Breast Augmentation

Breast augmentation surgery can bring out the new you! It can give you what you’ve never had – but always wanted, or restore something you lost after pregnancy and breast feeding. The journey through augmentation surgery can be exciting and challenging and my aim to guide you through this. I will work with you to give you a the best result possible, focusing on your own issues and desires.

Breast augmentation developed a bad reputation because of misleading information published in the media, because of lack of full disclosure about the problems that do occur and because of the negative attitudes towards cosmetic surgery. I hope this information helps answer some of your questions and address some of these issues.

Cosmetic surgery can give people a real boost in their self-esteem – but only for those people who really want the surgery for themselves! You need to be sure in yourself you are not considering breast augmentation for the wrong reasons, and that the risk of the above problems make it still worth it for you. Most women who undergo this surgery are very happy they did.

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Is it true silicone implants are safe?

In 1992 the FDA in the USA placed a moratorium on the sale of silicone filled breast implants. At that time there was some concern that silicone caused autoimmune disease. We now know that is not true (see additional material if interested). The FDA has subsequently approved silicone gel breast implants. The NZ Government did not ban them at any time.

It was believed by some people that silicone somehow caused the body to attack itself – e.g. rheumatoid arthritis is a disease where the body attacks joints, scleroderma is a disease where the body attacks its internal organs. Science and medicine are now comfortable saying there is no evidence that silicone has any relation to these diseases.

The manufacturers, on the other hand, did make implants that ruptured too easily, and they didn’t do enough clinical studies in the past, so they are a bit at ‘fault’ for many things, but not for silicone causing disease.

Silicone is everywhere – hairsprays, makeup, anti-colic medicines for babies. In fact all our needles and syringes are lined with liquid silicone – so we all get a little bit with each injection. Diabetics probably have more than anybody, and they do not get autoimmune diseases any more frequently than the rest of us.

You need to know all this about silicone because all implants (even saline) have a silicone shell. If you are not convinced that silicone does not cause disease then you should not have a breast augmentation. You will still hear about silicone in the media because they like a good ‘story’.

Why do some patients develop hardening of their breasts after breast implants?

The main problem with breast implants is tightening and hardening. When you have anything foreign in your body, whether it is a splinter, an artificial joint, a pacemaker or a breast implant, your body makes a capsule around it. The capsule is made up of your cells, which form a thin membrane around the foreign body. This membrane then tightens – it is actually trying to do it’s job of walling off then foreign object – to get rid of what doesn’t belong. Many of you know someone who has had a piece of glass come out of their skin many years after a car accident. Capsule formation is what allows that to happen. Capsule formation is an appropriate process under normal circumstances,, unfortunately if the capsule gets too tight or thick around the breast implant it can make them feel hard and look distorted. The implant itself doesn’t become hard/distorted, it is the tightening of the capsule that makes them appear that way.

How many patients develop breast capsules? Everyone!

How many get capsules that are firm? Probably about 10% – but many patients actually like some firmness.

How many want to do something about the firmness? Probably only about 5%, with only 1% ever wanting them out completely. There are, however, other reasons that repeat surgery may be necessary, and all patients need to recognize that breast augmentation is not usually a one-time procedure. Repeat surgery may be needed to replace the implants (see later) as well as for capsule formation.

If we could predict who will develop capsular contracture, or if we knew how to prevent it, or even if we could successfully treat capsules, breast augmentation would be an excellent procedure with very little controversy surrounding it!

Some people believe that placing the implant below the muscle helps prevent hardening, although if it is not the best place for YOUR implants, you may not get the best result.

If you get a troublesome capsule the next step is to re-operate, surgically release the capsule and hope that it will not form as thickly or as tightly as before. Capsule release or removal is not successful in all cases.

Can someone tell if I have implants in place?

You should only undergo breast augmentation surgery if you are prepared that they may be obvious in certain circumstances. Sometimes folds and ripples develop which can be felt, or even see, through the skin. We do everything possible to prevent this from occurring, but we often don’t have much control over this particular problem. The thinner the patient, the more likely these ripples will show. The less breast tissue there is to begin with the more likely they are to show also. If you develop significant capsular contracture they may also become obvious.

How long can I expect the implants to last?

Implants are man-made and you cannot expect them to last forever. They may last a lifetime in some patients, but individual patients should not count on it. You need to look at breast augmentation as needing ‘maintenance’ procedures during your life. If you are not prepared for this, you should not undergo the surgery in the first place.

It is difficult to predict how long the newer implant will last. In the 80’s the standard answer was about 10 years, but the newer cohesive gel implants are likely to last much longer. In general, if they are not causing you any problems they do not need to be replaced.

