There are two methods of breast augmentation: silicone implants or lipo-filling by transferring fat from one part of the body to the breast.
Silicone Breast Implants
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.
Is there any deformity to breasts when having implants removed?
There can be some changes in the breast shape and/or size due to excess skin. This can improve with time and skin shrinkage but there is always the risk of breast ptosis (drooping) and wrinkling after implant removal.
In placing the implants under the muscle, does this damage the muscle in any way? What happens to the muscle if the implants need to removed for any reason?
This is a good question. The reasons for any muscle changing in function if it is not used for any reason, injured, the nerves been damaged or the muscle length and therefore its tension has changed. Initially the muscle is damaged because we have to incise it partially to get the implant under it. This is why sub-muscular implants are more painful postoperatively than implants placed directly under the breast. Also initially because it is stretched the muscle will function slightly differently, but nature is forgiving because the muscle will learn to behave as normal after a period of recovery.
I have not detected any long term functional problems with the muscle (called the pectoralis major muscle). However, if you were a professional swimmer, tennis player, athlete (such as a javelin thrower, gymnast) I would not recommend any sub muscular implants to be inserted. For “normal people” in the long term, I do not think that there should be any impediment to sporting activities and every day life. Long term the muscle, I believe, fully recovers.
If the implant is removed the muscle will function as before but I suspect that there will be a relatively short period of full functionally recovery as the muscle gets used to the decreased length and tension after the implants have been removed.
MRI scans – should I do this every few years to check for any ruptures?
This is a complex and important question. There is no indication for regular MRIs in my opinion to check the state of the implants. An MRI should be carried out only if there is clinical suspicion that there is something wrong with the implant. For example a volume change, a change in shape or the presence of pain, may indicate rupture (implant failure) or capsule formation. I also believe if the patient is anxious , or feels she is experiencing odd symptoms or the implants has been in a very long time; then a scan should be done. A simple ultrasound is probably as good as an MRI in the right hands for detecting implant rupture. If an implant is damaged then they should be removed with the option to replace them with a different implant, perhaps consider fat filling.
What is a long time? This is not really known but after 10 years it maybe prudent to have an ultrasound. This is an arbitrary figure based upon the fact that nothing man-made lasts for ever and the cause of implant failure is multifactorial. Unfortunately, sometimes I am sure that an implant maybe damaged and ruptured but not detected clinically. This is because the natural capsule that forms around the implant keeps the implant in shape and in position. This logically begs the question of whether it is dangerous to have a ruptured implant in your body with internal extrusion of silicone. The opinion of the majority of medical practitioners and available research of statistical data (known as meta analysis), indicates that it is not dangerous. There is no evidence that silicone is harmful to the human body although of course, if the silicone used in implants is of low-industrial grade (such as in the PIP implants), then I believe that they can cause side effects and abnormal internal inflammatory responses. In my practice with Nagor, Allergan and Mentor implants I have not seen ruptured implants causing serious systemic problems. For some PIP cases, I have seen bad abnormal capsule formation and lymph node involvement and also historically in patients who have had implants that ruptured many years ago with old generation implants.The patient has to listened to and examined carefully should there be some change in.
The other reason for scans and investigations would be for diseases that may affect your breast in the future. This is a separate issue and must be treated on their own clinical merits. The implants would not affect the efficacy or the way diseases of the breast itself can be investigated. There is no evidence that you are more at risk or there is less chance of diagnosing breast disease because of silicone implants. There is certainly no evidence that they cause cancer.
What would be the likely costs of re-operation or replacement?
Any emergencies will be covered free of charge.
But long term surgery is not free. For example, if a hard capsule forms around the implant after several years, the cost of the implant will be covered (as this is under warranty) but not the cost of the surgery. The rate of capsule formation is about 10%.
If the patient wants bigger implants or the implants removed then there will be a cost in the region of £2900 to £4900 dependant upon the surgery required/requested.
How would I best control pain after the (breast augmentation) surgery?
We will give you the appropriate pain killers and instruct you how to use them. Postoperatively, after the local anaesthetic has worn off, it will be painful. However if the pain killers are used as instructed then the pain will be tolerable and last a few days, although this is so variable.
On a scale of 10 (when 0 is no pain and 10 is the worst pain ) from our audits the pain has varied from 0 to 9. The average is between 5-7. however the perception of pain is so variable between patients. I have observed that the unknown and anxiety causes pain perception to increase.
The knowledge that pain after a procedure is normal and expected will always somehow help patients dealing with discomfort along with the appropriate use of analgesics.