Breast Augmentation

Breast Augmentation is a surgical procedure designed to enhance the size and shape of a woman's breasts.

Breast augmentation (breast enlargement/boob job) involves placing a breast implant behind the breast to enhance the volume of breast tissue and improve the shape. It creates a more balanced appearance to your body if you have relatively small breasts, or replaces breast volume you may have lost after having children, breast-feeding, weight loss or as part of the natural aging process.

Breast augmentation can help to improve a woman’s sense of body image, and in many instances can enhance self-confidence. As a Female Plastic Surgeon I intimately understand how a woman’s feelings about her breasts can influence her self-image and feelings of femininity.

Most women requesting augmentation find that their breasts are small when compared to their body proportions, or that their breasts have become deflated after having children. Other women are seeking better symmetry of their breasts if one is a different size or shape than the other. All women who undergo breast augmentation simply wish to feel more balanced in their body shape and improve their natural curves. Breast implants can also used to help correct abnormal shapes of the breast.

An example of breast augmentation.

Most women requesting breast augmentation want to avoid an obvious and unnatural fake look. My goal is always to create a beautiful, natural breast augmentation result that looks as though you were created that way.

Who Is It Suitable For?

Good candidates for breast augmentation include women who are healthy, in good physical condition and at their ideal body weight (which should be stable). The surgery is suitable for women with small breasts relative to their frame, women who wish to have fuller breasts or those who wish to improve the shape of the breasts. Breast augmentation may also be suitable for women wishing to correct breast asymmetry.

Sometimes a breast augmentation is combined with a breast lift (mastopexy) if there is also significant breast droop. At consultation you will be examined to determine whether a combined mastopexy-augmentation (breast lift with implants) procedure is appropriate.

Who Is It Not Suitable For?

Women who have a significant medical history, women with unrealistic expectations. Women who have been encouraged by others to change their appearance.

What Implants Should I Have?

There is a huge variety of available breast implants. They vary in size, shape, surface and fill.

Implant size varies from 50 to 800cc. Implants are designed to fit the width and height of your chest wall. The variation in volume comes from the projection of the implant; it may be low, moderate, high or very high projection. The height and width of your chest wall are fixed but the volume that you desire can be determined at consultation using a sizing kit.

Implant shape is either round or anatomical (tear drop). Round implants can provide more volume in the upper half of the breast whereas teardrop-shaped implants have the natural shape of a breast and aim to give a more natural result with less upper fullness.

The outer shell of all implants is made of silicone. Silicone is a natural element and an inert solid that is biochemically most similar to carbon (the element that makes us “organic”). Silicone is used safely in lots of different implantable medical devices. The shell may be smooth, textured (rough appearance) or polyurethane-coated.

Implants can be either saline filled or silicone filled. Most patients opt for silicone filled as they look more natural, feel more like breast tissue and are less likely to develop folds and ripples longer term. Additionally in the event of rupture a saline implant is more likely to deflate whereas a silicone implant will maintain its shape as it is in the form of a cohesive gel. Very recently an additional type of silicone implant has been added to the market that incorporates air pockets within the silicone gel resulting in a lighter weight implant for the same given volume. If appropriate this type of implant can be discussed at consultation.

The most appropriate implant for you depends on many factors including your age, chest width and height, breast volume, breast density, skin elasticity, weight and aesthetic goals. There is no “one-size fits all” and as part of the consultation all these factors will be considered to formulate a unique treatment plan for you to achieve the result that you desire.

Is Silicone safe?

Breast augmentation is a personal decision for you as a woman, and should not be taken lightly. I encourage all patients to educate themselves about the safety and science of breast implants before considering a surgical procedure.

Breast implants are made from medical grade silicone. Silicone is one of the most widely-used soft implantable materials in medicine. It has been used for decades in medical devices such as grommet tubes in children’s ears, pacemakers and artificial joints. Silicone breast implants are the most extensively studied implantable medical device.

The FDA approved silicone gel-filled breast implants for cosmetic breast augmentation after reviewing a large amount of scientific data, and clinical research supporting the safety of silicone breast implants.

