Philip Turton Cosmetic Breast Surgeon

BREAST AUGMENTATION

Information Sheet for Patients Undergoing Augmentation

Introduction

The breast is a powerful symbol of femininity and has been so since the earliest time.  Often, to a woman, in her perception of her body and her concept of self, the size and shape of her breasts plays a dominant role.  Whilst padded bras do give the illusion of increased breast size and they help superficially they can paradoxically cause increased problems for a woman once they are removed and the breasts assume their natural appearance.  Augmentation mammaplasty or breast enlargement is an established surgical technique that in the majority of women is proven to improve a woman’s body image and perception of self with positive psychological effects. 

Who chooses to have breast augmentation?

There are two main groups of women who request this operation.  The commonest group of women are represented by mothers of children who either enjoyed the sensation of enlarged breasts during pregnancy, or have found that subsequent to the completion of the family the breasts have decreased dramatically in size and they are unhappy with the subsequent appearance.  The second group is represented by young women who are yet to start a family who wish to have breast enlargement as they consider their breasts to be of insufficient size. 

How do I go about finding more information on breast augmentation?

Unfortunately unless there is a significant underlying medical condition which has lead to a deformity of the breast or a post-operative deformity that requires correction it is not possible to obtain augmentation mammaplasty on the NHS except in exceptional circumstances. There are numerous sources of information on augmentation from books, magazines to articles posted on the internet, and these should be complemented by a good quality in depth consultation with the surgeon who will perform the augmentation.

It is possible for women to approach their surgeon directly through the local private hospitals, but it is considered good medical practice for the surgeon to keep the patient’s general practitioner informed of any medical interventions that subsequently occur. 

How do I select a surgeon?

Breast augmentation should only be performed by a Specialist Surgeon trained in the technique, whether their background is in the specialty of plastic surgery or as in increasingly the case, a Specialist Breast Surgeon who comes from a General Surgical background but whose usual clinical workload relates almost entirely to women with breast disorders.  It is worth checking that the surgeon is a member of the relevant specialty organisation. This includes the Association of Breast Surgeons of the British Association of Surgical Oncology (ABS of BASO) or otherwise the British Association of Plastic Surgeons. Your surgeon must be on the Specialty register of the General Medical Council. The National Care Standards Commission is a new agency set-up by the government to ensure the regulation of cosmetic surgery in private hospitals and if you approach a surgeon offering augmentation mammoplasty in the private hospitals within Yorkshire they will have had to fulfil the requirements to be allowed to provide this surgery.  It is obviously our opinion that any surgical intervention is better carried out by local experts rather than travelling far and wide. Mr Turton is a Specialist Breast Surgeon and performs Cosmetic Breast Surgery including breast augmentation, reductions, mastopexy and correction of nipple inversion. He is a general surgeon whose specialist training is in Breast Surgery and his special area of interest is cosmetic breast surgery. His general surgery practice is dominated by specialty breast surgery work, including oncoplastic breast surgery, breast reconstruction, benign disease and breast cancer surgery, and all aspects of aesthetic cosmetic breast surgery. He is an accredited member of Association of Breast Surgeons of the British Association of Surgical Oncology.

Pre-operative evaluation

You will be seen by your consultant and various questions asked concerning your approach to breast augmentation.  You will be asked why you wished your breasts to be enlarged, what size you would like them to be and if you had been pregnant the breast size that was attained.

The most common answer to the first question is that women wish to look better in their clothes and be in better proportion to the rest of their body, or be returned to the size they were prior to pregnancy.  As far as the second question is concerned it is unrealistic to give an exact estimation of cup size following the procedure but a general opinion can be given. It is important to achieve a balance between what the woman wants and what is possible surgically given the limitations of the woman’s chest size etc.  Finally if the woman did not enjoy having larger breasts during pregnancy it is unlikely that a breast augmentation will be a positive experience.

Your medical and any previous surgical history will be taken and any medications that you currently use will be documented. Pre-existing illnesses especially of any skin diseases will be gone into in more depth.  Any allergies will be recorded.

