The decision to have breast augmentation is an entirely individual and personal one. Few will understand how a woman feels and why she may wish it. Some reasons why women choose to increase the size of their breasts are: the size of their breasts is small in proportion to their body build, their breasts have become smaller after weight loss, breast feeding, pregnancy, age or they have asymmetrical breasts.

METHODS

The most common and simplest method for breast augmentation is the use of an implant. Another less commonly available method is the use of autologous tissue (natural body tissue).

Incisions

Incisions can be inframammary (crease beneath the breast), axillary (armpit), periareolar (margin between coloured nipple-areolar and breast skin) or periumbilical depending on the wishes of the woman and the type of clothing she normally wears.

IMPLANTS

The simplest method for breast augmentation is the insertion of an implant in a pocket made behind the breast (subglandular) or behind the pectoralis major muscle (submuscular).

Implant placement

Subglandular		Submuscular

The advantage of placement in the submuscular pocket is that there is a lower incidence of capsular contracture and that the contour of the breast is improved because the edges of the implant are blunted by the muscle.

A potential disadvantage of submuscular placement is that the implant may move when the woman exercises.

Most implants are now made of a silicone elastomer outer case and are filled with silicone gel or saline (salt water). The advantage of the silicone gel filler is that it feels more like breast tissue than saline. The more modern ‘cohesive’ silicone gels that are used as implant fillers will not disperse into tissues if the implant should rupture. Saline filled implants tend not to have the feel or consistency of breast tissue and have a higher tendency to ripple (visible movement of fluid beneath the skin) or wrinkle (visible fold of implant shell).

Most women request breast augmentation after full development of their breasts. However, some young women with a marked size difference between their breasts can be very distressed. It is possible to augment the smaller breast with an implant expander that can gradually be inflated as the breasts continue to develop.

AUTOLOGOUS TISSUE (natural body tissue)

An innovative method for cosmetic breast augmentation is the use of autologous tissue (the woman’s own natural tissue) in the form of free tissue transfer, for example the DIEP (Deep Inferior Epigastric artery Perforator) or SIEA (Superficial Inferior Epigastric Artery) perforator flaps. These flaps consist of the fatty tissue from the lower abdomen that is normally excised in an abdominoplasty or ‘tummy tuck’ operation. This operative technique is most commonly used for reconstructive breast surgery after mastectomy. It is an elegant method where the abdominal wall muscles are left behind and only the skin and fat are transferred with the blood vessels as the ‘perforator flap’.

The limitations with the autologous breast augmentation technique is that it is only suited to a small number of women. These are mature women who have adequate abdominal tissue to augment both breasts, who have completed their family and would also like an abdominoplasty or ‘tummy tuck’ operation. It involves a microsurgical free tissue transfer procedure, is complex, lengthy and costly and requires special surgical expertise.

The main advantages of the use of autologous tissue as opposed to an implant are that the augmented breasts will be soft, warm and similar to normal breast tissue. The autologous augmented breasts will change in size and proportion to overall body weight changes. There are none of the risks associated with implants such as capsular contracture, implant ‘bleed’ or rupture of the implant.

The injection of free fat into or behind the breasts for breast augmentation is not recommended as it may cause lumps or changes on a mammogram that may confuse the diagnosis of a breast cancer.

ESSENTIAL CONSIDERATIONS AFTER BREAST AUGMENTATION WITH IMPLANTS

Breast feeding and pregnancy

Silicone has never been shown to harm a breast fed baby. Implants themselves do not usually interfere with the ability to breast-feed. If a periareolar incision is used for insertion of the implant, some of the milk ducts may be divided and could impair breast-feeding. Pregnancy and breast-feeding may cause breasts to naturally enlarge as much as 3 bra cup sizes. A very large implant will add further to the weight and stretching of the skin. Breast milk is sometimes produced for a few days after breast augmentation surgery if a woman has breast fed in the year before surgery and usually resolves on its own.

