Breast augmentation is the most popular cosmetic procedure requested by women. It involves an operation where artificial means are used to increase the size and / or improve the shape of the breasts. Estimates suggest that over 3 million women world-wide have had breast implants in the last 35 years, and each year tens of thousands of women continue to have breast augmentation surgery. Many women consider having breast augmentation to improve their size or shape because they think the breasts are to small, uneven in size or shape, or unattractive. Some women have breasts that do not fully develop or have significantly changed in size or shape after pregnancy, weight change or ageing.

The decision to undergo breast augmentation should be a personal one and not to please someone else. As with any cosmetic procedure, breast augmentation will not resolve any of life's major problems, but may help to boost a patient's own body image and self-esteem. All the potential benefits will be discussed and assessed at the time of your consultation.

These days the woman wishing to have a breast augmentation has number of options and choices open to her. These should allow her to achieve the appearance and result that she wants. Some of these choices and options are: implant type, size, placement as well as incision. Obviously there are pros and cons to each choice and option, however, providing a woman has been informed accordingly, then ultimately she can decide which is best for her.

Basic facts on breast implants

It is important to understand that the outer shell or envelope of all breast implants is made of silastic. This is a polymer of silicone. However, the actual filling substance can differ giving rise to various types of implants including saline (salt water), or silicone gel.

Silicone gel implants are currently the most common type used in my practice. However between 1992 - 2005 saline was more popular due to FDA restrictions. As silicone gel implants have been available since 1963, surgeons have over 35 years of experience with these types of implants. This is more than any other type in use. Evolution has brought changes a shell and improvements over the years with the introduction of textured surface envelopes and shells made of newer formulations designed to minimize the "bleed" or diffusion of what is usually tiny amounts of the silicone oil.

Importantly the standard silicone gel by most accounts arguably "feels" the most natural of all breast implants. This is probably as a result of the inherent smoothness and weight of the silicone gel content.

A Few Facts on Silicone

Many ladies considering this type of surgery will no doubt have heard of frightening stories about silicone toxicity or autoimmune / connective disease, due to gel "bleed" or migration. As a result, breast augmentation has, in the last 13 years, received much unfavorable publicity mainly through the irresponsible actions of the media whereby, regardless of the facts, claims have been made with respect to silicone safety. Undoubtedly, most of these stories began to attract attention after the American Food and Drug Adminstration (FDA) in January 1992 imposed a ban on the use of silicone gel breast implants. At that time, the FDA concluded, "there was no evidence that silicone gel filled breast implants are unsafe, but there was insufficient evidence to prove safety".

For fourteen years the FDA collected data including scores of large multi-center studies showing silicone were safe.

Finally in late 2006 the FDA lifted the restrictions on Silicone implants - so now they can be used in cosmetic patients as well as reconstructive patients.

"Gummy Bear Implants"

The standard silicone implants Dr. Loeb uses care often referred to as "gummy bear implants" because the silicone filler is "cohesive" meaning if cut it does not drip but sticks to itself like a gummy bear. This gives some reassurance to those who worry about the implants shell breaking - however rare this is!

Are there different shapes and consistencies of implants?

There are different shapes and types of gel fillers with breast implants. Traditionally, all implants have been round. The majority of all implants currently used are still round. Viewed from the front, they are circular and in profile, they appear to be half moon shaped. The consistency of most round implants has usually been semi-fluid, rather like a thick gel. Saline implants feel more like water than gel filled shells

How do I choose which size of implant is the best for me?

Implants come in a wide variety of sizes and it is possible for any woman to comfortably carry a variety of sizes on her chest. Most women have a rough idea as to how big they may want to be in terms of bra sizes. The objective during the examination is to determine which size of implant will give the desired appearance. As you can imagine different size implants in different framed women gives different results. The secret is to choose a size that will give you a more balanced, proportionate look overall and more inline with your desires. At the time of your consultation Dr. Loeb will take specific measurements of your breast and chest in order to try and determine which size would be suitable for you. In addition to these measurements he will take into consideration your vision of your ideal breast size.

