In detail – breast enlargement

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What is a breast enlargement (augmentation)?

A breast enlargement is a surgical operation in which an implant is placed behind the breast to increase the breast size or to improve the breast shape. The procedure is

sometimes called a breast augmentation, an augmentation mammoplasty, a breast enhancement or colloquially a ‘boob job’.

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Who might consider having a breast enlargement?

There are two main groups of people who usually have breast enlargements. The first is women who have always wanted larger breasts and the second is women whose breasts have lost volume and shape either with age or

frequently following pregnancy and breast feeding. Breast implants are also helpful in treating people who have significant asymmetry. They are also used to reconstruct a breast after surgery.

What should I expect when having a breast enlargement?

You are admitted into hospital on the day of your operation. The time you come in varies on when your operation is scheduled. The operation is carried out under a general anaesthetic (asleep). The operation usually takes between one to one and a half hours. The stitches are absorbable (‘dissolving’) and are placed under the skin, so that you can not see them. A dressing is placed over the wounds at the end of the operation. Drain tubes are almost never necessary. You will be prescribed regular painkillers while you are in hospital and to take…

home. You are advised to wear a supportive (not wired) sports type bra for 4 weeks following surgery. You are offered a dressing check one week after surgery and you have a follow up consultation with your surgeon 4 weeks after the operation. If you are worried at any time after you have gone home you can phone the ward, phone the cosmetic nurse advisor or the consultant’s secretary for advice. If necessary you can return to the ward at any time for a check (please phone first).

How is the operation done?

An incision is made in the skin and a pocket developed under the breast tissue. An implant is then placed in the pocket.

An alternative is to make the pocket under the pectoral muscle (see below). The skin is closed and the wound dressed.

Where will the scar be?

The most usual place for the scar is under the breast either in or just above the natural fold under the breast. It is usually about 2 inches (5cm) long.

Implants can be placed leaving a scar round the edge of the nipple and in the armpit but these are less frequently used.

Under or over the muscle?

The majority of implants are placed under the breast and on top of the pectoral muscle. If you are very slim and have little tissue thickness above the nipple there may be benefit in placing the implant under the pectoral muscle. This gives an extra layer of covering over the top of the implant and tends to make the implant less visible. As a guide you should measure the pinch thickness between the collarbone and the nipple. If this is less than 2cm then it would not normally be advisable to place the implant under the muscle. A further benefit of placing the implant under the muscle is that it makes it easier to do a mammogram. The main disadvantages of placing the implants under the muscle include it being a more painful operation with a slightly longer recovery. The implants will move when the muscle contracts which some people do not like.

Dual plane: some people refer to submuscular placement of the implants as ‘dual plane’ because the implant is under the muscle in its upper part and under the breast in the lower, so it is in 2 planes. However, this is a long standing approach which is usually called submuscular. When the term dual plane was introduced it described a new idea where the pocket and implant was placed under the muscle as a normal sub muscular implant. The plane between the breast and the muscle was then opened up so the breast could be lifted on the muscle. As this was a new concept it would seem reasonable to give its own name ie dual plane. (If dual plane confuses you do not worry it is not recommended for most patients).

Will I need drains?

Almost certainly not. In the past plastic drain tubes were placed from around the implant passing through the skin to a drainage bottle. This was to collect any

excess blood or tissue fluid. For the majority of people this is unnecessary and it is most unusual for Mr Hurren to use drains for breast enlargement operations.

How do I choose my implants?

Everyone is different so the choice must be made for each person. In practice, round, textured, silicone implants of between 260ml and 340ml give a very pleasing result for the majority of patients. However, there are a number of alternatives

and options you may wish to consider. Implants may be round or shaped (anatomical or tear drop). They may be silicone or saline. Implants may be smooth or textured on the surface and they can be of differing volumes.

What sized implants should I have?

