Breast Enlargement

Breast  Enlargement using implants

Breast Enlargement – Breast Augmentation is an operation used to enlarge and usually improve the shape of breasts,  using implants. Psychological studies have shown that patients who have successful breast enlargement often have a significant boost in their self-confidence and are much happier about wearing revealing clothing and more comfortable with their sexuality.

The consultation

The consultation can be quite lengthy as there are many issues to discuss. Sometimes you may need to return for a second consultation to finalise details. You will be asked about your medical history. This will include information about any medical conditions, drug allergies, medical treatments you have received, previous operations, including breast biopsies, and medications that you currently take. You will be asked whether you have a family history of breast cancer and about results of any mammograms. Your breasts will be examined and photographs will be taken for your medical records. Factors that need to be considered are; the size and shape of your breasts, the quality of your skin and the placement of your nipples. If your breasts are sagging, a breast lift may be recommended as well as a breast enlargement If you are planning to lose a significant amount of weight, be sure mention it as it may be better to stabilize your weight prior to undergoing surgery. It is important to point it out if you plan getting pregnant in the future. Pregnancy can alter breast size in an unpredictable way and could affect the long-term results of your breast augmentation. There is no evidence that breast implants will affect pregnancy or your ability to breast-feed, but if you have questions about these matters, don’t hesitate to ask. If you are a smoker, you will be asked to stop smoking well in advance of surgery. Aspirin and certain anti-inflammatory drugs can cause increased bleeding, so you should avoid taking these medications for a period of time before surgery. There may be additional preoperative instructions at the time of consultation.

Breast implants

Breast implants are made of an outer layer of silicone, but may be filled with silicone gel, salt water or a combination of both. Implants filled with soya oil have been withdrawn from the market. The silicone inside the breast enlargement implant can be in liquid form (gives a very soft and natural feel) or less liquid jelly ‘cohesive’ silicone (Gummy bear), which feel more firm but can come in a variety of shapes and is less likely to leak oven if rupture occurs.  Shaped implants can also rotate leading to a poor result. Currently, some surgeons are looking at cone-shaped implants as a solution to the problem of enlarging droopy breasts.  However cohesive gel implants are more expensive and the advantages are probably minimal. Both soft round implants and cohesive shaped implants can give excellent results.
Implants can have a smooth or textured surface. For years it was thought that textured implants have a lower capsular contracture rate but this has recently been questioned and this issue has caused great controversy in 2019, see complications.
Another type of implant which is claimed to have a lower capsular contracture rates  are the polyurethane coated implants. These breast enlargement implants tend to be quite firm but many surgeons use them in cases of previous capsular contracture. The manufacturers suggest that the life expectancy of breast implants is approximately 10 years, although implants can stay in without problems for a much longer time.

PIP implants

PIP implants were a range of breast implants which are now regarded as faulty. They were not produced according to the strict medical standards that all other implants are subject to.
They had a tendency to rupture and the contents were composed of non-medical grade silicone , which contained impurities. It is thought that only some product batches were faulty but none the less it has been recommended by most authorities that these implants should be replaced to avoid a possible risk of cancer.
None of the reputable /fully qualified plastic surgeons (FRCSIplast) used these implants in breast augmentation but some of the cosmetic clinics did.

Are there alternatives to breast implants?

Using padded bras or inserts can make your breasts appear bigger with a better shape. Natural breast enhancement pills that contain phytoestrogens (plant hormones that copy natural hormones) may help to increase the size of your breasts.  However, these pills have not been properly tested, may increase the risk of certain cancers and may cause you to put on weight. You may benefit from using the Brava® system that involves using a special bra to apply gentle suction to your breasts. The continued suction may stimulate new tissue to grow. However, there is little evidence that the system is effective and the long-term results are not known. Fat grafting is a very promising alternative which is being used for small augmentations in some centres. The woman’s own fat is harvested from the abdomen or thighs and re-injected into the breasts. The problem with this treatment is that it usually requires multiple procedures to achieve a modest enlargement and is therefore very expensive. But results when successful can be very natural and soft with none of the long term complications of implants.

