Breast augmentation

Breast enlargement or augmentation is one of the most common and successful procedures that we do. In the vast majority of people a Breast Enlargement involves placing an implant behind your breast tissue to increase the projection and fullness of your breast. The basics of the operation are straightforward but there is a great deal to consider about the operation and it’s implications that you need to think carefully about before making a decision as to whether a Breast Augmentation is right for you.

The operation is carried out as a day case under a full anaesthetic. Dressings are in place for a week, wound sutures are buried and absorbable and we will ask you to wear a firm support sports bra for 3 months after surgery.

Following a breast augmentation your breast will be firmer than your natural breast, it will not be as mobile but will look very natural.
Prior to surgery you will need to consider the following:

The vast majority of implants that we use have a silicone outer shell with a silicone gel filling material. They usually have a textured surface to reduce the incidence of hardening of the breast due to capsular contracture. Smooth implants are available for use in specific circumstances.

Saline or salt water filled implants are also available but do have higher rupture rate probably due to failure of the filling valve.

Round implants are used to restore volume to the breast with a shaped implant being preferable to create new breast shape. A tear drop shaped or anatomical implant gives us greater control over the shape of your new breast keeping the volume low in the breast with a natural tear drop shape and avoiding too much fullness in the upper part of the breast which can occur with round implants. Some patients however do prefer a fuller upper part of the breast when a round implant may be preferable.

The choice of implant is of course yours but we will help guide you in your choice of implant to achieve the result that you are looking for.

The size of implant that you choose is of course critical in achieving the right result for you. The implant size is determined by measurement and the use of trial implants. Sizing is usually done at a second pre-operative appointment. We will ask you to buy a full cup sports bra of the size that you would like to be. The band size will be your chest measurement with the cup size being your choice. Prior to your appointment try the bra at home filling the cup with socks or similar to pad out the bra so that you have a good idea of the profile that you would like to see in your upper body. If you are unsure as to the size that you would like to be buy a selection and return those that you don’t want and do try with various items of clothing so that you are sure in your own mind how you want your body to look.

Back in clinic we will the measure your present breast dimensions and select a range of implants that we expect to create the result that you desire. We will then use implants sizers inside your bra to allow you to select the correct implant for you.

It is important to remember at this stage that there are limits to the size of implant that can be used. This limit is determined by the size of the cavity that can be created behind your breast to accept the implant.

Occasionally we use a sizing implant at surgery to confirm that the chosen implant is appropriate. This is usually where a patient wants to be larger than we think may be possible in which case we may have to use a smaller implant.

            
Your present breast shape, thickness of your tissues and choice of implant will help determine where it is best to position the implant. I use an incision in the fold underneath your breast to insert the implant. There is a reduced risk of infection when using this incision and we are able to control the size and location of the space required to accommodate the implant best through his incision. The implant can be placed behind your breast tissue only or where we need more tissue to disguise the implant it is placed partly underneath muscle. The positioning partly underneath muscle is known as a “Dual Plane” placement. Drainage tubes are rarely required which also reduces the risk of infection.

As a day case you will be able to go home on the day of surgery. We use tape on the incisions and tape across the upper and lower part of your breasts to stabilise the implant in the early days following surgery. You should wear your bra on top of these dressings. We will see you at a week following surgery when all dressings will be removed. The incisions are closed with absorbable sutures which are buried underneath the skin and do not need removal.

Once the dressings have been removed you can bathe normally and we would suggest that you use a moisturising cream on the wounds.
We would encourage you to be fully mobile as soon as possible. You should not drive for 48hrs after an anaesthetic.

You can return to a full exercise regime once the dressings have been removed providing that you are wearing your sports bra although we do ask you to avoid prolonged running or jogging until 8 weeks after surgery.
We ask you to wear your sports bra at all times for the first month after surgery and then during the day only for the second and third months after surgery.

We normally review your progress in clinic after another month and then again after another 3 months.

Unfortunately, surgery cannot be made completely safe and complications can occur. You will need to consider these as part of your decision making process before you proceed with surgery.

Complications related to the anaesthetic and surgery in general are considered in a separate section.

Complications specifically related to a breast augmentation include the following.