The size of implants you choose will be influenced by many things. These include your build and breast shape and how large you wish your breasts to be. Furthermore you will be advised what can be achieved surgically or what is advisable. An experiment which may help you to consider what size you would like is to place water in a freezer bag (dry rice in a stocking foot is an alternative) and seal it carefully then place it in a supportive sports type bra. You can try this with different tops. The most frequently-used volume in breast

augmentation is 280ml to 320ml. This will increase most people’s cup size by 2 to 3 sizes (i.e. A cup to C or D cup). Implants of less than 200ml would be very unusual and more than about 400ml is unusual. The largest standard implants are about 800ml. Larger implants are more likely to give you an ‘implanted’ appearance, more likely to cause the breast to droop over time and are more likely to lead to complications. Larger implants are likely to result in you needing further surgery in the future.

 

What type of implants are available?

All implants are made with an outer shell of silicone elastomer. Implants vary in what is contained within the implant (the filling). Most implants used in the UK are filled with silicone gel.

The main alternative is saline which is salty water. Saline filled implants tend to feel less natural. Saline implants are more likely to rupture and when they do they deflate very rapidly.

Should I have textured or smooth implants?

Most implants used in the UK are textured. Originally implants had a smooth surface. In the UK it is considered that textured

implants have a lower rate of capsular contracture and so almost all surgeons recommend textured implants.

Should I have round or shaped (anatomical)

Round implants give a good result for most people. Round implants are often softer, can rotate without affecting the breast shape and give high satisfaction to most

people who have them. Shaped implants may help to achieve a certain appearance for the breast. They can rotate leading to asymmetry and are more expensive.

What results can I expect?

The majority of people who have a breast enlargement procedure are pleased with the results. It is reasonable to expect your cup size to increase by two to three sizes (e.g. an A cup to a C or D) depending on the size of the implants. Many people feel more confident and feel able to dress more freely. If you are unlucky enough to experience complications, this

may affect the end result and how you feel about the surgery. People who are unrealistic about what they are expecting from surgery may feel dissatisfied. Breast enlargement does not change you or how other people feel about you. You should not have a breast enlargement for someone else or because you think it will affect how they feel about you.

What do the scars look like?

The scars are usually about 5cm long and lie in the fold under the breast or on the breast just above the fold. In most people these scars settle down very nicely as a thin pale line. As with any scar they can stay red

or become lumpy (hypertrophic or keloid). It is most unusual for people to complain about the scar. Scars can also be placed at the edge of the areola (brown area surrounding the nipple) or in the armpit (axilla).

How long will I need to recover?

Most people go home the day after surgery, although a few go home on the day of surgery. Most people take 10-14 days off office-type work and return to driving a car at the same time. Some people find they need less than a week but this is unusual. By 4 to 6 weeks the majority of people are getting back to normal and returning to their normal activities. Individuals vary and if there have been complications, recovery may be delayed. The following reflects most patients experience:

Go home: usually next day (some can go home on day of operation).

Shower and bath: day after operation (dressings are waterproof).

Driving car: not for at least 48 hours. Most people wait 7-10 days.

Office work: varies, allow 10 days some people need less than a week.

Pick things up: as you feel comfortable, avoid straining to lift for at least 2 weeks.

Wear wired or ‘pretty’ bras: after you have had your follow up outpatient appointment (4 weeks).

Exercise gym: walking is good from day one. Rest for 2 weeks. Lighter lower body (eg power walking) 2-4 weeks. Build back to normal 4-6 weeks.

Swimming: 4-6 weeks.

Sex: as you feel able and comfortable. Squeezing or direct pressure on the breasts should be avoided for 6 weeks.

Flying in an aeroplane: usually not for 2 weeks.

Back to normal: most people feel back to normal after about 4-6 weeks.

How long will my implants last? Do they need to be changed?

The majority of Implants do not have a set life span and do not have a specified time when they need to be changed.

Implants can last your life time although this can not be guaranteed. You must understand that implants may need to be removed or changed.

Is silicone safe?

There is no convincing evidence that silicone in the body makes people unwell. There is no evidence that it causes immune illnesses, arthritis or breast cancer. Silicone is widely used in medicine, foods, drinks and cosmetics. Many women have had silicone breast enlargements over the years and they do not suffer from more illnesses than those who have not had implants.

