Breast Augmentation (Breast Enlargement) with Implants

BREAST AUGMENTATION, also known as augmentation mammaplasty, is one of the most frequently performed cosmetic surgery procedures worldwide.
It is a surgical procedure to enhance the size and shape of a woman's breast/s. Mostly, the surgery is performed to increase the size of both breasts in women who have small breasts or who want larger breasts.

Underdevelopment of the breasts, ageing, pregnancies, breast-feeding and gravity all contribute to small or sagging breasts. The breasts of these women can be improved by breast augmentation, which results in a lifting and a filling of the breasts. Sometimes this kind of surgery may be accompanied by a tightening of skin to further lift the breast: a mastopexy. This may need to be done as a secondary procedure 6-9 months later.

Most women have some minor degree of breast asymmetry. In some women breast asymmetry may be extreme, while others may have a particular condition such as Poland's syndrome or tuberous breasts. Differential breast augmentation, or tissue expansion can be used to correct asymmetry. In addition, breast implants can be inserted as one form of breast reconstruction following mastectomy for cancer.

A breast augmentation procedure always leaves a scar, as the implant has to be inserted through an incision. The incision can be placed in the armpit (trans-axillary), around the areola (dark skin around the nipple) or in the crease underneath the breast (infra-mammary).
All patients develop a thin capsule (scar) around the implant. In most cases this is thin, pliable and not noticeable. Some patients will, however, with time, develop a capsular contracture which can leave the breasts hard and misshapen. In this group of patients, the capsule may require removal and the implant may need replacing. It is important to know that further breast surgery in the future is likely e.g. to replace the implants or for attention to the capsule.

Despite these potential problems, breast augmentation remains one of the best plastic surgery operations and most patients are very happy. The surgery is quick and safe, the results predictable and immediate and the recovery quick and relatively pain free.

Initial Consultation

At your first visit, your suitability for the procedure and your fitness for surgery will be assessed. Your breasts will be examined. If your breasts are sagging, a breast lift (mastopexy) may be recommended.

It is frequently difficult to decide on what size implant is required. Women will often state that they want to go from a B to a C cup, but this does not help in deciding what size implant you will need. Bra manufacturers frequently vary in what they define as a particular cup size and one manufacturer's C cup might be another's B or D cup. Surgeons define implant size in millilitres (1 ml = 1 gram). Although looking at pictures of women with similar breasts to yours and what you want may be helpful, there are also pitfalls with this method. Putting a sizer in the bra is also helpful although, again, once implanted under your breast, the effect may be slightly different. A plastic bag or nylon stocking filled with rice to your required breast size can make a useful sizer and allows you to measure at home what volume you want.

Currently there is some debate regarding conventional round vs. anatomical implants. Anatomical implants are teardrop shaped: thinner above and thicker below. They need to be placed precisely - if they rotate their effect is the exact opposite of what is intended. Anatomical implants are about one and a half times pricier than round implants. During the initial consultation Ms Grob will discuss with you what shape of implant is best suited for you. Most women need a bit of volume above (especially older patients with empty breasts).

Preoperatively it is important that you understand the procedure and what it can achieve. You should be aware of the risks and complications. All your questions should be answered. A well-prepared patient will do better with surgery and will be more satisfied with the final result.

Safety of silicone gel-filled implants

The current view of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), the American College of Rheumatology, the Centre for Disease Control and the American Medical Association is that there is no relationship between silicone breast implants and any disease process, and this view has also been formally expressed by the American Food and Drug Administration (FDA).

Silicone gel filled implants still give the most natural look and feel and I believe them to be the best form of augmentation.

Surgery

My usual method of breast augmentation is described below. I will vary this surgery according to patient's individual requirements, but I find the method below provides me with excellent results in the majority of patients. I will give alternative options to my protocol and reasons for doing what I do.

Surgery is usually performed under general anaesthetic with a one night postoperative stay. On arrival on the morning of surgery, you will meet the anaesthetist and I will mark the incision lines and various other landmarks on your skin with a pen. I will also take pre-operative photographs at this stage.

I prefer to use an incision in the crease underneath the breast (infra-mammary), which leaves a well-hidden scar. This incision lies within the natural body crease line and therefore heals up very well and usually becomes inconspicuous with time. It allows good exposure to create an adequately sized cavity to accept an implant and, very importantly, it allows excellent visualisation of any bleeding points, which can then be controlled. Silicone gel implants are placed through the incision with ease, although saline implants can be inserted via this incision as well. Other incisions - in the armpit (axillary) or at the edge of the pigmented tissue around the nipple (areolar) or umbilical (belly button) - make the procedure more difficult and longer. Visualisation of the cavity is less good and control of bleeding is less precise. The incision in the armpit can form unsightly scars that may be visible in an evening dress, vests, short sleeves, etc. The incision around the areola usually provides very limited access, which allows insertion of only small implants. Incisions in the belly button vastly overcomplicate a relatively simple procedure for very little benefit - the implants frequently are placed too low and the risk of complications is higher.

