LMSSA(Lond), LRCP(Lond), LRCS(Eng), MS,FRCS
Consultant Oncoplastic Breast Surgeon
Breast Augmentation
Breast augmentation is one of the most popular cosmetic surgical procedures. It is associated with extremely high rates of patient satisfaction. Implants, usually containing silicone gel, are inserted behind the breast via small incisions situated in the crease under the breast. The aim is to produce a natural and aesthetically pleasing appearance and feel to the augmented breast.
295cc Silicone Gel Implants inserted into a Dual plane II pocket.
Patients requesting breast augmentation often come from one of two cohorts, either women aged 18-25 years in whom the breast has never fully developed, or women who have finished their families and whose breasts have become empty. Some patients have other problems such as asymmetries, chest wall anomalies or tuberous breasts.
Patients who smoke are at greater risk of complications including bleeding and wound infection and are therefore advised to refrain from smoking ideally for two to four weeks prior to surgery and a similar time period post-operatively. Patients should also avoid Aspirin and equivalent anti-inflammatory agents for two weeks prior to surgery as these can increase the risk of bleeding.
It is recommended that patients on the combined oral contraceptive (not HRT or the progesterone only mini pill) should stop taking the pill for four weeks prior to surgery, as the pill is associated with an increased risk of deep vein thrombosis (DVT). During this period alternative forms of contraception should be used.
At the initial consultation after a discussion regarding the specific concerns a full medical and surgical history will be obtained. Details regarding the operation, the aims, the limitations, the recovery, and the risks will be discussed. Before the operation you will usually attend for a pre-operative nurse led assessment. You may require a blood test. Any significant health problems not previously identified may be discussed with Mr Sarakbi or the anaesthetist, and a further assessment may be required to determine suitability for the procedure.
At admission the nurses will again assess you and you will be measured for a pair of compression stockings. These are worn to reduce the risk of thrombosis formation and should be worn for a minimum of two weeks post-operatively. You will be seen by the anaesthetist prior to surgery and will be able to discuss issues pertaining to the anaesthetic and also pain relief in the immediate post-operative period. You will also see Mr Sarakbi who may make some pre-operative markings and will take photographs for the medical records.
The operation of breast augmentation is undertaken under general anaesthesia and usually takes approximately 1 to 1¼ hours. The operation is undertaken on the day of admission and some patients are able to go home the same day but others stay in hospital for one night following surgery. The stitches that are used are self-dissolving and drains are occasionally used. The drains are usually removed on the day of discharge.
In patients who are very slim the implant is usually placed behind the muscle to improve the takeoff and reduce implant visibility. This is the sub-pectoral pocket. In some patients it may be desirable to place the top half of the implant under the muscle and the bottom half just behind the breast. There are several variations of this placement, usually termed Dual plane I, II and III. These placements are particularly useful in slim patients where there is an element of breast laxity, or droop.
The pocket can be in front of the muscle either in a sub-glandular position, or in a sub-fascial pocket. In this latter placement the implant is placed behind a gristle layer that sits in front of the muscle. This helps to improve the takeoff of the breast in the upper portion and so can give a more natural look.
In patients who are very slim the implant is usually placed behind the muscle to improve the takeoff and reduce implant visibility. This is the sub-pectoral pocket. In some patients it may be desirable to place the top half of the implant under the muscle and the bottom half just behind the breast. There are several variations of this placement, usually termed Dual plane I, II and III. These placements are particularly useful in slim patients where this is an element of breast laxity, or droop.
There is a very large range of breast implants available with sizes ranging from 80 to 800 cc. Larger sizes are available but only on a custom made basis. The implants can either be round or breast shaped (often termed tear-drop, anatomical or bio-dimensional). In most augmentations round implants are used. These have the advantage of looking natural both when upright (as the filler will tend to move down in the implant), and when lying (the filler will move to the side). In shaped implants the shape is constant in both positions. Also if a shaped implant rotates a very undesirable appearance will result.