Where implants can cause health problems, these are problems in the breast and are related to the implant in the breast these are discussed under risks in the next section. For a copy of the report from the independent review group into the safety of siicone gel breast implants, please visit: www.mhra.gov.uk.

What are the risks?

As with all surgery there are potential risks. There are the risks of having a general anaesthetic and the risks that exist for any operation. There are also risks that need particular consideration with breast enlargement:

Bleeding and haematoma:

Bleeding may occur after any operation. A build up of blood around the implant after the operation is called a haematoma. The great majority of patients do not have a haematoma. If you do have a haematoma it is usually advisable to re-operate to remove the haematoma. Although this usually means an extra night in hospital it does not normally delay recovery by a significant amount. You are not left without an implant.

Infection

Infection is a rare complication of breast augmentation. If an implant becomes infected it usually needs to be removed. Once the infection has settled an implant can again be placed behind the breast. This should normally be six months after the infection has fully settled.

Seroma

Fluid build up around an implant called a seroma is an unusual problem. The fluid is usually absorbed by the body.

Implant extrusion (‘rejection’)

If implants appear to be rejected it is usually due to infection (see above). Large implants or where the skin is thin may cause the skin to break down giving the impression of the body rejecting the implant. This is usually only a problem with very large implants. (True rejection is where the body’s immune system attacks something in the body such as a kidney transplant. This process does not occur with implants.).

Asymmetry

Many women’s breasts are naturally asymmetrical. The chest wall may be a different shape on each side or the breasts themselves may have a different shape, position or volume. Sometimes the difference may be disguised by breast augmentation. Sometimes asymmetry may be more obvious after surgery.

Wrinkles, folds, knuckles irregularities

Breast implants are made in two parts, the outer shell and the inner filling. Sometimes the implant may lie such that folds or wrinkles form in the outer shell. These may then be felt through the skin or occasionally be visible. If a fold occurs near the edge of the implant then a prominence may be felt or seen. These are more likely if you are very thin or have very little breast tissue. The great majority of people do not have these problems.

Capsular contracture (‘implants going hard’)

Following breast enlargement with implants the body forms a layer of scar tissue around the implant. This has some advantages because if the outer shell of the implant breaks this capsule usually keeps the silicone with in the capsule and so it does not leak out. However, in some people the capsule starts to tighten and this makes the implants become round and feel hard. This is called a capsular contracture (‘implants going hard’). At worst they can become like ‘tennis balls’ and even be painful. Most capsular contractures form in the first year although less than 5% percent of patients are dissatisfied and seek further surgery at this stage. Capsular contractures may occur at any time following surgery. Capsule formation is reduced by using textured implants and may be reduced

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by placing the implant partly under the pectoral muscle (under the muscle). The presence of a capsular contracture does not necessarily require treatment. The main treatment for breast implant capsules involve surgery. A capsulotomy involves removing the implant and surgically dividing the capsule to release it.The implant can be replaced during the same operation. There tends to be a high rate of recurrence of the capsule following this procedure. A capsulectomy is more involved in that the capsule is removed with the implant rather than just split. The recurrence rate for capsules following capsulectomy is lower than for capsulotomy. If capsules recur further capsulectomies can be carried out but recurrence is common. It is important to appreciate that the cost of capsule surgery is similar or greater than for the original breast augment. For someone with a strong tendency to make capsules the choice may lie between living with capsules or having the implants removed. Closed capsulotomy is no longer recommended. This involved squeezing the breast until the capsule splits. Recurrence was common.

Rupture, gel bleed & silicone granuloma

Implants are very strong. You can stand on them and they do not break. However they are man made and over time the silicone gel that is with in the silicone elastomer shell may leak out. This is called ‘gel bleed’. For the most part the capsule around the implant keeps the silicone gel where it should be. However if significant amounts of gel leak out into the tissues you may develop a lump called a silicone granuloma. These usually require removal along with the implant although another implant can usually be put in at the same operation.

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Loss of nipple sensation

Frequently the nipples are over sensitive following breast enlargement. This usually settles within 4-8 weeks. Sensation may also be reduced and the nipples may be numb. Numbness is usually temporary although recovery can take a number of weeks. Uncommonly the nipples can be permanently numb.

