Introduction

Breast augmentation is one of the most commonly sought cosmetic surgery procedures in the world. Women may wish for a breast enlargement for a variety of reasons. Women with a small bust may simply wish to go larger. Following childbirth and breastfeeding, or with increasing age, the breasts may lose volume and the breast skin may lose elasticity, thereby resulting in empty drooping breasts. Breast implants can replace this lost volume and ‘recruit’ some of the redundant skin, giving more of a youthful appearance. In some cases, the drooping of the breasts may be significant; in these instances, a different procedure may be required, such as a mastopexy (breast lift), or a mastopexy augmentation (breast lift and implants). I will discuss with you in detail which procedure would be most suitable, taking into consideration what your expectations and desired outcomes are.

The Consultation

Please bring with you a tight white T-Shirt. After examining you, I will provide a bra for you to wear. There are implant ‘sizers’ that may be used to place into the bra, which will give us an estimated volume of implant to help you achieve your ideal breast size. After trying a variety of sizers, we will agree on a range of acceptable sizes of implants, subject to restrictions indicated by your height, chest width and body shape.

Things to discuss during the consultation:
During the consultation, I will explore the reasons for you requesting a breast augmentation. We will discuss what you expect from surgery and the ideal size and shape you are hoping to get.

Size

Breasts vary in cup size depending on where you were measured for your bra. Therefore the existing bra size is noteworthy but not entirely indicative of where you are currently. We can aim to achieve a certain size, but I cannot promise a specific bra cup size following surgery. The most important determinant of the size we are hoping to achieve is how you look and feel with the sizers in the bra with a T-Shirt on. It is also important to note that larger implants are heavier, and will cause the breast to droop faster over time due to the ageing process.

Shape

The biggest single determinant of breast shape following surgery is the shape of the breasts and their proportions prior to surgery. However there a few small variations during surgery that can help to improve the shape or existing asymmetry.

Implant

The implants that I use are made of the highest grade of silicone available on the market. They have the best safety record and come with a lifetime warranty (subject to conditions). Implants vary in volume, shape, width height and projection. The choice of implants you will need is based on a number of factors and I will discuss this with you in detail. The final implant we choose will be joint decision between us so you are completely satisfied with the final outcome as you will have played a major role in implant selection.

Incision

Implants may be placed under the breast through a variety of incisions, including the armpit, around the nipple or even the belly button. However, by far the best method, in my opinion, is via a 5cm incision below the breast in the inframammary fold (breast crease). The wound is closed using absorbable sutures and covered with a waterproof dressing.

Implant placement

This is a frequently asked question. For most women with a reasonable amount of breast tissue, my preference is to place the implant above the pectoralis muscle. This is also known as the submammary or subglandular plane. The advantages of this position is that it is less painful, with quicker recovery, and the breast moves ‘as one’. With ageing, the breast droops and the implant will follow it. It is important to keep the implant covered by the breast tissue. If the implant is too wide, it may be visible on the sides (side-boob). Implants are soft and they naturally ripple. If placed entirely under breast tissue, this rippling should not be seen.

In women with very little breast tissue, insufficient to ‘camouflage’ the implant, I place the implant under the pectoralis muscle, known as the subpectoral or submuscular plane. The advantage here is that the implant has an additional layer of tissue (the muscle) covering the implant and therefore hides the implant better. The disadvantage is that the procedure is more painful as some of the pectoralis muscle has to be cut through to make space for the implant. Secondly, the implant will move as the muscle moves (the so called ‘dancing breast syndrome’). Finally, with ageing, the natural breast will droop while the implant will stay in its original position (as the muscle does not droop). This may result in the so-called ‘double bubble’ appearance.

In certain cases, depending on the availability and distribution of your breast tissue, I may suggest placing the implant half under – and half above the muscle (so called ‘dual plane’).

After examining you, I will advise you on the best place for the implant to sit.

Sutures

The incision is closed in 3 layers using absorbable sutures. Sometimes, I leave the knot of the suture outside the skin and this will be trimmed at one week. The incision is then covered in a state-of-the-art waterproof dressing which will fall off after about 3 weeks.