In general, if the implant only lasted a short time before rupturing, the implant company may pay for the cost of a replacement implant. If there are medical problems such as infection after the surgery (where the implant needs to be removed, the infection allowed to settle, and the implant replaced at a later date), or the implant ruptures after a greater time period you would be responsible for the costs involved with the new implants including surgical, anaesthetic, facility and implant fees.

I’ve heard mammograms are harder to perform when breast implants are in place. Is this true?

Mammograms are x-rays and they cannot see though either gel or saline. There are special techniques that are used when implants are in place, but the firmer the implants feel, the more difficult the mammogram. You cannot go for a ‘screening’ mammogram, you need to go for a ‘diagnostic’ mammogram – where the radiologist is on site so he/she can look at the films and decide if more views are needed.

Mammograms do not need to be performed any more frequently if implants are in place. All you need to do is follow the guidelines form the NZ cancer society and your GP.

Is there any relationship between breast implants and breast cancer?

Breast cancer is not an issue. Several studies have shown that there is no relationship between breast cancer and the presence of breast implants. In New Zealand approximately 1 in 8 women will develop breast cancer. If you have implants, the risk is still 1 in 8. In fact, it has been shown that women with implants who develop breast cancer often find it at an earlier stage, probably for several reasons.

•There is less breast tissue to examine and confuse the issue

•Patients with implants are more comfortable examining themselves

•The implant provides a bit of a platform to feel against (the implants sit behind the breast tissue or tissue/muscle) so you can feel for lumps more easily.

It is human nature to want to blame something if a problem develops. Therefore, if a patient develops breast cancer, it is easy to see why they might believe the implant had something to do with it – and this is probably also why the whole issue of autoimmune diseases became blown out of proportion.

What is ALCL and should I worry?

ALCL is lymphoma, a type of cancer involving cells of the immune system. It is not cancer of the breast tissue. It has been diagnosed in some women with breast implants. ALCL is very rare; it has occurred in only a very small number of the millions of women who have breast implants.

Although the risk is quite small, we want women to be aware that there have been reports of ALCL occurring around saline and silicone gel-filled breast implants. In the cases reported, ALCL was typically diagnosed years after the implant surgery. In most of these cases, the women were diagnosed after they observed changes in the look or feel of the area surrounding the implant.

Q: What advice is FDA giving to women?

A: If a woman with breast implants has no symptoms, FDA does not recommend doing anything additional. Women should continue monitoring their implants and obtaining regular breast screening evaluations. FDA does not recommend removing the implants.

Women who see changes in the way the area around the implant looks or feels—including swelling or pain around the implant—should see a physician for evaluation.

Women considering breast implants should be aware of the very small, but increased risk of developing ALCL and discuss it with their surgeon.

What makes implants rupture, and how can I tell?

Implants rupture because there are folds that develop in the implant shell and the ‘point’ of the fold wears away. If the implants are saline they just deflate. With the newer cohesive gel implants the gel doesn’t leak because it is ‘cohesive’ – a bit like the inside of a gummi-bear!

If you have silicone implants you may not notice the rupture. The gel stays inside the shell and capsule and sometimes the only sign I that the capsule may start to tighten a bit more, perhaps after years of being soft. The only way to be 100% sure if an implant is leaking is to operate and look. A mammogram, ultrasound or MRI may help but they are often wrong! There is no rush to replace gel implants unless there is evidence the gel has leaked outside the capsule, and this was likely only with the 1980’s implants where the gel was very runny. If this happens, lumps will develop where the body’s immune system attack and encapsulate the leaking silicone.

Remember, implants don’t rupture just because someone is rough with you or you are hit in the chest. They rupture because of wear and tear of the silicone envelope, or significant trauma such as a car accident.

I’ve been told it is better to put the implants behind the muscle. Is that true?

There is no one answer that will apply to all patients. It is an unnatural place for extra ‘breast tissue’ to sit under the muscle. Your breast is not under the muscle.

If at all possible, I place the implant above the muscle. When everything works well, this can give you the most ‘natural’ result. However, if a patient has no ‘padding’ at all (either breast tissue or subcutaneous fat) the under the muscle may be better as it makes the edges less likely to be visible or palpable. Most people have very little fat over their collarbone, and you can see that very easily. If you don’t have enough of your own chest tissue, the implant can be as visible as that if not put under the muscle.

The problem with placing the implant under the muscle is that every time the muscle contracts it tends to push the implant and push it outwards and upwards. We do release the muscle a little bit off the breastbone to decrease this effect, but don’t want to destroy the muscle action completely.