After discussing the woman’s motivation and desire to final appearance a full physical examination will be performed. The measurements taken will be recorded on a special anatomical sheet and kept in the notes.  In particular any asymmetry of the chest or back is noted as if there is some element of asymmetry of the breasts at the start of the procedure due to skeletal deformity then this will obviously need to be taken into account and can affect the final results. Discrepancies that cannot be altered by surgery will be demonstrated to the patient to avoid any dissatisfaction post-operatively. It is worth remembering that augmentation will not produce a perfect type cleavage with nipples pointing straight ahead unless that is what the woman started with. 

Specific considerations

 

Ptosis – ptosis (sagging) is the medical term for nipples that have dropped below their original position.  There are various grades and in the worst cases they can actually be pointing directly at the floor. Breast augmentation cannot correct anything other than the mildest case of ptosis.  If the woman requires a ptosis correction then an alternative procedure known as a mastopexy would be required which can occasionally be combined with an augmentation (albeit with greater risks). This however leads to additional incisions and hence scarring around the nipple and lower breast. Care should be taken to discuss this with your surgeon should you wish the nipple position to be altered. Some women are happy to live with a degree of ptosis so long as the volume of the breast can be returned with the augmentation. So long as they understand that in a bra they will have good volume and projection but once the bra is removed they will have the downward deflection of the nipples as before. At all times it should be emphasised that we are aiming to achieve what the woman wants and not some pre conceived idea of perfection.

Implant size

Consideration is taken into account of the patient’s desires.  Between 125 and 150 mls of volume will increase the bra size by about 1 cup.  Although there are many other considerations eg: the base size of the implant, the shape of your chest wall, the thickness of your current breast tissue, skin elasticity and the shape of the implant that should all be discussed with the patient.  A round implant will give a fuller appearance in the upper part of the breast (this can give a more artificial look though) and there are now also anatomically designed implants that give a less pronounced fullness in the upper part of the breast.  You should ask your surgeon to discuss the various merits of each of these with you prior to selecting an implant. 

Implant type

The implants have an outer silicone shell but they can be either saline-filled or silicone-filled.  It must be stressed that the recent concerns about silicone have proved unfounded, but your surgeon will discuss things with you in more depth. So called natural oil based implants have recently caused concerns and are no longer recommended. The UK market is dominated by silicone filled implants as these give a more natural look and feel.

 

Positioning of the implant

The implant can be placed either directly under the breast in a subglandular position or under the muscle of chest wall known as the subpectoral position.  Generally for women with very little existing breast tissue a sub-muscular approach is recommended to reduce the palpability of the upper edge of the implant, but every woman obviously represents an individual case and you should discuss the various advantages and disadvantages of each approach with your surgeon.

The Operation

You must not smoke either before or after surgery ideally from 6-weeks before to 6-weeks after. Smokers have higher rates of all complications both in the short and long term. The operation is performed under a general anaesthetic. Various approaches are available for the placement of the implant. The commonest approach is by placing the scars underneath the breast in what is called the inframammary position. This is generally considered the one required for the placement of silicone implants as they do not compress enough to be squeezed through holes in either the armpit or around the nipple. However these other approaches are available with saline implants. Your surgeon should discuss the surgical approach with you prior to the operation. The stitches used are dissolvable.

Following the procedure the wounds will be dressed with white adhesive strips called steristrips and over this a waterproof see through dressing will be placed.  This will allow you to shower and bath in the post-operative period but you should still keep the dressing dry. An overnight stay is generally required and if the implants are being place sub-pectorally the discomfort can lead to an additional nights stay in hospital if required. Antibiotics are given to cover the procedure and for a period of days afterwards. 

Returning Home

The patient is advised that she should restrict her arm movements for the first 3 days trying to keep her elbows close to her sides. On the fourth day she can resume routine non strenuous activities and drive a car if it is not uncomfortable to do so. However, she must avoid lifting her arms above shoulder height. She will be reviewed 7-10 days after the procedure and the dressings removed.  At the end of 6 weeks if all is well she can resume normal activities including aerobics, except when a shaped (anatomical) implant has been used when the period of restriction is far longer to reduce risk of implant rotation..  It is worth remembering that exposure of the scars to ultraviolet light will produce permanent pigmentation in the scar.  It is therefore advised to avoid tanning booths and exposure of the scars to sun until the scar has gone a white colour which can take 6-12 months.

Routine massage of the implants (as is described for smooth shell saline implants) is not recommended or required and may encourage capsulation. Please do not do this.