At the current time all the breast implants that are available are made of silicone in their outer layer (some now have polyurethane covering this). The filler material can either be silicone gel or saline (salt water). Most surgeons feel that the silicone gel containing breast implants give a more natural shape and feel to the breast. In recent years the silicone gel within the implant has been rendered cohesive. The cohesive gel is more bound together, this giving the advantage of reducing gel leakage whilst at the same time maintaining a natural feel. There are several grades of cohesiveness available, although firmer, more cohesive, implants are only used in exceptional circumstances.
There have been a number of concerns over the years regarding the safety of silicone gel implants though at the current time there is a very substantial body of evidence and research, which has confirmed the safety of these implants.
For further details regarding this, the following websites are recommended:
2. Information from UK government organization
One of the key factors in determining the success of the augmentation is getting the right size of implant for the patient. Too small, and patients feel that they have not benefited from the operation. Too large, and the implants will look unnatural and not fit the frame of the patient. Also clothing will not fit properly and the heaviness of the implants can predispose to premature drooping of the breasts. There are no ideal ways in which to find the right size. Probably the most accurate method is to use a water bag technique. This will be described during the initial consultation.
Patients blood pressure and pulse will be taken regularly following their return to the ward. Patients will have an intravenous infusion (a drip), which is usually removed once patients are able to tolerate diet and fluids comfortably. If pain or discomfort is experienced in the initial period following surgery, painkillers are given either by injection or as tablets.
Following a bilateral breast augmentation procedure the breasts will inevitably feel tight and will often look too pert for two to three weeks following surgery. Sometimes the breasts feel too full in their upper portion. This will resolve over several weeks as the implants settle down and gravity takes effect.
Some loss of sensation around the scar line and between the scar and the nipple is inevitable though this will recover but may take several months to do so. Nipple sensation is frequently affected following breast augmentation often becoming hypersensitive and on some occasions painful. If this persists then the nipple/areola complex should be massaged and tapped to desensitise it. Avoiding touching or stimulating the nipple/areola complex will only prolong hypersensitivity. A few patients notice a reduction or loss of sensation in the nipple. In most cases this will recover spontaneously, though yet again this may take several months.
Bilateral breast augmentation can occasionally cause a lot of discomfort especially with the submuscular placement. For the first few days following surgery it is advisable to take pain relief on a regular basis to keep on top of any pain or discomfort. After four to five days, pain relief is usually taken only as required. Occasionally, patients find that the pain gets worse forty-eight hours following surgery and then may take several days before it resolves again. This is a result of bruising and swelling. Pain relief should be prescribed prior to discharge.
In the initial 24 - 48 hours patients should avoid Aspirin containing or any other equivalent non-steroidal anti-inflammatory agent (including Brufen, Ibuprofen, Neurofen and Voltarol) as this may increase bruising.
At the end of the operation, tape is applied to the wound underneath the breast and this is then covered with a light dressing. A further light dressing is placed over the drain sites. , patients will need to attend a review appointment with Mr. Sarakbi in clinic which will be made 7-10 days following discharge, and at that time the dressing will be changed.
The wound should be covered with a dressing for approximately ten days following surgery and during this time the wounds need to be kept dry. A small sterile tape will have been applied to the wound at the end of surgery. Ideally this should be left on as long as possible, though if it has not come off by itself at 3 weeks it should be peeled off. At three weeks following surgery it may be beneficial to apply some Vitamin E containing cream or ointment to the scar line once or twice day for a few weeks just to minimize the scarring. All of the stitches are self-dissolving and none will need to be removed. Occasionally at the ends of the scar line you may notice a small lump or feel the end of the stitch. This is entirely normal and no action is required as the stitch will dissolve away in due course.
Patients are advised to use a sports bra as soon as possible following surgery. The sports bra should be kept on for a total of six weeks being worn both day and night. The purpose of the sports bra bra is to offer gentle pressure around the breast to help the implant bed in and also to keep it in the right position. After the six week period normal bras can be worn including under-wired ones.