In rare cases implants may fail and the silicone gel may leak out. Small amounts of silicone may leave your implants and be taken up in the lymph glands. However there is no evidence that a ruptured breast implant and the resulting leakage cause ill health. It may cause symptoms such as pain and deformity of the breast. It will require re-operation to remove and replace the
implants. Removal of silicone from the lymph glands is rarely necessary.

Which Incisions are Used For Breast Augmentation?

The Inframammary Fold (IMF) Incision (in the natural fold beneath the breast) is the most commonly used incision. This incision leaves the scar in a natural crease and does not tend to stretch or become raised, as can happen in other areas. This approach conserves the anatomic structures of the breast (milk ducts, nerves and blood vessels). No breast tissue is transected during surgery. Therefore this incision in theory has the least interference with future breast-feeding and nipple sensation.

Once you have had implants there is the potential that you will require maintenance surgery at some point during your lifetime. The inframammary incision provides the best access for surgeries  such as implant exchange, breast revision or breast lift.

Inframammary scars are hidden when viewing the breasts from above or from the front, are concealed in bras and bikinis, and are generally only visible when the breasts are lifted.

Peri-areolar incisions are made around the bottom of the “areola”, the pigmented circle that surrounds the nipple. Bacteria live in this region together with milk ducts, blood vessels and nerves leading to the nipple. Some of these structures must be divided during surgery when using this incision, resulting in a higher potential risk of complications (infection, numbness, breast feeding difficulties). In addition, if abnormal scarring occurs it is visible in this area. For these reasons, I use the peri-areolar incision is used less commonly.

Trans-axillary breast augmentation makes an incision in the armpit, known as the axillary area. This is not an approach that I use.

Implant Under or Over the Muscle?

Breast implants can be placed behind the breast tissue (Subglandular) or behind the breast tissue and the pectoralis major muscle (Submuscular). There is also a technique called “dual plane” which is essentially a partial sub-muscular placement but still requires the pectoralis muscle to be lifted.

I recommend the Subglandular Position for most ladies. The reason for this is multifactorial, but in the creation of a natural result I try to interfere with anatomy as little as possible. The volume has been lost or is missing from the glandular space so it makes sense to replace the volume into the space from which it is missing! Lifting the pectoralis muscle alters its function and whilst it may be the only option for some ladies, I avoid it when I can. An implant placed in the subglandular position will move normally with changes in body
position, maintains its shape over time and does not become “animated” like submuscular implants. Subglandular implant surgery is less painful compared to submuscular implants.

The “submuscular, “subpectoral” and “dual plane” procedures all place the implant beneath the pectoralis major muscle to some extent. Occasionally, in certain ladies, particularly those who have very little of their own breast tissue and thin skin I may recommend placement in the submuscular position to help disguise the implant and reduce the chance of the edge of the implant being visible and palpable.

What to Expect from your Consultation

At your initial consultation we will discuss your general health, lifestyle and any medications that you take, prescribed or otherwise. I will then discuss what specifically troubles you about your breasts and what you are hoping to achieve with an augmentation. It is important that you are open and honest at this stage so that I can really understand your motivations and desires.

You will then be examined and a number of measurements of your breasts and chest wall will be taken. Based on these measurements and the discussion that we have had I will suggest some options using a sizing kit to help you decide on size. The best implant size is individualized to you based
on your height, weight, lifestyle, frame and expectations. There will always be a second consultation prior to making any final decisions and of course additional consultations if necessary.

Although much of the decision-making is made during your pre-operative consultations there is also an element of sound surgical judgement and use of an aesthetic eye in the operating room to ensure that you achieve the desired result. It is useful if you can find images of breasts that you would like and breasts that you don’t like to bring with you to one of your consultations. Although I cannot guarantee to get results exactly as shown in pictures, it helps to clarify in my mind the look you are hoping to achieve and this aids that process of aesthetic judgment in the operating room.