Through the incision a pocket is created either in front of or under the chest wall (pectoral) muscle (so called sub-muscular placement). If you have sufficient breast and subcutaneous tissue then placing the implant right underneath the breast tissue creates a normal looking breast with good cleavage and breast shape. If however you are very thin with not much natural breast tissue or subcutaneous tissue then it is more sensible to place the implant in a sub-muscular pocket. The edges of the implant are then less visible. This is also associated with a reduced risk of capsular contracture and less interference with mammogram examinations. We will discuss which option may be best for you.

Once the pocket is created, I ensure that any bleeding point is controlled. I wash out the cavity with an antiseptic solution and place the implant. I generally use textured (as opposed to smooth) surfaced implants because the capsular contracture rate is lower. I use silicone gel filled implants rather than saline implants as the feel and consistency of silicone is infinitely better than saline; the implants do not slosh or wrinkle and I believe that currently there is no better alternative to silicone gel.
Following placement, the incisions are closed with dissolving sutures and a light dressing is applied. I usually place drains (small plastic tubes coming out from under the implant to remove any excess fluid or blood) which stay in for 24 hours.

The surgery takes approximately one hour. After surgery, you will be transferred to the recovery area and then back to the ward.

Post-Operatively

When you awake from surgery in the recovery area, you should be relatively pain free. As the local anaesthetic wears off, you may feel a little sore, but painkiller medication will be prescribed. On the first postoperative day you should be up and about, and shower. Your breasts will be a little swollen and bruised. The swelling and bruising take about three weeks to settle, but enough of the swelling will be down by the end of the second week to allow you to go shopping for a new bra.

I will see you one week post-operatively for your first visit. Following this, you should slowly get back to normal (about 7 to 10 days off work, and 6-8 weeks off sport). It is advised that you are able to fly short haul 2 weeks after the operation and that you can fly long haul 4-6 weeks post-operatively.
Massaging the scar with an aqueous cream helps them to settle.
Some numbness in the breast and particularly the nipple may be noticed for the first few weeks after surgery. Hypersensitivity can also occur. Both are usually transient.

If you have small children at home you will certainly need help for the first week. With regards to driving, I usually advise a similar period (1 week) of no driving but again this is very personal and some people recover very quickly and can get back to driving in a short time. You should be able to return to work within a week or two, depending on the level of activity required by your job. Your breasts will probably be sensitive to direct stimulation for two to three weeks, so you should avoid much physical contact. Physical exercise can resumed generally after 6 to 8 weeks.

Risks and complications

Breast augmentation is a relatively straightforward procedure. As with any surgery, however, there are certain risks and complications. It is important to understand what these are.

