered sensation in breast and chest 
• Scar tissue that distorts the shape of the breast implant (capsular contracture)
• Implant position changes
• Implant leakage or rupture

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2. Unsterile environment, devices, and practice

In this specific case, the procedure was conducted in a residential set-up, making it the next glaring red flag. Houses are not hygiene-compliant environments for invasive procedures such as breast enhancement. Based on reports of symptoms exhibited by the victim, it is highly likely she had sepsis [4] shock, also known as “blood poisoning” from an infection. 

Medical procedures must be conducted in a sterile and hygienic environment with stringent aseptic techniques [5], such as clean instruments and rooms and approved sterile medical implants. The lack of a sterile environment exposes patients to bacteria, viruses, and a whole host of other potential germs that will undeniably increase the risk of mortalities. 

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3. Hyaluronic acid and its increased risks of complications

It was also reported that the victim had received hyaluronic acid injectables for her breast enhancement procedure. Hyaluronic acid [6] is a naturally occurring substance that can be found in your body. It is also manufactured as a medical-grade injectable material for various indications, including alleviation of knee conditions, hydration of skin, and volume augmentation in dermal fillers. 

However, hyaluronic acid is not indicated for breast augmentations in Singapore for safety reasons [7]. Many findings [8] have shown hyaluronic breast fillers as harmful, the dangers of which include: 

• Increased risk of infections: a large amount of hyaluronic acid (80-100 times more than facial treatments) is required for breast enhancement procedures. Subsequently, an increased risk of infection is present, especially in a non-sterile environment. Additionally, where infections occur, it will be difficult to remove the infected, multi-layered filler, unlike a single breast implant. Consequently, the spread of infection progresses rapidly, poisoning the bloodstream. 
• Increased risk of injury to vital organs: with fillers, operators cannot visualise some of the critical deep structures. In the case of the breasts, sensitive organs like the lungs and heart, which are situated just behind the breasts, have risks of injury if injectables are performed wrongly. 
• Risk of local anaesthetic agent overdose: many hyaluronic acid fillers on the market contain lignocaine as a local anaesthetic agent. In small and clinically safe amounts, lignocaine helps to alleviate discomfort during an injection. However, in the case of inappropriate use with large amounts, it may result in an overdose that is potentially dangerous or fatal.
• Migration of fillers in the breast: breast fillers tend to migrate away from the breast footprints [9], subsequently causing deformities and complications [10] involving the formation of abscesses and swollen lymph nodes. Studies [11] have found that the fillers may even diffuse into the gland through the breasts and into the lymphatic system, increasing risks of inflammation, enlarged lymph nodes [12], and granuloma [13] formations. 
• Impedes breast cancer surveillance: if the fillers are poorly placed and cause undue changes to the breast tissue, it may complicate the patient's subsequent breast cancer surveillance. Thus, this results in unnecessary investigations and treatment. Breast fillers also obstruct early detection of malignancy, a factor that is pertinent in the survivability rate of cancer. 

However, it is important not to vilify hyaluronic acid altogether. Hyaluronic injectables for aesthetic indications are widely accepted as safe when applied with good anatomical knowledge and informed suitability to address specific issues such as dermatological/skin problems. Overall, it is still considered safe and continues to be allowed by health authorities worldwide. To summarise, hyaluronic fillers are safe, provided they are used appropriately in the right amounts and areas. 

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Are Singaporeans free from the dangers of unlicensed operators?

Thankfully, Singapore does not have a serious prevalence of unlicensed operators in Singapore. The laws in Singapore are appropriately stringent to safeguard patients’ safety. However, that in itself may not be sufficient to protect Singaporeans from disastrous outcomes. 

Many Singaporeans have reportedly sought low-cost aesthetic treatments from overseas operators [14] or just across the causeway. Even within our borders, there has been coverage of unlicensed [15] operators luring patients with tempestuous prices.  

Even as a globalised and affluent nation, Singapore is still at risk of illegal operators peddling their trade [16]. If Singapore does not maintain a vigilant stance in our enforcement and regulation, there may come a day when something similar may happen here, too. You should always seek qualified professionals for any form of medical-grade procedures, fillers, lasers, or surgery. 

Whilst beauticians, therapists, and estheticians are essential spa and wellness industry members, they are only allowed to perform non-invasive aesthetic treatments. Any form of injection or surgery is generally prohibited. Consumers need to be discerning and careful when considering aesthetic treatments.

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How to safely conduct breast augmentation procedures? 

The breast enhancement options approved and available in Singapore are silicone implants [17] and autologous fat grafting [18]. Both these options are deemed safe with low risks of complications. It is still important that these options are conducted with good patient selection, modern techniques, licensed facilities, approved implants, and in the hands of a board-certified plastic surgeon. 

Anyone interested in breast augmentation should start with a well-informed consultation to explore whether the procedure is appropriate and safe for them. Your doctor will weigh risk factors [18] and the appropriateness of the procedure with preparations for potential complications accordingly. 

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Conclusion 

Where unorthodox techniques, unsafe devices, unclean facilities, or lack of qualifications are involved, the chance of complications and even death is undoubtedly high. Therefore, it is not the procedure itself that caused the victim’s demise, but ultimately, the procedure performed by an unlicensed practitioner that exposed her to deadly risks. 

To surmise, breast enhancement procedures are safe in the right hands. Qualified medical practitioners and approved devices, techniques, and substances are pivotal in ensuring the safety of breast enhancement procedures. The pursuit of an enhanced self should not be scrutinised. However, patients must do their due diligence when seeking the best provider to conduct medical procedures. 