Preparing for Breast Augmentation

You should be physically fit and at your ideal weight which should be stable prior to embarking on breast augmentation. Your health will be assessed pre- operatively and you may need some tests that will be arranged if required. You should stop smoking at least 6 weeks ahead of surgery to reduce the risk of wound healing problems. You should stop aspirin, anti-inflammatory medications and any non-prescribed medication at least a week before surgery. If there is any change in your health prior to your surgery date you should let me know. Your health and general well being are my primary concern when I am treating you therefore if you are unwell for any reason it may be necessary to postpone surgery.

What to Expect on the Day of Surgery

Breast augmentation is performed as a day case procedure under general anaesthetic. The procedure usually takes 1-2 hours. An incision is placed in the inframammary fold (unless an alternative has been decided – see above), and a pocket of space is created for the breast implant. A temporary implant (sizer) may be used at this stage and is placed into the pocket that has been created. I then assess you in the sitting position to ensure that the volume and dimensions of the augmented breast are in line with your goals. When necessary the sizer can be adjusted to determine the final choice of implant.

In ladies that have 2 breasts of different sizes, different implants may be selected in order to achieve better symmetry. Once a final decision is made the permanent implant is placed in the pocket and the wound is closed with dissolvable stitches. You will have local anaesthetic blocks to reduce the post-operative pain and I do not routinely use drains.

You should be back on the ward around an hour after surgery and able to go home later the same day once you have had something to eat and drink.

After Surgery

Initially you will feel quite swollen and the area may feel tight or like there is pressure on your chest. This often gets worse over the first couple of days as the swelling reaches its maximum and then starts to settle. You will be discharged with appropriate painkillers. There will be a dressing over the wound and you should keep this dry for the first week. You will need a friend or relative to pick you up from hospital and stay overnight with you. You will have your first wound check at one week post-op.

You need to wear a supportive post-operative bra day and night for 6 weeks. At two weeks you should be able to return to low impact exercise including swimming. At 4 weeks you can do normal exercise provided you have a good supportive sports bra. I am happy to advise on this if you bring your bra into

The scar should have healed by week 2 and at this stage I will ask you to start scar massage. You will need lubricant for this and whilst there are a number of commercial scar creams and oils available, a simple moisturiser will suffice.

Over the course of the next few weeks the breasts will soften and drop as the swelling goes down. Sometimes this process happens more quickly on one side than the other so there may be a short period when the breasts feel asymmetrical or lopsided. It can often take a few months for the final result to become apparent.

Risks and Potential Complications

As with any surgical procedure, breast augmentation is associated with some potential complications. Having a general anaesthetic is associated with low risks of chest infection, respiratory or heart compromise and blood clots in the leg (DVT) or lung (PE).

Early in recovery you may notice altered sensation, swelling, bruising and a small difference between the two sides. It is normal for all these to settle with time. Occasionally the procedure and be complicated in the immediate post-operative period by infection, haematoma, delayed healing and opening up of the wound which exposes the implant (extrusion). In the case of infection or extrusion it is necessary to remove the implant and allow the infection to be cleared and the tissues to settle for 3-6 months before having a new implant.

Other early to medium term complications include formation of a seroma, which is a collection of tissue fluid next to the implant. This normally self resolves but on rare occasions may require drainage by a radiologist. The scar does normally settle to be a pale fine line, however, in the first few months it is often pink and may become thickened. In this case you will be given an additional scar management plan to help this settle.

The bodies’ natural processes will wall off any foreign material in the body, including implants. A capsule (or internal scar) of tissue forms around the implant. This process usually has occurred by around 6 weeks post-op. The capsule can gradually thicken and get tighter with time and when this happens it is called capsular contracture. It can cause a change in the shape / position and size of the breast and in the later stages it may cause pain. This process is very patient dependent and occurs much more rapidly in some ladies and never in others. The most common reason for requiring further surgery to the breast after augmentation is to treat capsular contracture.

In ladies who have had anatomical (tear drop shaped) implants, there is the potential for implant rotation. Rarely this may require re-operation to re-orientate the implant.

Nipple sensation can be altered following augmentation. It may be increased or decreased for a number of months however the change is unlikely to be permanent.