Initially many patients find it too uncomfortable to sleep on their side or on their front. This discomfort will settle after two to three weeks. Patients who sleep on their front may experience difficulty as a result of the presence of their new breasts though lying on them after two or three weeks will not cause any problem.
It is recommended that patients on the combined oral contraceptive (not HRT or the progesterone only mini pill) should stop taking the pill for four weeks prior to surgery, as the pill is associated with an increased risk of deep vein thrombosis (DVT). During this period alternative forms of contraception should be used.
For the first week following surgery patients are advised not to drive as the safety belt can potentially put undue pressure on the breasts and also because patients will not be able to react properly in the event of an emergency stop. Most patients take one to two weeks off work although some patients return after a shorter period of time. Some patients where work involves a lot of manual activities including heavy lifting may require a longer period of time off. Advice regarding this will be given at the initial consultation. For patients with children, especially young babies or toddlers, help will be required in the initial two weeks following surgery.
Sporting activities including gym work, tennis and badminton should be avoided for 4-6 weeks following surgery and any vigorous sporting activities where contact is possible should be avoided for three months. There are no specific restrictions on sexual activities but the breasts should be handled with care for several weeks following surgery.
Patients are usually reviewed by Mr. Sarakbi for wound check in clinic at 7-10 days postoperatively and then at 3-6 months postoperatively.
Breast augmentation obviously increases the size of the breast, but does not necessarily correct pre-existing problems. Patients with breasts that have a large gap between them will still have a gap (though frequently smaller) as the gap is a result of the width of their breastbone. In these cases if the implants are placed closer together the implant edge may become visible and the nipple will not be centred on the mound of the breast. Similarly patients with breasts that point outwards will still have the same configuration post breast augmentation.
With a small amount of breast droop the augmentation may appear to correct this however when the droop is considerable it will still be present and can sometimes appear as a double bubble in which the original breast droops off the implant mound. In some patients this still produces a very acceptable result, but in others a mastopexy (breast uplift) will be required. The amount of breast droop will be determined at the initial consultation and the consequences and options discussed.
No one is perfectly symmetric and in any individual breasts will frequently have slight differences in size, shape and nipple position. Additionally there may be slight differences in the chest wall muscles and in rib cage shape on either side. These differences will usually be identified at the initial consultation and the effect on the result discussed. In patients with significant differences in nipple position this may become more noticeable post augmentation and occasionally it is appropriate to undertake a nipple repositioning procedure. In patients with size differences either a small amount of tissue can be removed from the larger breast or different sized implants can be used.
As with all types of surgery complications can occur. Fortunately with breast augmentation they are relatively uncommon and in most cases can be resolved with no significant long-term effects. Click on any topic for additional information.
Bleeding
Infection
Asymmetry
Rippling
Double bubble effect
Breast ache
Bleeding
Scar
Seroma
Capsular contracture
Implant rupture
Many patients having breast implants may go on to have children. Breast augmentation has no effect on breast-feeding and silicone has never been detected in breast milk (it should be noted that teats on baby bottles are routinely made of silicone). Some patients may require mammograms following augmentation. Patients should advise the doctor or nurse that they have silicone implants as 1-2 extra views may be required and some breast screening units may undertake ultrasound scanning to supplement or replace the mammogram.
In the past patients were advised that their implants would need to be changed at 10 years. This is no longer considered to be correct and implants may last much longer, and in older patients may never need to be changed. The commonest reasons for changing implants is patients requesting size changes or developing one of the problems as described above, in particular capsular contracture.
Early identification and prompt intervention is important and should patients have any cause for concern they should either contact the hospital or Mr. Sarakbis’ secretary, the contact details being shown below.
In all cosmetic surgical procedures undertaken by Mr. Sarakbi, there is a fixed fee policy which means that no further surgical charges are incurred for complications that occur within one year following the initial surgery. There may however (depending on the local hospital policy), be a charge for the hospital and the anaesthetist for repeat procedures occurring over 30 days from the original operation.
The vast majority of patients are delighted with the result of breast augmentation surgery. In many it results in a dramatic increase in self-confidence and patients feel not only more proportioned but also more feminine.
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