The breast enlargement operation

breast-implant-surgery-behind-breast-tissue

Implant directly behind the breast tissue

Implants are usually inserted through a cut in the crease under the breast (inframammary fold). Alternatively, the incisions may be made around the areola or in the armpit however these techniques have lost popularity and are usually reserved for special circumstances. Very great care is taken to maintain sterility during the operation. Contamination of the implant with certain bacteria will cause infection requiring removal of the implant in many cases. It is thought that very low-level contamination with relatively harmless skin bacteria may be the cause of capsular contracture.  Additional sterile precautions are therefore taken when doing implant surgery. (Antibiotics, double gloving /changing gloves,  double prepping, breast pocket washout with saline and antibiotics, minimal implant handling, nipple covers).
A pocket is then created for the implant which is either under the breast itself or behind the muscle on which the breast lies. In my practice, implants are most often placed behind the breast as this gives a very natural result. However in very thin patients, who have very little breast tissue, (particularly if they have not had children), it may be better to place the implants behind the muscle to avoid the outline of the implants being obvious.

breast-implant-surgery-behind-pectoral muscle

Implant underneath the pectoral muscle

The surgery takes approximately one hour and is usually done under general anaesthetic. The implant is placed in a pocket either directly behind the breast tissue (left) or underneath the pectoral muscle which is located between the breast tissue and chest wall. Individual factors and personal preferences will help you and your plastic surgeon to determine your appropriate breast size, the location of incisions, and whether the implants will be placed on top of or underneath the chest muscle.

Post operative recovery

Like all operations, there will some post-operative pain which is usually well controlled by pain killers. Each patient experiences very different degrees of pain but in general patients don’t find it particularly bad. It is often sore for a few days along the breast bone particularly is the implant is placed under the muscle. Moving your arms can be uncomfortable for two to three weeks after the operation but this gradually settles. The breasts are often swollen and tense to begin with but this settles down and the breasts become more natural looking after a few weeks. Sometimes there can be  bruising around the cleavage and under the breasts but this settles within two weeks. Most women will have reduced feeling (sensation) in the breast and nipple after the operation. While much of the feeling returns within a year in some cases the loss of feeling can be permanent.

 

COMPLICATIONS ; what can go wrong?

Bleeding

An important part of the operation is to ensure that there is no bleeding in the pocket for the implant at the end of the procedure. However about one in forty cases will develop a collection of blood which will make the breast swell and cause pain. Usually, this means the patient has to return to the operating theatre for removal of the blood collection. Even a small collection of blood is worth removing as it may cause problems long-term such as capsular contracture.  As long as the blood is removed there should be no long term problem from having this complication.

Infection

Minor wound infections around the incision are not common but can be treated with antibiotics. However, a major implant infection is very uncommon (less than 1%) but very often requires implant removal. Once the infection has settled and the wound healed in  3-4 months, the implant can be replaced.

**Capsular contracture***

This complication is by far the most common problem with implants. It is the single most common reason for exchange of implants – more surgery!   The body normally forms a thin envelope of scar around the implant called a capsule.  However, this capsule can become thickened and tightened,  making the implant feel hard and even changing its shape. If it is very bad, the implant can feel and look like a tennis ball and is often uncomfortable and even painful. The cause of capsular contracture in most cases is thought to be due to low-level contamination of the surface of the implant with bacteria (usually harmless skin bugs). These bacteria cause ongoing irritation and inflammation in the surrounding capsule eventually leading to contracture. We take many additional precautions to ensure the sterility of implants, (14 point plan) but absolute sterility may be impossible to achieve. The implants can also become colonised many months or years after surgery by bacteria entering the bloodstream at the time of an injury, surgical or dental work or an infection such as cystitis.

The newer designs of implants have features to reduce the chance of this happening. However, capsular contracture still occurs to some extent in around 3-4% of patients in their first year after surgery. Additionally,  1-2 % of patients will develop capsular contracture every subsequent year, which means that by 5 years the contracture rate may be as high as 10%. If the contracture is very mild and symmetrical, most women will not need treatment. However is it more severe, the feel and appearance will no longer be acceptable to most women and further surgery will be required. The operation involves removal of the implant and the capsule (capsulectomy), and a new implant is then returned to the fresh pocket. Some patients are very unfortunate and they get recurrence of their capsule despite a second or even third operation. Some surgeons use polyurethane coated implants and claim that they have a lower capsular contracture rate, however many do not agree with this. Nonetheless, polyurethane implants may be a useful alternative particularly if contracture has already occurred.