  • Bleeding, As with any surgical procedure, excessive bleeding following the operation may cause some swelling and pain. If excessive bleeding occurs, another operation may be needed to control the bleeding and remove the accumulated blood (haematoma).
  • Seroma, This is a build-up of fluid around the implant. The body can reabsorb a small amount of fluid. If there is a larger amount there could be a need for surgical intervention.
  • Infection, A small percentage of women develop an infection around an implant. This may occur at any time, but is most often seen within a week after surgery. A postoperative temperature and local redness, warmth and pain of the breast are signs that may indicate the beginning of an infection. Sometimes this can be controlled with the use of antibiotics, but in other cases the implant may need to be removed. A new implant will be inserted at a later date when the infection has resolved completely.
  • Capsular Contracture, When breast implants or any other foreign material are placed into the body, the body forms a lining around it. This lining or foreign body capsule is formed by the body’s own tissues. Many refer to this lining as the “tissue capsule” or “scar capsule”, although it is not exactly the same as scar tissue. This is the body’s natural response to foreign material. Capsular contracture is one of the most common complications following breast augmentation and can occur in up to 5 % of patients. It can happen at any time, but seems to be more common in first few years after surgery. Capsular contracture may occur more often after infection, haematoma, and seroma. The contracture is usually mild and difficult to feel. In some patients the capsule will tighten and squeeze the implant. This makes the breast implant feel hard and distorts the appearance of the breast. In the later stages, the implant can feel very firm, may be painful to touch and can take on a “ball-like’ look.  One of the ways to prevent capsular contracture is to use textured implants that have, overall, about a 50% lower rate of development of significant contracture as compared with smooth implants. Placement of the implant into a sub-muscular pocket has also been shown to reduce the incidence of capsular contracture. Once significant contracture occurs, the treatment is usually with surgery – the implant is exchanged and the capsular contracture either cut (scored) or, sometimes, excised. Some surgeons used to practice a “closed capsulotomy” by firm manipulation of the breasts with the aim of trying to fracture the capsule. The risk of implant rupture with this technique is high and the procedure is therefore not recommended.
  • Scarring, If a surgical scar is under tension it can stretch and widen. Some patients have a predisposition to develop hypertrophic or keloid scarring. Early treatment of this (as soon as noticed) can help to treat these problems.
  • Sensory Changes, Some women report sensory changes: their nipples become oversensitive, under-sensitive, or even numb. This is independent of the type of incision that is used. You may also notice small patches of numbness near the incisions. These symptoms usually disappear with time, but may be permanent in a few patients.
  • Palpable Implants and Skin Folds (“Rippling”), Women with very little breast tissue may feel the implant by touching their breasts. Vertical skin folds, so-called “rippling”, may be slightly visible as well, esp. when the implant has been placed in front of the pectoral muscle. The problem can be corrected by placing the implant behind the breast muscle.
  • Fertility, Pregnancy and Breast-feeding, There is no evidence that breast implants will affect fertility or pregnancy. Most likely you will be able to breastfeed your child, but it depends on the type of breast augmentation you had. Most approaches are compatible with breastfeeding. Incisions made in the skin crease underneath the breast or through the armpit should not cause any problems with breastfeeding. A “smile” incision around the areola increases your risk of having breastfeeding problems. If you have nursed a baby within the year before augmentation, you may produce milk for a few days after surgery. This may cause some discomfort, but can be treated with medication.
  • Implant Rupture, Occasionally, breast implants may leak, tear or rupture. Rupture can occur as a result of injury or compression. Implants do not burst like a balloon – some women have fears that the breast will explode – this does not occur! There is no danger with air travel or deep sea diving.  If a saline-filled implant breaks, the implant will deflate over a few hours to days and the salt water will be harmlessly absorbed by the body.  If a break occurs in a gel-filled implant the silicone gel may be contained by the scar capsule around the implant and you may not detect any change. Many women are walking around with ruptured breast implants and do not know they have had an implant rupture. As long as the silicone is within the capsule there is little risk. Whether any treatment is needed at this stage is controversial. If the silicone gel leaks out of the capsule and into the breast tissue you may detect a change in the shape or firmness of the breast. An appropriate ultrasound examination or MRI scan can help to show whether the implant has been damaged. An operation will then be required to replace the broken implant and remove the leaked silicone.
  • Interference with the interpretation of X-ray Examinations, Breast implants may interfere with the detection of breast cancer. Different mammography techniques using special views may be required. An additional ultrasound examination or magnetic resonance imaging (MRI) of the mammary gland will maybe also be advised. While the majority of women do not experience complications, you should make sure that you understand the risks and consequences of breast augmentation. For many women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their new, fuller appearance. Your decision to have breast augmentation is a highly personal one that not everyone will understand. The important thing is how you feel about it. Overall, despite much of the previous media hype around breast augmentation, it is one of the best procedures offered by plastic surgeons and one with a high degree of patient satisfaction.
  • General Surgical Complications, General surgical complications such as deep vein thrombosis. This is a rare but serious complication of surgery and anaesthesia, where a blot clot forms in the veins, usually the legs and may migrate to the lungs interfering with their normal function resulting in possible life threatening consequences.
  • Anaesthetic Complications, Problems with anaesthesia, drugs, etc. These should be rare and the risks will be explained to you by your anaesthetist.


Checklist

  • Make sure I know all the medications you are taking before surgery.
  • Do not take any Aspirin or blood thinning drugs (which include some homeopathic supplements) for at least 2 weeks prior to surgery. Paracetamol is safe.
  • Oral contraceptives can increase the risk of Deep Vein Thrombosis or Pulmonary Embolism. The contraceptive “pill” should ideally be stopped a month prior to surgery but please use some alternative form of contraception.
  • It is advisable not to smoke at least 2 weeks prior to surgery and until complete healing has taken place. Nicotine reduces oxygen levels required for wound healing.
  • Please buy a loose sports bra (one/two sizes up from your current size) and bring this into hospital with you. You will need to wear it day and night for about 6-8 weeks after surgery. You must not wear an underwired bra for at least six weeks after your operation.
  • Please have a shower in the morning of surgery and do not apply deodorant or any other products (e.g. body lotion, perfume etc.)
  • Please do not have anything to eat (including chewing gum) 6 hours prior to surgery. You are able to drink still clear water up to 2 hours prior to your admission.

If you are worried post-operatively

  • Telephone the ward of the hospital from which you have been discharged.
  • Phone Ms Marion Grob under +44 7881808974.
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