The decision to alter the shape or size of the breast is a supremely personal one.
There are artistic, clinical and cultural ideas of the size, shape and proportions of a “normal” breast. However, I personally do not believe that this is applicable to a part of the body with such intrinsic variation.
Certainly there are abnormal breasts: breasts that are very asymmetric or are too large or pendulous can cause real functional and psychological problems; men with breasts (gynaecomastia); and women with no breasts, very small breasts or changes of the breast tissue after pregnancy or breast-feeding, can suffer true psychological pressures from within and from the outside world. An odd comment there or an unintentional quip can lead to prolonged misery.
Therefore, when a patient has a consultation for breast augmentation it is important to try and determine the reasons behind their desire for the procedure. It is imperative that the surgeon is sure that cosmetic augmentation will improve wellbeing and confidence. In terms of semantics there is a distinction between cosmetic augmentation, which deals with alteration of a pre-existing breast, and reconstructive surgery which concerns deformity, missing breasts or major asymmetry. However, techniques used are often within the same surgical spectrum.
For cosmetic breast augmentation the patient must have maturity, both physical and mental, to be able to handle the implications of surgery, especially if implants are used. The key is informed consent. Knowledge of the predicted change in size and shape will help greatly but this is often difficult to determine with accuracy, despite modern computer imaging software. Women will usually have some sort of idea of the volume change needed. Sometimes a photograph of the size and shape of a breast desired is shown at consultation. Often change is expressed in alterations in bra size. However, in my experience this is really not an accurate predictor of what is possible or indeed correct in terms of aesthetics for the individual. The use of “bra sizers” containing an implant fitted over the pre-operated breast helps but is only quite a crude predictor of the eventual result. It is true that it is easier to fit a bra to a breast than the other way around. The reason for this is that the clinical and technical constraints for the maximum size of implant are dependent on several factors. This includes the surface area of the front of the chest wall, the quality of skin as well as the size and degree of ptosis (droopiness) of the pre-operated breast.
There are a number of contraindications, too. The patient has to be medically fit and very careful judgement has to be used if there has been previous breast surgery, pathology or radiotherapy. In my opinion, there has to be exceptional circumstances to carry out cosmetic augmentation before the age of eighteen as there are profound psychological and physical changes occurring before that age. At the other end of the spectrum, in my experience, patients are self-selecting and it is rare to augment women above the age of sixty.
Once it has been established that breast augmentation will benefit the patient, the different techniques, possible complications and long-term implications must be explained. Augmentation can be carried out with either lipo-filling techniques or with the use of implants. This surgery can be carried out under local anaesthetic with or without sedation as day cases – which is what we do at The Westbourne Centre in Birmingham.
Lipo-filling, also called fat transfer, uses the patient’s own fat (usually harvested from abdomen) to enlarge the breast. I tend to use this for smaller augmentation or for the treatment of asymmetry. There are several advantages to lipo-filling. It uses the patient’s own tissue, it is safe and is not associated with capsule formation which silicone implants can cause. However there is always some fat resorbtion and, for larger volumes, several stages maybe needed and therefore the costs are usually much higher. In the long-term there maybe problems with the interpretation of mammograms as sometimes, when fat resorbs, specs of calcification can occur. Subsequently this can be apparent upon mammography. This is often quite typical and easily recognised, however, patients must be aware this may possibly lead to an increase need for biopsy in the future.
Insertion of silicone implants is still the main technique used throughout the world for breast augmentation. There is no definitive evidence that silicone is harmful but I believe that there will always be controversy and patients must be aware of this. As with lipo-filling, there is no evidence that augmentation with silicone implants increases the chance of breast cancer but the interpretation of mammograms of breasts with underlying implants requires experience. Certainly, criminal manufacture of breast implants with industrial silicone, as with PIP, is very rare and hopefully will never occur again. However there is always a terrible chance of history repeating itself.
The different shapes in use (tear drop and round) are confusing. The choice depends on the look of breast the patient desires. The teardrop implant fills the lower part of the breast while the round implant will give a general projection. Projection itself (the amount the breast protrudes from the surface of the chest wall) will depend on quite a few factors such as the amount of breast tissue already present to the ratio between the width and projection height of the implant itself. No matter what technique is used, with time, the shape will evolve and usually become more ptotic (droopy).