Garments

You will be asked to purchase 2 bras at the consultation, which are a snug fit. Please bring them with you on the day of surgery. You will be placed into the bra before you wake up from the general anaesthetic. I will provide a breast ‘band’ which wraps around your chest keeping pressure on the top part of the implant, preventing it from riding up. I would advise wearing the support bras (nothing under-wired) 24 hours a day for 6 weeks, and the breast band for 2 weeks. The bra may be taken off for showering, which can be done after the first 48 hours. I advise all my patients to wear a support bra all the time, even at night. This is the best way to maintain the shape of the breasts and delay age related drooping.

Medications

I will see you immediately after surgery to discuss how things went and to check that all is well. I will make sure you are comfortable before you go home. In the vast majority of cases, patients undergoing breast augmentation are able to go home the same day. You will be given adequate pain relief. Please avoid taking any aspirin or blood thinning medication, including Nurofen (ibuprofen), and Voltarol (diclofenac). You will also be given a 5 day course of oral antibiotics to reduce the chances of infection. Finally, you will be given a 3 day course of a tablet that reduces the chances of bleeding.

Recovery

For the first 48 hours following surgery, please minimise the activities you are undertaking. Any activity that increases your blood pressure may trigger bleeding. You may return to very light duties after a week and back to work within 2 weeks. I strongly advise against any heavy lifting (including children) for 6 weeks and this may affect the position of the implant.

Eat well and stay well hydrated by drinking lots of fluids. Abstain from alcohol for at least a week as this can cause dehydration. Smoking or use of any nicotine replacement product is to be avoided for at least 6 weeks to allow the body to heal as quickly as possible.

You may return to driving after 2 weeks if you feel comfortable and able to maintain full control of the vehicle. You may fly ideally after 6 weeks, but make sure you drink plenty of fluids (not alcohol) and wear compression stockings on your calves.

Scar management:
After 3 weeks, wounds have generally healed. You are advised to gently massage the scars as tolerated as this helps to soften, flatten and desensitise them. I would advise massaging the entire breast as well as the scar. You may use any lotion of your choosing, such as E45 or bio-oil. 5 minutes morning and evening for about a year. Make this part of your ‘routine’. Secondly, scars tan faster than normal skin. Therefore avoid exposing the scars to the sun, but if you have to, then apply factor 50 sun block daily, for a year. It takes about a year for a scar to fully mature and caring for your scars in this manner will ensure optimal healing. In some cases, I may advise using silicine gel (such as Kelocote), to be smeared onto the scar daily for a year.

Possible complications

Breast augmentation surgery, whilst safe, can result in significant complications and it is important you are fully aware about them. This is why there is a 2 week ‘cooling off’ period to allow you to make a considered decision about proceeding with surgery.

General anaesthesia: Any operation involving a general anaesthetic carries a risk of developing blood clots in the calves (deep vein thrombosis – DVT), which could break off and move to the lungs causing a pulmonary embolism (PE). Early mobilisation and keeping hydrated will reduce this risk, as will avoiding smoking before and after surgery for at least 6 weeks. There is a risk of allergy to the drugs for anaesthetic and antibiotics / pain relief, and a very small but theoretical risk of major life threatening complication / death related to the anaesthetic (1 in 100,000 risk).

Bleeding and haematoma: This very rare and precautions are taken during surgery to minimise the risk of this. You will also be given medication to reduce the change of bleeding after surgery. However, in the rare instance that significant bleeding occurs, one breast may swell quite obviously and become painful. This will require a return to theatre, removal of the implant, control of the bleeding vessel and replacement of the implant.

Infection: Many precautions are undertaken during surgery to minimise the chances of infection, including giving you antibiotics after surgery for 5 days. Unfortunately infections can occur and this may be very superficial to the incision site, and easily treated with antibiotics. If the implant becomes involved with the infection, the breast can become red, hot, swollen and tender. You may feel quite unwell with temperatures and rigors. Unfortunately this will require removal of the implant and a few days in hospital with intravenous antibiotics. After 3 months, when all the infection has cleared, a new implant can then be safely placed back into the breast. This is extremely rare.

