Breast enlargement/augmentation is a surgical operation to increase the size of the breasts by placing an implant under the breast tissue. It is useful technique to increase the size and fullness of the breasts either in patients who have always had small breasts or in those who have lost breast volume following pregnancy. It is also a useful procedure in patients who have different sized breasts and would benefit from an operation to a single side to achieve breast symmetry.
Subglandular or subpectoral ?
The breast implant can be inserted under the breast tissue(subglandular) or under the pectoralis muscle(subpectoral). Both techniques have pros and cons. Implants placed beneath the breast tissue tend to help fill lax tissues a little better and is less painful compared to placement under the muscle, however there may be a higher chance of feeling or seeing the implant if a large implant is used. Also placement under the breast tissue is not appropriate in patients who are very thin and lack breast tissue. Placement under the muscle is the preferred option if there is a lack of breast tissue. There is also less chance of feeling or seeing the implant edge due to the coverage of the implant under the muscle. In addition, there is a slightly lower chance of developing a capsule around the implant with this technique however it can be more painful and increase the risk of developing a haematoma compared to a subglandular approach due to the need to divide part of the pectoralis muscle.
All breast implants consist of a silicone shell filled with either silicone (most used in the UK) or saline. Silicone filled implants tend to have a more natural feel to them and are usually chosen because of this. The silicone that fills modern implants come in the form of a thick gel known as cohesive gel. This prevents it from movement and helps maintain its shape should the silicone shell surrounding it rupture. Implants also come in different shapes, sizes and profiles, and so it is important to choose the right implant for you.
This is probably the most important decision to make as it will ultimately determine the eventual augmented breast size. Implants come in a whole range of volumes from 80-800mls. Most patients already have a general idea of what size they would like to be, however it is also important to take into account the ideal size for your body habitus. As a rough rule of thumb, 100-125mls will increase your cup size by one.
In terms of shape, there are many options although the 2 commonest are round and anatomical. Round implants are very popular and give excellent results with the majority of patients. Anatomical implants have less volume in the upper half compared to the lower half and are sometimes selected for patients with small breasts where the shape of the implant may be more apparent.
The profile of an implant denotes how proud the implant sits from its base and therefore how pert the breast is likely to be after insertion of the implant. The profile can be low, medium or high.
Choosing the right implant
There are so many factors in the choice of implant that it can get rather confusing. All these factors will be discussed with you at length at your consultation to empower you in making an informed choice for yourself.
What should I expect ?
Breast augmentation is usually performed under general anaesthetic although it can also be performed under local anaesthetic and sedation. You will be admitted on the day of your surgery and will usually need to stay overnight. The duration of the surgery generally takes 1.00-1.30 hours depending on whether it is under the breast tissue or muscle. During the procedure, an incision is made on the underside of the breast, in the inframammary crease, and a pocket is dissected. The implant is then inserted and wound closed with dissolving sutures. The wound is then dressed with skin glue and a simple dressing. Occasionally a drain is inserted, usually when the implant is inserted submuscularly. If this is the case, then the drain is removed prior to your discharge. On the ward, you should wear a sports bra in your planned new cup size. This should be soft and supportive but not underwired. On discharge, you may shower as the dressings are shower resistant. In the first week, you should take things easy and avoid too much physical activity. Most patients recover fully after 2 weeks however strenuous exercise should be avoided for at least 6 weeks. The appearance of your breasts will be a little firm initially however this softens and becomes more natural over a period of 4-6 weeks with the final appearance being apparent at 6 months.
What follow up will I have ?
You will be seen a week after your surgery to check that all is healing well and again at 3 months to ensure to all is well and you are happy with the result.
What are the potential risks and complications ?
Breast augmentation is a routine operation with the majority of patients achieving a good result. As with any operation however, it is important to understand the potential risks and complications that can occur.
Risks and complications associated with the operation
Scarring : There will be a scar on the underside of the breast which may initially be red and raised, however it will settle over a period of 6-12 months, eventually fading. In a small minority of patients, the scar may remain lumpy and red or become stretched
Bleeding/haematoma : Bleeding resulting in a haematoma within the implant pocket can occur in approximately 2% of patients. This is slightly higher in patients who have a submuscularly placed implant. If this occurs, you will require a further trip to theatre to have it washed out
Altered nipple sensation : The nipple sensation may be altered in some patients, becoming more or less sensitive. This is usually temporary however in a small percentage of patients(<5%) this may be permanent
Disruption of breast feeding : Breast feeding can be affected in approximately 20% of patients.
Wound problems/infections : Wound problems such as wound breakdowns and infections are rare however when they do occur and are serious, the implant may need to be removed
Asymmetry : In patients with different sized breasts, a symmetrising augmentation can help match the size and shape however some asymmetry usually remains between the two breasts
Need for further operations in the future : Implants do not have a fixed lifespan and can last anywhere between 10-30 years. If you do not encounter any problems, the implants need not be exchanged however you should accept that there is a possibility of the need for further operations in the future
General operation risks : Deep vein thrombosis and pulmonary embolism, the formation of clots in the legs or lungs are rare but can occur with any operation. These are potentially life threatening and so you will be given compression stockings to wear on your legs and blood thinning injections to reduce the risk of this.
Risks and complications associated with the use of implants
Rippling : Rippling is the appearance of the natural folds or buckles of the implant on the skin. It occurs more commonly in patients who have had a subglandular implant insertion
Implant rupture : All implants may rupture. Recently with the reporting of sub-standard PIP implants, there is understandably a lot of concern regarding implant ruptures. The medical grade silicone gel that is used in modern implants however has been shown to be safe with over 40 years of research. Whilst an implant rupture is alarming, it is not usually considered an emergency. There are two types of implant ruptures. Intracapsular ruptures and extracapsular ruptures. Intracapsular ruptures are implant ruptures that are contained within the scar capsule that normally forms around an implant. As it is contained, the silicone does not leak out into the breast tissue. An extracapsular rupture is an implant rupture that is not contained within the scar capsule and the silicone can therefore leak out into the breast tissue. This leaked silicone can collect within the breast tissue or in the lymph glands in the armpit, causing deformities and be a source of infection. It is therefore advised that the implant be removed in these cases
Capsular contracture : The inserted implant is inert however the body still recognises it as a foreign body and in 10% of patients over a period of 10 years, a scar capsule can form around the implant. This capsule can cause the implant to deform and in severe cases be painful. When this happens, the implant will usually need to be removed. To deal with the loss of volume, a new larger implant can be inserted to fill the space, or a breast lift (breast mastopexy) can be performed to reshape the remaining breast tissue provided there is sufficient volume. If the breast tissue is very droopy and lacking in volume, then an augmentation mastopexy may be required (combination of a mastopexy and insertion of an implant)
Further information is available here in this Breast Augmentation guide