The decision whether the implant is placed under or over the chest wall muscle depends on the size of the pre-operative breast. In my practice, if there is little breast tissue then the implant is placed under the muscle. Implants are usually inserted via a short incision in the natural sub-mammary crease line, which is situated between the lower part of the breast and the chest wall. This usually heals inconspicuously.
Complications and Consequences
The patient must be aware of both short and long-term complications. In reality there is no definitive guarantee that the size and shape of the breasts will be satisfactory, although, naturally great efforts are expended to achieve an optimum result. Early troubles such as bleeding and infection can take place after any operation however this is relatively rare in breast augmentation. Nipple sensation changes can occur but, for silicone implants, probably the most important complication is capsule formation or hardening around the implant. This in turn can lead to breast shape changes and sometimes pain. The cause is multifactorial but surgical technique and type of implant, as well as patient factors, probably play a part. The incidence of capsule formation within the first five years is about 10% but with time this undoubtedly rises and close liaison with the surgeon is needed long-term.
Lastly, how long do implants last? Certainly not forever and changes in volume or consistency may indicate rupture or leakage and the need for exchange. The incidence and timing of this is very variable. It may never occur or happen after just a few years.
In conclusion, cosmetic breast augmentation carried out for appropriate, well-informed patients is an excellent procedure to improve psychological wellbeing. The keys to success are selection, clinical expertise and experience as well as an informed patient with knowledge of the personal benefits and long-term consequences of surgery.
Can I decide where on my body I want the fat taken from, for breast augmentation?
Yes. As long as there is fat in the location requested then we do our best to harvest from the area of the body the patient requests. This is not always possible but I will discuss that with you during consultation.
My friend had to go to the surgeon several times to have her breasts enlarged with fat transfer, how many procedures does it take?
The number of procedures depends on the degree of augmentation needed. It is not unusual to need several lipo-filling procedures to achieve a desired breast volume. Two or three times, or even more, is not unusual and done safely under local anaesthetic with sedation.
In the past I have been very susceptible to recurrent mastitis, does this have any relevance?
Mastitis means bacterial infection of the breasts (not the same as mastalgia which is pain in the breasts or inflammation sometimes associated with the menstrual cycle). If it is mastitis, this may be important. If this is spontaneous and unrelated to pregnancy it is quite unusual We would need to have a conversation about when and how often this situation occurs prior to deciding upon breast implants.
Putting the implant under the muscle would lessen the chances of infection of the implant during mastitis but if this is a frequent problem I would not recommend any form of breast implant and you will need to be investigated as to the cause (unless this is related to pregnancy or breast feeding).
Can I have a tummy tuck and breast lift at the same time?
If this is clinically judged to be appropriate by your surgeon, then doing both these procedures at the same time is often a very good way of managing the dual cosmetic problem of excess tissue causing looseness and droopiness of the breasts and abdomen. However this will never be recommended if the patient has any significant problems such as a high body mass index (30 is a probably a universal cut off), diabetes or unstable weight or mood.
How soon after breast surgery can I resume exercising?
After breast surgery I believe that normal activity should be resumed as quickly as possible. Normal activity means walking and light duties and this can occur between 24 and 48 hours for some patients, and there is much individual variance.
I also believe that when the body is challenged, such as after surgery or any form of trauma, recovery is enhanced with sensible rest. Simple surgical wounds take ten days to heal primarily and three months to reach 70% strength.
During this time, in breast augmentation, the capsule that surrounds the implant develops and strengthens and all the inflammation, which is essential for healing subsides. However there is probably much individual variation as to the exact timing in this process as well.
Therefore, as a compromise, I would not recommend extreme or severe exercise until at least six to eight weeks has passed. Remember it is possible to keep fit and have a sense of well-being by sensible graded return back to full on exercise, and to do this one should always be in touch with how you feel and of course discuss this with your surgeon or the clinical nurse specialist at any stage.