Keeping the scars tapped with a thin strip of low allergy tape such as Micropore™, for 3-9 months can help reduce stretching of the scar whilst it matures, and hence help to keep it as imperceptible as possible. If you have a tendency to form thickened or raised scars there are silicone gels that can be used which might be beneficial.

Special consideration/side effects/complications

Pregnancy should preferably be avoided for 6-months after the procedure. It is normally possible to breast feed after breast augmentation but a small number of women will find that they are unable to do so or that the volume of milk has reduced. It should be remembered that some of these women may not have been able to breast feed even without an augmentation.

The antibiotics given during the procedure may make the oral contraceptive pill ineffective. Barrier contraception should therefore be used until an uninterrupted pill cycle is restarted.

Haematoma

Haematoma or bruising is the most common complication after most surgical procedure and occurs in less than 1% of patients undergoing augmentation mammoplasty. It normally appears within the first 48-hours and is associated with a sudden increase in breast volume with a tight feeling and discomfort.  Small haematomas can be treated conservatively and will settle. However larger haematomas may need to be treated surgically with evacuation under anaesthetic. 

Infection

The infection rate is extremely low at less than 1%, but if it occurs it usually requires implant removal for a period of time. This obviously produces a marked asymmetry if only one breast is affected. It is possible to place an implant subsequently, but there is an increased risk of infection with the second procedure.

Nipple Stimulation

Approximately 15% of all patients undergoing primary augmentation will have permanent alteration in sensation on one or both sides. This can involve the nipple, the areola (the brown skin surrounding the nipple), or indeed some of the skin on the breast itself.  It may be less sensitive or totally numb. It would be considered permanent if it is still present after a year and even removing the implant will not bring it back. Women should therefore be honest about the importance they place on nipple simulation on their sex life. If it is important to the women then they should consider whether this operation would be advisable given the risk of nipple sensation loss.

Capsular Contracture

A contracture is a tight fibrous capsule that the body forms around the breast implant causing it to become less natural looking. Approximately 1:4 women will develop some form of contracture around the implant. Whilst most women will not realise there is a thick capsule that has formed, occasionally the contracture becomes so bad that the implants require removal. The incidence of contracture is falling with only 15% of women who choose the newer textured prostheses being affected, but follow-up data in this group remains immature. Various conservative treatments have been suggested including the use of antioxidants such as vitamin E, however nothing is foolproof and a certain percentage of patients will develop contracture no matter what they do or how many times they undergo revisionary procedure. Women should be aware of this before undergoing breast augmentation. However a small amount of capsular contracture is very common and often accepted by other women undergoing this procedure.

Rippling

Unsightly ripples may appear in the skin on the outside and inside of the breast particularly when the breast is in a dependent position (eg when bending down). This is due to adherence to the underlying implant. Submuscular (under the muscle) rather than subglandular (under the breast) positioning reduces this complication and is recommended if there is little natural breast tissue to cover the implant.

 

Palpable Implants (edges, knuckling, folds, kinks)

Occasionally the top or edge of the implant can be felt as a definite step or fold under the tissue.  Submuscular placement reduces this problem but in athletic individuals can lead to cosmetic problems when the chest muscles (pectorals) are tensed.  In addition to alternative implant positions the newer biodimensional implants (also called “anatomical” or “shaped”) have a less pronounced “take off” than the round prosthesis and whilst they give less fullness in the upper cleavage they give a more natural shape to your augmentation. These may be particularly appropriate for women with little breast tissue in the upper part of their breasts. You should ensure your surgeon discusses these points with you.

Deflation / Replacement

With saline implants (rarely used in the UK) there is the risk of deflation and even with silicone implants no women should regard her initial augmentation as necessarily being life long. It is possible that at some stage the implants will have to be adjusted or replaced, although this is often 10-15 years or perhaps longer after the initial augmentation and may be due to contracture or other cosmetic problem rather than just deflation or gel “bleed” (the name given to the slow diffusion of silicone out of its covering). Given the continued development of new implant designs it is difficult to predict the expected lifespan but it is certainly longer than with the older designs. With saline implants deflation can occur slowly or the prosthesis may rupture causing a dramatic deflation. With silicone implants any loss of integrity in the outer shell is generally compensated for by the fact that the body forms a capsule around the silicone and this is referred to as “intracapsular” rupture. This was not uncommon with the older implant designs and is normally asymptomatic. With the more modern high cohesive gels it is extremely unlikely that any silicone would travel any distance from this capsule.  The inside of the high cohesive type is more like a jelly baby rather than runny silicone. I specifically recommend the use of high cohesive implants.