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Tenderness and pain

Tender and painful breasts particularly before a menstrual period is experienced by many women. If you already experience breast tenderness or pain then implants may make it worse and this is something you must consider. Some women who have not had breast pain in the past find that they do have areas of tenderness or (rarely) pain following breast augmentation.

Deep vein thrombosis (DVT):

A breast augmentation is usually an operation carried out under general anaesthetic so there is a risk of a thrombosis (clot) in the deep veins of the legs (a DVT). A serious complication of a DVT occurs when a thrombus breaks off and travels to the lungs to cause what is called a pulmonary embolus (PE). A large pulmonary embolus can be life threatening. During your operation and time in hospital we will take measures to protect you from DVT formation, although these cannot guarantee complete protection. Once you go home the best prevention of DVTs and PEs is regular walking.

The combined oral contraceptive pill (the pill) increases the risk of DVT with surgery. If you are on one of these pills you should discuss this with your surgeon. If you stop the pill four to six weeks before your surgery then your risk returns to normal. If you stop the pill and you are having sexual intercourse then you must use alternative contraception otherwise you may become pregnant.

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What else should I consider?

Mammograms after breast enlargement

In England women between the ages of 50 and 70 years (this may change to 47 to 73 years in the near future) are offered a screening mammogram every 3 years. This is to try and detect cancers at an early stage. Breast implants make it more difficult to do mammograms. In some women mammograms may become almost impossible. Usually you have to have your mammograms at the breast center rather than on a mobile van and extra views may need to be taken. There is a small risk of damage to the breast implants. If your implants are placed behind the pectoral muscle then mammography is easier than if they are behind the breast.

Pregnancy and breast feeding

There is no convincing evidence that breast implants cause any harm to unborn babies. Breast milk is the best for feeding small babies and there is no evidence that silicone implants cause any harm to breast feeding babies.

Mammograms after breast enlargement

In England women between the ages of 50 and 70 years (this may change to 47 to 73 years in the near future) are offered a screening mammogram every 3 years. This is to try and detect cancers at an early stage. Breast implants make it more difficult to do mammograms. In some women mammograms may become almost impossible. Usually you have to have your mammograms at the breast center rather than on a mobile van and extra views may need to be taken. There is a small risk of damage to the breast implants. If your implants are placed behind the pectoral muscle then mammography is easier than if they are behind the breast.

Pregnancy and breast feeding

There is no convincing evidence that breast implants cause any harm to unborn babies. Breast milk is the best for feeding small babies and there is no evidence that silicone implants cause any harm to breast feeding babies.

What are the alternatives?

A good well fitting Bra and external prosthesis

A good bra will make the most of your natural breasts. Bras with additional filling will give the appearance of larger breasts. This approach does not involve surgery and is much cheaper.

Mechanical External Breast Suction Devices

Devices have been developed that are worn over the breasts and apply suction to the breasts. Modest levels of enlargement are possible with considerable time and effort.

Macrolane (no longer available in the UK)

Macrolane is a hyaluronic acid filler material that can be injected behind the breast to increase the size. The amount that can be injected is significantly smaller than a breast implant so it is best for people who have very small breasts or need a small increase in volume to the upper pole. It is very similar to the hyaluronic acid which is a normal part of your body. It tends to absorb over time so further treatments will be necessary to maintain the effect. Most people seek a top up after a year. One particular advantage is that it can be carried out under local anaesthetic.

Mastopexy or breast uplift

Mastopexy is an operation in which excess skin is removed from the breast so as to lift the breast. For some women with droopy breasts this is a better option than implants. Combining a mastopexy with implants is an operation with a significant complication rate. It may be better to have the uplift first and the implants 6 months later.

Fat injection, fat grafting or lipofilling

Fat injection is being more and more widely used. It involves taking fat from one part of the body and grafting it into the breast. This can fill out a defect in the breast or be used to increase the volume of the breast. It is a lengthy process and currently not widely recommended for routine breast enlargement.