Age

Breasts naturally change in size and shape with age. Augmented breasts will also change with age and the outcome is not predictable.

Mammography

Screening mammography for the detection of breast cancer is currently offered to women aged 50-64 years in the UK. Silicone implants do obscure breast tissue on conventional mammograms. It is therefore important to inform the radiographer (person who takes the x-ray pictures) when breast implants are present.
For women with breast implants, additional mammogram views can be taken and special techniques used to obtain a better view of the breast tissue. Other imaging techniques such as ultrasound or MRI (Magnetic Resonance Imaging) are available for specific breast problems.

Sensation

Nipple sensation is altered in about 1 in 7 women after breast augmentation. It can be reduced, heightened or lost. These changes are usually temporary but can sometimes be permanent in a small number of women.

Sexuality

The enhancement of physical appearance can have immeasurable psychological benefits in terms of confidence and self-esteem. Many women who have had breast augmentation say that it has had a positive effect on their sexuality.

Scars

Scars used for breast augmentation are placed in areas so that they are not noticeable. All scars are permanent. Most scars go through a phase where they become firm for a few months before softening. Some scars become red and wide but usually settle down with time to become less noticeable. Discussion of scar placement with the surgeon before the operation is essential for each individual.

Asymmetry

Marked degrees of asymmetry between natural breasts can be adjusted by the insertion of different sized implants. Most women have some degree of mild asymmetry between their breasts in terms of size, shape and placement on the chest wall. Breast augmentation may make these mild discrepancies more noticeable.

Cleavage

Breast augmentation usually enhances a woman’s cleavage but depends on the width and shape of the chest wall. Symmastia (breasts joined together) is an uncommon drawback after breast augmentation and occurs when the implants are placed too close together. A further operation is required to correct this.

COMPLICATIONS

Breast implants have a limited life span (about 10 years) and women should be aware of the possible need for further surgery for change of implants and the future costs involved.

Implant leak or rupture

If a saline implant leaks, the woman usually notices that the breast has become smaller. With a silicone gel filled implant, a slow seepage of silicone gel may not be noticeable. The leaked silicone gel is normally contained within the body’s fibrous capsule that surrounds the implant. Silicone leakage that has moved beyond the capsule has never been conclusively found to cause serious health problems. An operation to remove the leaking or ruptured implant is recommended and replacement with a new implant is usually possible during the same operation.

Visible implants

With age, breast tissue becomes thinner and the edges of the implant may become more obvious. Submuscular placement of the implant usually improves this appearance.

Capsular contracture

The formation of a capsule (scar tissue around an implant) is the body’s natural reaction and happens in all women. It is not a problem in itself unless the capsule becomes very thick, painful and distorts the breast. This happens in about 10% of women receiving silicone breast implants. Some of these women will require further surgery for open surgical capsulotomy (release of capsule) or capsulectomy (removal of capsule). A closed capsulotomy procedure is not recommended as the implant may rupture and cause dispersion of silicone gel into the tissues.

Infection

Infection surrounding an implant usually requires a further operation in order to clear the infection and sometimes to remove the implant. After the infection has completely settled down (usually after about 3 months), it is possible to insert another implant to augment the breast.

Bleeding

As with any operation, there is a small risk of bleeding that can cause pain and swelling. If a haematoma forms, a further operation may be necessary to control the bleeding and remove the accumulated fluid. This usually happens within the first week after surgery.

Women who are most pleased with the results of their cosmetic surgery are those who have had it done for themselves rather than for anyone else. It is important to find out as much as possible about all the possible options when undergoing any surgery and to have a thorough discussion with the surgeon about the complete process. This is done with complete confidentiality between the woman and the surgeon. Cosmetic surgery can have immeasurable benefits to a woman’s self-esteem, sexuality and feelings of femininity.

LINKS

www.dh.gov.uk/bimplants

www.silicone-review.gov.uk

www.mhra.gov.uk

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