Capsular contractures can occasionally be associated with chronic seromas, a fluid collection around the implant. These collections can enlarge and shrink unpredictably,  giving the appearance of a different sized breast on that side. This uncommon association of capsules with seromas has recently been linked with a rare form of lymphoma (cancer).

Anaplastic Large cell lymphoma,(BIA-ALCL)

In recent years, a strong link has been found between capsular contracture and this rare form of cancer. This tumour is completely unrelated to common breast cancer of the breast tissue and seems to occur in longstanding, irritated, contracted capsules. There is an associated with chronic seromas (fluid around the implant). It is a rare but serious complication and has caused much concern and debate amongst plastic surgeons in the last few years. There are a few hundred cases in the world literature and no reported cases in Ireland to date. Nearly all cases have been cured with capsulectomy and exchange of the implant. There are a handful of cases who died due to late presentation and advanced disease.

Textured implants and Anaplastic Large cell lymphoma,(BIA-ALCL)

Most cases of BIA-ALCL have been associated with textured implants. However, it is difficult to make comparisons as the majority of cases have had textured implants and not smooth. The evidence for a link between textured implants and BIA-ALCL is contentious.
Because of this doubt and embarrassment relating to the PIP scandal, this year, the French authorities requested further information from the Allergan, the implant company, regarding their textured implants prior to renewal of the licence. When such information is requested, a licence (CE mark) can be suspended or temporarily renewed. France has chosen to suspend the CE mark while awaiting further information. Because of EU rules, Such a suspension is applicable to the entire EU. Allergan has withdrawn all its textured stock from the market until the licence situation is established. This will take 3 months minimum.

****The current recommendations regarding women who already have textured implants are that the implants DO NOT need to be exchanged. However, if there is significant capsular contracture or new swelling of the breast, an investigation is required and removal considered.

Rupture

With newer breast enlargement implants rupture is now quite uncommon in the first 15 years after surgery. It is possible that these implants may fail as they become older and it may be advisable to replace implants which are older than 15 years. Some of the older implants model were more inclined to rupture and particularly the notorious and faulty PIP implants were prone to leakage. Some of these patient developed collections of silicone in the glands of their armpits. Leakage of silicone can occur either as a slow seepage, or following  rupture of the implant shell . The silicone is almost always contained within the capsule which the body forms around the implant. Rupture is usually caused by aging of the implant. Occasionally trauma is involved but it does not occur during flying. Silicone leakage has never conclusively been linked to serious health problems. A rupture usually does not cause any pain or obvious symptoms, apart from the occasional enlarged glands.

Shape , size and positioning of implant – cosmetic issues

It is important to try and establish beforehand how big the breasts are to become. Obviously,  not enough enlargement will be disappointing,  but sometimes the skin is too tight or the patient too thin to take a very large increase in size. A very large increase (from A cup to D cup) can lead to a very unnatural look which is tight and often out of proportion with the rest of the woman’s body. Sometimes despite a lot of discussion and attempts to get the size correct, occasionally ,  the patient thinks the result is too large or too small. This is because it is difficult for the patient and the surgeon to predict exactly how a particular size implant is going to look under the breast of every individual. Mr O’Broin’s practice for estimating size involves the use of water bags of varying sizes which can be tried out at home. This method can be very useful and gives the woman much more input into this important decision. Occasionally the implants can take up slightly different positions on each side,  although it is usually not obvious enough for the patient to require a re-do operation. Most women have some degree of asymmetry between breasts and breast enlargement may occasionally exaggerate this difference.
A breast that has an underlying implant will not necessarily feel like a normal breast, and some women may be acutely aware of the implant as a foreign body within the breast. The size and shape of the breast following breast augmentation surgery will adjust with time and is to some extent unpredictable. It is also not always possible to create a cleavage with breast augmentation. The weight of the implant may influence the age-related changes that normally take place in breasts.

Kinking and rippling

It is quite common for implants to develop slight kinks with time. These irregularities may be felt but are usually not obvious. They may be a sign of early capsule formation but can also happen as the breast ages and drags the implant downwards. Sometimes they require replacement. Movement of the fluid which fills the implant may occasionally be seen through the skin, this being more likely in the saline (salt water) filled implants, and less likely in silicone implants, which also have a more natural feel.

