Breast Enlargement (Augmentation)

In 1992, the Food and Drug Administration in the United States, placed a moratorium on the sale of silicone gel filled breast implants. Australia’s Therapeutic Goods Administration (TGA) followed suit. At that time, there was some concern that silicone caused autoimmune diseases, among other things. We now know that this is not true.

It was believed by some people that silicone somehow caused your body to attack itself – like in rheumatoid arthritis which is a disease where the body attacks its own joints. Big studies since 1992 have repeatedly shown no evidence that silicone has any relation to these diseases.

The manufacturers, on the other hand, did make implants that ruptured too easily, and the gel that was used was like honey and would run out any hole in the implant shell, and into the tissues. The implants now come with a much tougher three-layered bag, and contain ‘cohesive’ gel that behaves like a jelly, not a liquid – and doesn’t run anywhere nearly as much as the old implants, if at all.

Silicone is everywhere – hairsprays, makeup and baby bottle teats. In fact all our syringes and needles are lined with liquid silicone as a lubricant, and they have been able to measure the amount of silicone that is injected each time – so, we all have a little liquid silicone in our bodies. Diabetics probably have more than anybody, and they do not get “autoimmune” diseases any more frequently than the rest of us.

Australia’s TGA examined all the scientific evidence and since 2001 has allowed us to use silicone gel implants. There is a comprehensive booklet about breast implants on their website which I recommend you read (http://www.tga.gov.au/docs/html/breasti.htm). Comfortingly from late 2006, the FDA also has allowed silicone gel back onto the market in the U.S.A.

The main problem with breast implants is capsular 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 forms a scar -called a ‘capsule’ around it. These are your cells and they form a thin membrane around the foreign object. This membrane then can tighten – it is actually trying to do a good job – getting rid of what doesn’t belong. You may know of someone who has had bits of glass come out of their skin years after a car accident. Capsule formation is an appropriate process under normal circumstances – it’s just with breast implants it can then make them feel hard and distorted. The implants themselves don’t actually “go hard” – it is the tightening of the capsule that makes them feel hard and often gives them a distorted shape.

How many patients develop breast capsules? Everyone. How many get capsules that are firm ? – probably about 6%, but many patients actually like some firmness. How many want to do something about the firmness? Probably about 3%, with only about 1% or less ever wanting the implants out completely.

If we could predict who would develop capsular contracture, if we knew how to prevent it, or if we could always successfully treat capsules, then breast augmentation would be an excellent procedure and there would be very little controversy surrounding it.

We cannot predict who will get capsular hardening. But we do believe that there are some things that can be done do to prevent them from forming.  You will have a smooth surfaced implant, we ask you to perform exercises where you stretch the capsule on a twice-daily basis for the first 5 months, and daily there-after. Hamish will show you how to do this.

If you develop a hard capsule that bothers you, the next step is to re-operate, surgically release the capsule and hope (with aggressive exercises) that the capsule will not tighten again.

No. Several studies have shown that there is no relationship between breast cancer and the presence of breast implants. If 1 in 10 (approximately) women develop breast cancer, then 1 in 10 women with breast implants will develop breast cancer. In fact, it has been shown that women with breast implants have tended to find their cancers 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 – they are often more familiar with the feel of their breasts and interested in the changes that occur.
• The implant provides a bit of a platform to feel against, so you can usually still feel for lumps quite easily.

It is human nature to want to blame something if a problem develops. So, if a patient develops breast cancer, it would be hard not to believe that the implant might have had something to do with it -though statistically, we know that there is no relationship.

You should consider breast augmentation only if you are prepared that they may be obvious in some circumstances. Your figure will change and the proportions will change, so this may be evident to those who know you well. For most women who are small chested, an augmentation makes their tummy look flatter, and their hips ‘fit’ better into their shape, once balanced by a bigger bust. This will leave a natural sense of proportions so the breasts just seem to ‘fit’ too, and hence are not obvious, though to you they may take some time to get used to!

Sometimes, folds and ripples can be felt through the skin and occasionally actually seen. We do everything we can to prevent these from being visible or palpable, but you need to be aware that we do not have much control over this problem. The thinner the patient, the more likely these ripples will show. The less breast tissue that is present to begin with, the more likely the ripples will show, and the less natural they will look. Ripples are more common in saline than silicone implants.

If your breasts sag a lot, then a breast uplift (mastopexy) with or without an implant will be recommended. With pregnancy and weight fluctuations, the skin of the breast gets stretched, and once the breast gets smaller, there is too much skin so the empty breast sags. To get a pert breast once more, you either need to fill the skin up completely again (augmentation alone), or make the skin small enough to fit snugly around the breast you have (mastopexy alone), or do both (augmentation mastopexy).

The scars for the breast uplift are more extensive and more visible than a breast augmentation alone. The scar goes around the areola and then vertically down to the fold, (you may see some diagrams that show a scar all along the crease or fold under the breast as well – resulting in an anchor shaped scar – but I don’t use this scar. We prefer a “racquet” or “lollipop” shaped scar, avoiding that scar along the fold completely).

The difficulty in trying to avoid the extra scars of mastopexy is that often a very large implant would be needed, and this means you need to be happy with a larger bust size, and be aware that you may will suffer from the weight of large implants on your back and neck, and that gravity will be working harder with the bigger implant to ruin your shape.

There are three choices we use for incisions:

1. Just under the areola
2. In the fold or natural crease of the breast
3. In the armpit

You may have heard of the “belly button” incision, but take that with a grain of salt – it is American marketing more than a good technique – it is difficult to get a good shape or make any adjustments through that incision.

The armpit incision can be appealing, but if you need another procedure, we will use one of the other incisions for access. Remember also, that you show your armpits to a lot more people than you show your breasts. In other words, most women tend to wear sleeveless outfits more commonly than they would go topless. The armpit incision can look quite good, but sometimes can be obvious.

The incision under the areola can also look good. But, if it turns out not to be a good scar, it will be very obvious. It is also the incision that is most likely to interfere with nipple sensation. Although loss of feeling is rare (and usually just temporary), it can be a very important issue for some patients.

The incision under the breast – in the fold or just above it – is our preferred location. It cannot usually be seen when standing, and it only rarely interferes with feeling. It also is the most commonly used approach if you should need any later surgery or adjustments.

All the incisions are usually about 4 – 4.5cm in length.

Very few patients ever want them out completely – even when some hardness develops. If you have had children already, your breasts will probably look much as they did before surgery (taking into account the changes that naturally occur with time and gravity). That is because your breasts have already been stretched out by pregnancy and you know how well (or poorly) they shrink back to their original shape.

For patients who have not had children, we don’t know how well your skin will retract after having been stretched and full. If you decide to have the implants removed completely, your breasts may look as if you had gone through a pregnancy.

Since the implants are placed behind breast tissue – or behind breast tissue and muscle – your ability to breast feed would not be impaired by the implants. In fact, the breast tissue itself is barely disturbed during the breast augmentation procedure itself.

What might change would be your breast shape. Everyone is different in how well their skin retracts after pregnancy and breast feeding. If the shape after feeding is not to your liking, then a breast lift (mastopexy) may be indicated.

Injecting fat to enlarge breasts is a specialised procedure, and is really only useful for fixing small dents or contours, not making the whole breast larger.

You may have heard of taking fat and skin from the abdomen or buttocks to reconstruct a breast after mastectomy. This is a complicated procedure with a long recovery period and it is only appropriate for patients requiring reconstruction, and not just for augmentation.