The cost for many invasive procedures is justified as high standards in practice can be costly. Attempting to seek low-cost procedures can be a fatal mistake. Regulatory bodies and authorities are important in safeguarding patients and maintaining the integrity of invasive procedures. Please protect yourself with appropriate information and discretion before pursuing any invasive surgery. Whilst beauty can be painful, it should never be deadly. 

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References 

1. Wixtrom, R.N. et al. (2020) Device-specific findings of imprinted-texture breast implants: Characteristics, risks, and benefits, Aesthetic Surgery Journal. Available at: https://pubmed.ncbi.nlm.nih.gov/31121016/ (Accessed: 29 August 2023).
2. Singapore Medical Council (2022) SMC: Guidelines on Aesthetic Practices for Doctors, Guidelines. Available at: https://www.healthprofessionals.gov.sg/smc/guidelines/guidelines-on-aesthetic-practices-for-doctors-(2016-edition) (Accessed: 29 August 2023).
3. Division of Healthcare Quality Promotion (DHQP) (2023) What is sepsis?, Sepsis. Available at: https://www.cdc.gov/sepsis/what-is-sepsis.html (Accessed: 29 August 2023).
4. WebMD Editorial Contributors and Brennan, D. (2021) What to Know About Aseptic Technique, WebMD: A to Z Guides. Available at: https://www.webmd.com/a-to-z-guides/what-to-know-about-aseptic-technique#:~:text=Sterile%20technique%20is%20used%20in,Surgical%20aseptic%20technique. (Accessed: 29 August 2023).
5. Cleveland Clinic Medical Professionals (2022) Hyaluronic acid: What it is, benefits, how to use & side effects, Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/articles/22915-hyaluronic-acid (Accessed: 29 August 2023).
6. Jeyaratnam, J. and Joethy, J. (2021) Dangers of filler breast augmentation, Plastic and reconstructive surgery. Global open. Available at: https://pubmed.ncbi.nlm.nih.gov/34849315/ (Accessed: 29 August 2023).
7. Hedström, K., Sackey, H. and Delgado, A.F. (2022) Filler injection for breast augmentation - potentially harmful injections, Lakartidningen. Available at: https://pubmed.ncbi.nlm.nih.gov/35332516/#:~:text=The%20filler%20can%20cause%20breast,and%20require%20several%20surgical%20treatments. (Accessed: 29 August 2023).
8. McCleave, M.J. (2009) Is breast augmentation using hyaluronic acid safe?, U.S. National Library of Medicine. Available at: https://pubmed.ncbi.nlm.nih.gov/19967357 (Accessed: 29 August 2023).
9. Sackey, H.S., Hedström, K.H. and Falk-Delgado, A. (2022) Breast augmentation with fillers can cause serious complications, Läkartidningen. Available at: https://lakartidningen.se/klinik-och-vetenskap-1/kommentar/2022/03/brostforstoring-med-fillers-kan-ge-allvarliga-komplikationer/ (Accessed: 30 August 2023). 
10. Trignano, E. et al. (2020) Complications after breast augmentation with hyaluronic acid: A case report, Gland Surgery. Available at: https://gs.amegroups.org/article/view/54727/html (Accessed: 30 August 2023). 
11. Mayo Clinic Staff (2021) Swollen lymph nodes, Disease and Conditions. Available at: https://www.mayoclinic.org/diseases-conditions/swollen-lymph-nodes/symptoms-causes/syc-20353902#:~:text=Swollen%20lymph%20nodes%20usually%20occur,ability%20to%20fight%20off%20infections. (Accessed: 30 August 2023). 
12. Cleveland Clinic Medical Professional (2023) Granuloma, Cleveland Clinic: Available at: https://my.clevelandclinic.org/health/diseases/24597-granuloma (Accessed: 30 August 2023). 
13. Linette Lai, L. (2016) Singapore residents scarred after Botched Plastic Surgery in South Korea, The Straits Times. Available at: https://www.straitstimes.com/singapore/health/singapore-residents-scarred-after-botched-plastic-surgery-in-south-korea (Accessed: 30 August 2023). 
14. South China Morning Post (2023) Singapore sees rise in cheap botched aesthetic procedures, Southeast Asia. Available at: https://www.scmp.com/news/asia/southeast-asia/article/3224510/cheap-botched-aesthetic-procedures-rise-singapore (Accessed: 29 August 2023).
15. Wee, G. (2023) Cheaper prices, peer influence fuelling demand for illegal home-based aesthetic services; experts warn of botched procedures, TODAY. Available at: https://www.todayonline.com/singapore/illegal-home-based-aestheticians-lip-reduction-botched-procedures-2195016 (Accessed: 29 August 2023).
16. Jones, B. (2022) How Silicone Is Used in Breast Implants, Verywell Health. Edited by M.M. LoTempio. Available at: https://www.verywellhealth.com/what-is-silicone-2710059 (Accessed: 29 August 2023). 
17. Turner, A. et al. (2020) Fat Grafting in Breast Reconstruction, U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023975/ (Accessed: 29 August 2023). 
18. Valente, D.S. et al. (2021) Risk factors for explantation of breast implants: A cross-sectional study, U.S. National Library of Medicine. Available at: https://pubmed.ncbi.nlm.nih.gov/33649754/ (Accessed: 29 August 2023).