Scar: There will be a short horizontal scar in the breast crease. How it heals depends on your body’s ability to heal scars. The scars will be red for a few weeks before becoming pale over the course of the first year. In a small number of patients, the scar may become thick and lumpy (hypertrophic scar) and this is a result of your body’s healing process. In some cases, as the breast skin is stretched by the implant, stretch marks may become visible. This may be permanent.

Seroma: There may be a small collection of fluid or air in the breast for the first few weeks – resulting in a minor sloshing or crackling sound. This is normal and will clear once the body absorbs these materials. Sometimes, the body may produce inflammatory fluid (again entirely normal) called a seroma, which if significant, may need to be ‘siphoned’ out using a needle under ultrasound guidance.

Asymmetry: Breasts are like sisters, not twins. There is always a degree of asymmetry between two breasts. To some extend I can attempt to correct these, but usually, these asymmetries remain. The asymmetry may be of both size and/or shape and also of the nipple position.

Nipple sensation: The nerves that supply sensation to the nipples are sometimes divided during surgery. This may alter the nipple sensation, and some women report either reduced, or increased sensation. Much of this normalizes over the course of the first 6 months.

Breastfeeding: Because the breast glands that produce milk are not disrupted, it is possible to breast feed as normal following surgery. It is also perfectly safe to breast feed a child using your breast that has been augmented with a silicone implant. Several studies have shown that there is more silicone in formula milk than in breast milk expressed from augmented breasts.
Mammography (breast screening): Past the age of 47, you may be invited for breast screening. This special X-ray of your breasts are important to identify early signs of breast cancer. Having an implant will not interfere with this X-ray but mention to the radiographer that you have an implant in place.

Capsular contracture: All foreign materials implanted into the body develop around it a thin film of tissue called a capsule. This is normal. In a small number of patients, for reasons not entirely understood, this capsule can become thicker, and start shrinking. At first, this may only be felt as a hardening of the implant. Then this may become visible. Finally, it may painful. This process may take several years and occurs in up to 10 % of patients. If severe enough, the implants will have to be removed and the capsule surgically removed (capsulectomy). New implants can then be replaced.

Swelling: It is normal for the breasts to feel slightly swollen for the first week or so, gradually resolving over the first 6-8 weeks.

Age related changes: With time, skin loses its elasticity. This age related change can be made worse by chronic sun exposure and smoking. Inevitably, breasts will droop over time, and augmented breasts are no exception. The larger the implants, the heavier they are and the faster they will droop. Over time, the implants may have to be exchanged for larger ones to ‘gather up’ the loose skin, or more commonly, your breasts may require an uplift (mastopexy), with or without new implants.

Visible implant: Silicone implants are soft. This means that they will ripple when standing. If there is insufficient breast tissue or muscle to camouflage the implant, the rippling may become visible. I will encourage you to stay within the limits of your breast base, even if this limits the volume we wish to gain.

Symmastia: Breasts that are too close together. This is an unsightly look and difficult to correct.

Implant rupture/leak: The silicone implants that I use are made of cohesive silicone, much like a jelly baby. In the highly unlikely event of a split in the implant, the silicone will not leak out. The implants that I use come with a lifetime warranty against rupture.

BIA ALCL (Breast implant associated – anaplastic large cell lymphoma): This is a very rare form of cancer of the lymph glands that has been associated with about 1:60,000 of the implants I use. If detected early, it is very treatable. Symptoms include an unexplained swollen breast that may become uncomfortable. This is an extremely low risk and most women do not change their mind on the basis of this risk.

The outcome of all cosmetic surgery is highly subjective. Whilst your surgeon will try to give you a realistic expectation, the satisfaction which you feel about your result depends on many things.

Most people are delighted with their outcome. If there are elements of your surgery which fall short of what you had hoped for, you MUST feel free to discuss them with your surgeon, as the majority of issues are easily resolved.