Thin ladies will be able to feel the edges of the implants. There is no way to avoid this and it will be permanent. The upper part of the implant can be placed behind the pectoralis muscle to try and reduce this but the implant edges will still be felt further down the breast. As a rough guide if you can see your ribs when unclothed you will be able to feel and possibly see the edges of the implant. Over time ladies who are thin are more likely to develop rippling of the implant that becomes palpable or even visible in certain positions.

Recently there has been much interest in a type of lymphoma that is associated with breast implants. Breast Implant-Associated Anaplastic Large-Cell Lymphoma (BI-A ALCL) is a type of lymphoma that develops in the capsule of breast implants in some ladies. There is currently much research going on to assess the true incidence and cause of this lymphoma. The reported rates vary from 1 in 1000 in certain types of implants to 1 in 10 000. The actual incidence is as yet truly unknown. The condition most commonly presents with unilateral swelling of a breast associated with a fluid collection around it. It usually presents at least a year after augmentation but more commonly later than this. Diagnosis involves sending the fluid for special tests. The treatment is to remove the implant and the surrounding capsule. In very rare cases some ladies have required chemotherapy.

Is Breast Feeding Still Possible after Breast Augmentation?

Provided the breast tissue and ducts are not divided during surgery all the structures that lead to the nipple are preserved. This is one of the many reasons why I normally recommend an inframammary incision. You should maintain the ability to breast feed, assuming you would have been able to prior to having surgery (there is a minority of women who find that they are unable to breast feed irrespective of whether they have ever had breast surgery).

Can I have Mammograms With Breast Implants?

Having a breast augmentation does not interfere with breast self-examination, breast examination by a doctor, mammograms, ultrasound, MRI or any other cancer detection techniques. However it is important that you notify the mammogram technician that you have implants. When you have implants the radiographer will perform additional images (Eklund displacement views) to ensure that all breast tissue is fully assessed. If you are of breast screening age you should be up-to-date with your mammograms prior to embarking on any breast surgery.

Will I need Additional Surgery after Breast Augmentation?

During your lifetime it is likely that you will require at least one additional procedure to maintain your implants. The most common reason for needing further surgery is the development of capsular contracture this is usually treated by removal of the capsule and replacement of implants. Other procedures you may require include removal of implants, adjustment of size or uplift (mastopexy) depending on changes in your body, your desires or personal situation. Breast Implants do not need to be routinely changed at
certain time periods.

I offer long-term follow-up appointments to ensure that you are still looking and feeling as good as you did immediately after surgery. If time, aging, weight change or gravity have influenced the result we can discuss at that stage what options are best for you and your lifestyle (which may have changed radically since your first augment). However, there is no reason to undergo any additional surgery unless you are experiencing a problem or you wish to have another procedure in the future.

Is Breast Augmentation Part of a Mummy Makeover?

Breast augmentation is often one part of a Mummy Makeover but it very much depends on how pregnancy, childbirth and breast-feeding have influenced your breasts. Some ladies will feel deflated following breast feeding and an augmentation is therefore suitable either on its own or combined with an uplift operation (mastopexy). Other ladies will simply need an uplift to rejuvenate their breasts whilst some will be left with much larger breasts and request a breast reduction. Whatever you feel you need to rejuvenate yourself following children, we will discuss it at your consultation and design a plan to get you the results you desire! See my mummy makeover section for more in depth discussion.

Is there an Alternative to Breast Augmentation?

Occasionally when I assess ladies requesting an augmentation I find that they still do have a reasonable volume of breast tissue; it is just sitting in the wrong place! If the primary problem is droop rather than volume loss then it maybe that an uplift procedure is more appropriate. I will discuss this with you once I have examined you!

To replace or increase volume the only other option is autologous fat transfer. This involves performing liposuction to harvest fat from other areas of the body and then processing it and injecting it into the breast area. Whilst this may sound an attractive proposition it usually requires several operations to achieve a noticeable difference and the fat transferred does get reabsorbed (melts away) to varying degrees.

"Thank you so much for everything you have done for me! You have really changed my life. I am over the moon with the outcome, I never thought I could feel this good about myself."

- PK Bilateral Breast Augmentation

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