Poor Scarring

Breast augmentation will always leave scars on the breast or in the armpit, and although the scars will settle over 12 or more months, the appearance of the scars does vary between different individuals. This scarring is placed in such a position as to minimize visibility even when wearing a swimming costume. Most scars are very good and barely noticeable however some women particularly if they have darker skin can develop thick red scars which are unsightly. These scars may need to be managed carefully to help them settle down.

Safety of silicone

Whatever the filling of the implant, the outer layer is made of silicone. Silicon is a naturally occurring element which becomes silicone when it is combined with carbon, hydrogen and oxygen. Silicone is manufactured into many items including cosmetics, foods and medical implants. Many studies have been conducted to establish whether silicone breast implants cause certain diseases. As a result of these studies, we can say that at present there is no evidence to suggest that silicone breast implants are associated with an increased incidence of breast cancer. There is also no evidence to suggest that these implants cause autoimmune diseases such as rheumatoid arthritis.

Sick Implant syndrome

There is no real evidence for this ‘sickness’, which includes a long list of vague symptoms which could be caused by a multitude of conditions apart from implants. The syndrome has been propagated on the internet fueling worry for patients and sometimes hysteria. However, surgeons are keeping an open mind in relation to this condition as all surgeons have occasionally encountered patients who feel generally unwell and improve on removal of implants. Theoretically, low-level contamination with relatively harmless bacteria could cause a low-grade inflammatory response, which in itself could cause this symptoms. Low grade inflamation might tip the balance in a patient with a tendency to autoimmune contitions such as Rheumatoid arthritis.

Pain

Pain, which is usually easily controlled with painkillers. You may feel quite sore along your breastbone, especially if the implant was placed under the pectoral muscle. Moving your arms can be quite uncomfortable for the first two to three weeks.  Some women can have more severe pain, often with numb patches on the breast. This pain is often described as ‘stabbing’ or ‘burning’ and is caused by injury to the small nerves that supply the skin. Usually, this pain usually settles after a few weeks. Numbness can last for up to six months and can sometimes be permanent. Very severe stabbing localised pain is rare but is often caused by a stretched or irritated nerve. This problem may require a return to the operating room to cut or relocate the nerve.

Breast feeding and cancer screening

Breast augmentation does not usually interfere with breast feeding, and there is no evidence of increased levels of silicone in breast milk of mothers with implants. The presence of breast implants can interfere with mammograms, which is an X-ray screening method for breast cancer.MRI or CT scans or ultrasound scans can be used as an alternative to image the breast.

General anaesthetic complications

Like all operations requiring a general anaesthetic patients can feel sick and may have a sore throat after the operation. However, with modern anaesthesia these problems are seen less frequently now. It is very unusual for patients having breast enlargement to have major anaesthetic complications like leg and lung clots, chest infection or reaction to an anaesthetic drug. We take precautions to prevent clots and other problems are extremely rare unless there is a past or family history.

Breast enlargement surgery frequently asked questions

How will I look and feel initially?
A day or two after surgery, you should be up and about. Any dressings will be removed within several days, and you may be instructed to wear a support bra. Your plastic surgeon will probably permit you to shower between three and seven days following surgery. Stitches are usually dissolvable and do not require removal. Some discoloration and swelling will occur initially, but this will disappear quickly. Most swelling will resolve within a month.  

When can I resume my normal activities?
After breast augmentation surgery, it is often possible to return to work within just a few days or a week, depending on your job. Vigorous activities, especially arm movement, may be restricted for two to three weeks. Sexual activity should be avoided for at least two weeks following surgery. After that, care must be taken to be extremely gentle with your breasts for at least another month.

How long will the results last?
Except in the event of a complication such as a tight capsule or rupture requiring a new implant, the results of your breast augmentation surgery will be long-lasting. However, gravity and the effects of aging will eventually alter the size and shape of virtually every woman’s breasts. If, after a period of years, you become dissatisfied with the appearance of your breasts, you may choose to undergo a breast “lifting” to restore their more youthful contour.

  References   1   http://www.silicone-review.gov.uk   2    http://www.doh.gov.uk/bimplants

Leave a Reply