It should be remembered that having breast implants does not stop the usual involution that occurs following pregnancy or with advancing age. Indeed correcting the aesthetic problems caused by these processes is often the reason women request implants in the first place.

Scarring

Obviously there is always the risk of overgrowth of the scar known as over granulation or Keloid scarring.  If the scar is hidden under the breast this becomes less of a problem but it can be quite dramatic. The scar is usually very fine though.

Double bubble

An unexpected result can occasionally occur leaving a less than optimal cosmetic result. One example is the double bubble appearance. It is slightly more common with pre-existing ptosis (sagging), and with shaped implants placed under the muscle. It is also more common where the crease under the breast is very well defined as the condensed tissue (fascia) fails to expand naturally over the lower part of the implant. Although it may improve spontaneously over a number of months you may need to pay for revisional surgery.

Granulomas

It is possible that small lumps may appear over the implant due to the reaction of the body to foreign materials such as silicone. However any lump occurring in the breast whether it has been augmented or not should be appropriately investigated.

Subsequent Breast Investigations

It is easier to investigate an augmented breast that has had a subpectoral implant (rather than subglandular) placed as obviously the breast tissue is pushed forward by the muscle and therefore it is possible to perform breast examination and breast biopsy so long as the investigating clinician is aware of the presence of implants.  However implants do interfere with mammography and specialist views are required. A woman should inform her mammographer that they had implants in place so that the proper studies can be done. It is slightly easier to perform mammographic views on a subpectoral implant than on a subglandular implant. Prior to augmentation if the woman is of a more mature age or there are any significant risk factors mammography may be performed as a screening investigation.

In Conclusion

Any woman considering augmentation mammoplasty should consider the following points as regards the recent negative publicity over silicone breast implants.

 

  • There is strong evidence that implants do not cause cancer.
  • There is no evidence that breast implants delay cancer detection if the appropriate investigations are performed.
  • There is no further evidence that silicone implants cause any form of autoimmune disease or rheumatic disorders.
  • The silicone gel of a high cohesive implant does not spread diffusely throughout the body in any detectable amount even if the implant is broken. The gel can be forced into the surrounding local tissues but produces only a non-specific local inflammatory response.
  • A general change in the cosmetic appearance may occur with time and you should assume that revisional surgery will be needed at some point in the future.
Breast augmentation remains a viable surgical intervention for women who appropriately select this procedure and are counselled concerning its possible effects.  If there is any doubt we recommend that you discuss the options with your specialist.
 

Additional Information

 

Remember:

 

  • If you can feel your ribs in front, underneath or beside you breast you will be able to feel the edge of your implant.
  • If feeling the edge of an implant shell could be a problem, do not have an augmentation.
  • If you are thin or have very little natural breast tissue you will be more likely to feel your implant. Sub-muscular placement is more likely to reduce this unwanted problem.
  • The larger your implant the worse your breast will look over time. A larger implant will stretch your tissues over time and cause more tissue thinning and sagging than a smaller implant.  Visible “rippling” may also occur if you chose a large implant relative to your current breast size.
  • No augmentation will provide a totally natural breast.
  • It is vital that you arrive at a realistic expectation of what can be achieved with the various breast implants.
  • Always disclose all gels, tablets and medication that you are taking including herbal remedies-some increase the risk of haematoma (bleeding) and must be avoided prior to surgery-
    • Any anti inflammatory drugs: like brufen, neurofen, and aspirin.
    • herbal remedies and vitamins:  St John’s Wort , Vitamin E, Vitamin C, Gingko Biloba, Echinacea, Garlic, Willow Bark Products.
    • Others: antidepressants, warfain, steroids, vioxx, or pain killers
  • Please ensure that these issues have been discussed with your surgeon to your satisfaction prior to undergoing breast augmentation.

Note:  This information is for general guidance only and represents the views and opinions of Mr Turton, Consultant Breast and General Surgeon.  It should in no way be regarded as either definitive or representing the views of any other surgeon, doctor or institution.

Further useful  information is available on the internet from the Dept Of Health detailing safety issues and complications relating to breast augmentation and implants: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance

 

  

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