Creating the space for an implant and stretching of tissue placing the implant can damage the nerves that provide feeling to the nipple. Feeling usually recovers but can be permanent in up to 5% of patients. Damge to nerves is more frequent the larger the implant used. In some patients feeling is enhanced temporarily in a similar way to the hypersensitivity during pregnancy.

Implants are manmade devices and can fail. A tear in the shell of the implant will allow the contents to leak with a loss of integrity of the implant and in time local irritation. Silicone is not toxic to tissues but if left for a long time the silicone can be absorbed by the lymphatic system and transported to lymph nodes in the axilla causing painfull lumps.

Saline filled implants have a higher rupture rate than silicone filled implants and will rapidly deflate as the saline, which is salt water is absorbed by the body.

If implant rupture is suspected a scan is usually required and if rupture is proven the implant should of course be replaced.

The risk of an implant rupture varies wildly in different studies but a reasonable estimate would be that 10% of implants will be found to be ruptured 10 yrs after implantation.

It is very difficult to rupture an implant mechanically although we do occasionally see patients who have been involved in a car accident where at impact the seat belt across the chest has ruptured an implant. This is a high impact injury.

Increasing firmness of the breast can occur over time due to a layer of scar tissue developing around the implant which shrinks and squeezes the implant making it feel harder. This can occur at any time during the lifespan of the implant and will occur in up to 10% of patients. In most cases the implant and breast feel firmer but in more severe cases the breast can be distorted with the implant being higher than normal and in severe cases it can be painfull.

There is increasing evidence that capsular contracture is caused by bacterial contamination on the surface of the implant either at the time of surgery or during the life of the implant. During our life bacteria do occasionally circulate in the blood stream when there is infection elsewhere or during an incident such as a dental extraction. This can occur around any implanted device in the body and if you do develop an infection you should take protective antibiotics.

To reduce the risk of contamination at surgery we follow a rigorous regime during surgery to minimise risk. This includes meticulous surgical technique, nipples isolation, copious washing of the cavity, minimal handling of the implant, antibacterial washes and prophylactic antibiotics and the use of insertion sleeves.

If capsular contracture becomes established removal of the capsule and replacement of the implant may be required.

Implants are not filled to full capacity to allow them to feel soft. As they sit in the body gentle folds can develop on the surface of the implant and in very thin individuals this can be felt and occasionally seen. A mild capsular contracture can cause a more marked fold or kink in the shell which can feel like a lump. Gentle pressure on such a “lump” will disperse it and as pressure is released you may feel it “click” back.

There is no evidence that implants can increase the risk of breast cancer. The figures that are available show a slightly lower incidence of breast cancer in women with implants. This is probably selective in that women seeking breast enlargement have smaller breasts than the general population rather than the implant being protective.

When notified it is important that you attend for routine mammographic screening. The implant will be visible on the mammogram and they will probably take extra views to image as much breast tissue as possible as some breast tissue will be shadowed by the implant.

There is no breast tissue hidden underneath the implant so you should continue self examination on a regular basis. Other examination techniques such as ultra sound and MRI scans are just as effective in examining the breast with an implant in situ.

Over recent years we have started to see a rare tumour in the capsule of scar tissue surrounding breast implants in a very small number of patients. The tumour is a lymphoma which arises from the cells in our bodies that fight infection.

It is a long term complication and to date there are around 400 patients worldwide in a population of many millions who have breast implants. The calculated risk is 1 in 24,000 breast implants so it is very rare.

ALCL presents either as a lump in the tissue surrounding the implant or a rapid onset of swelling. If either of these occur they should of course be investigated.

Treatment by removing the capsule and implant is very successful in early cases with chemotherapy being required in some patients.

ALCL has only been seen in patients who have textured surface implants and not in patients with smooth implants. It seems to be particularly associated with a vigorous texturing provided by some manufacturers. These implants have either been withdrawn or we have stopped using them.

We generally use implants which have a micro texturing as this does reduce the risk of capsular contracture very significantly which reduces the risk of further surgery which can lead to complications.

We will discuss with you the risk of ALCL and come to a decision about the type of implant that you would like to use. If you do choose a smooth implant we should place this in a partial submuscular or dual plane.

Post surgery pain usually subsides after a few days and long term pain is extremely rare. A few patients do have pain which lasts longer. This is probably due to local nerve damage that is inevitable during surgery and in the vast majority of patients will resolve in due course.