When I examine a patient I will pinch the area that can determine if the implant should go above or below the muscle. Placing the implant below the muscle does tend to leave you with a wider area between the breasts (cleavage), and even above the muscle they tend to give you a slightly wider cleavage than you may expect.

There is not one best placement and the advice will vary from patient to patient. Under the muscle may be better for padding and mammograms, but above the muscle may be better to prevent widening between the breasts and implant movement. Further examination and discussion will help come to the right decision.

In either position, the implant is placed beneath the breast tissue.

Which incision is better?

There are 3 main choices for incisions:

1Under the areola

2In the fold under the breast (inframammary)

3In the armpit

Some people talk about a belly button incision, but that is more American marketing then good surgical practice – it is impossible with gel implants, and even with saline very difficult to get a good position or shape. I do not offer this incision.

The armpit incision can be appealing at first glance, but it is again difficult to get a natural shape and position, can only be used with a limited range of implants, and if you need a second procedure for any reason, we would then use one of the other incisions. Another consideration is that people tend to show their armpits more often than their breasts – most women go ‘sleeveless’ more frequently than they go ‘braless’ or ‘topless’.

The incision under the areola can look good if I heals well, but if it turns out to not be a good scar it is on a very obvious place. It is also the incision most likely to interfere with nipple sensation. Although complete loss of sensation is very rare (and usually temporary) it can happen and be a very important issue for some women. Sometimes this incision cannot be used for the gel implants if you have a small areola. There is also a theory that it may be associated with a slightly higher rate of capsular contracture.

The incision under the breast – in or just above the fold – is my preferred incision. It usually hides very well when standing and only rarely interferes with nipple sensation.

All the incisions are about 5-6cm long.

I’ve heard some women also need a breast lift at the same time. How can I tell if I need one too?

If your breasts sag a lot than a breast uplift (mastopexy), with or without an implant is probably ‘needed’. How can you tell if your breasts are ptotic (drooping) enough to need a lift? One guide is where your nipples sit in relation to the fold under your breast when you are standing. If your nipple is above the fold, you do not have ptosis (sometimes your breast may appear saggy, but merely be empty). If your nipple is at or just below the fold, you should do well with just an implant. If you nipples are well below the fold, a lift is probably needed, as if an implant alone is used, the breast often appears to have ‘fallen off’ the implant – a so-called ‘double-bubble’ appearance. In this case the nipples need to be moved up, and the extra skin tucked up.

As long as implant problems don’t develop, an implant + lift gives a better result if you desire much upper pole fullness. A lift alone cannot always fill up the upper pole.

The scars for a lift are more extensive and visible than just for an implant. The scar goes all the way around the areola and the down to the fold – a ‘lollipop’ type scar. I try my best to avoid adding a horizontal scar under the breast.

What if nothing works and I want my implants removed completely?

Very few patients ever want their implants removed completely – even if some hardness develops. If you have had had children before the implants went in, your breasts will probably be similar to how they were before the implants (allowing a bit more droop for time and gravity!) This is because your breasts have already been stretched by pregnancy, and you will have an idea of how they shrink back to their original shape.

For patients who have not had children we will not know how well (or poorly) your skin will retract after being full and stretched. If you remove the implants permanently your breasts may look empty and droop – a bit like if you had gone through a pregnancy.

Will I be able to breast-feed with implants in place?

The implants are always placed behind the breast tissue (or behind the muscle and breast tissue). This means your ability to breast-feed will be unchanged. Not all women can breast feed even without breast surgery, so it is impossible to guarantee you will be able to after breast surgery, however as the breast tissue is not disturbed during the augmentation procedure, your chances are as good as the general population.

What may change is your breast shape. Everyone reacts to the breast changes of pregnancy differently, and everyone’s skin retracts differently. If the shape is not to your liking, a breast lift (mastopexy) may be needed.

I’ve heard fat can be injected into breasts to make them larger. Is this true?

Sometimes fat can be used for a small correction. Larger amounts, purely for augmentation, are very unpredictable and also very controversial. The jury is still out about the safety of injecting large amounts of fat into a normal breast.

We do take fat from the abdomen to recreate the breast using microsurgery, but this is really only for women who have had breast surgery for cancer.

What about special implants – anatomical or textured?

Each of these particular implants has their own pros and cons, and are usually used for specific indications. Shaped implants may allow someone on the border to get away without a breast lift. I don’t often use them in simple augmentation.

The textured implants have a lower capsular contracture rate, and work very well under the muscle or if you have enough padding. If they go under a thinner breast you may get extra rippling or folding.