It is important to understand however that ultimately, the limiting factor in choosing implant size is the space available beneath your breast. Its important to remember that as the volume of any breast implant increases, then so does its width. Therefore if you choose an implant that is excessively large, the edge of the implant may then extend around beyond the breast and potentially even under the arm pit. This would be undesirable for most people. In addition the potential for rippling (see below) and other long-term adverse problems increases. The vast majority of women however have a realistic outlook of what they wish to look like, and therefore it is not often that a surgeon cannot deliver the desired expectations to his patients.

Do Breast Implants cause Breast Cancer?

There is no evidence that silicone in breast implants causes cancer in humans. On the contrary, recent studies have shown that implanted women seem to have up to 30% less breast cancer that the general population (maybe because as a group they have less breast tissue?).

Does a Breast Augmentation affect the means detect to Cancer?

Perhaps the most significant concern over breast implants is the possibility of delayed detection of breast cancer with silicone and saline filled breast implants. Both of these are radiopaque, meaning the implants obstruct the breast tissue viewing to varying degrees on mammogram. Mammography techniques however have improved over the last 20 years enabling the radiographer to minimize the amount of breast that is hidden by the implant. It is important however to realize that 10-20% of breast cancers are invisible to x-ray, and therefore most breast cancers are still being discovered by self or physical examinations. In this respect, interestingly enough, some clinicians feel that the implant can actually increase the ease of palpation.

A woman with breast implants should be on the same schedule of routine mammography as all other women. The radiographer should be informed that she has implants and therefore special displacement (Eklund) views will be required for proper radiological evaluation.

In conclusion, implants make the job of the radiologist more difficult but they do not prevent him from carrying it out.

How long do implants last?

Like all man made products, breast implants may not last forever. Despite being very robust and resistant to even extreme pressures, they are susceptible to daily wear and tear over time. What this means in simple terms is that the outer shell or coating of the implant may wear. If this happens you can easily move the implant changed. In most cases the implant will last throughout your lifetime!

What kinds of incisions are there?

There are generally 3 types of incisions used for inserting the breast implants.

The peri-areola incision , Dr. Loeb's preference, which is made around the edge of the areola (the darker skin around the edge of the nipple). The scar heals essentially invisibly in 98% of patients.

The inframammary incision is made under the breast at the fold or crease line. The incision is about 4cm in length. This is a common incision, and the natural fold of the breast usually hides the scar quite well. It will probably always be covered by any clothing-even the smallest bikini tops. Because the incision gives immediate access to the space where the implant will be placed it is possible to very accurately create the size and shape of the pocket for the implant, and the carefully control the position of the implant within the pocket. This scar heals well in 92% of patients.

The third method is axillary incision , which is made in one of the crease lines of the armpit. This is used less often because it is more difficult to get proper placement of the implant in some patients, and if there is a problem in the future, an additional incision on the breast may be required. Although some patients thinking about this surgery may believe this approach is the least conspicuous, in truth this may not always be the case, particularly in light of sleeveless open type clothing which expose the armpit area quite readily and frequently. This heals well about 95% of the time.

Regardless of where the incision is placed it is important to remember that scar will always be present. The scars normally settle quite well and become less conspicuous with time. However no surgeon can ultimately predict the appearance of any particular scar.

In any case the incision does not cause loss of sensation to the nipple. Those nerves are inside the breast. In about 2% of cases, especially very large augmentations injury to the nerves is possible.

Where do you place the implant? In front of or behind the muscle?

Dr. Loeb's favorite location is the submuscular placement between the muscles of the chest wall and the rib cage. Submuscular placement increases the padding overlying the implants offering more coverage and camouflage to the shape of the implant. This is particularly helpful in women bearing very little or no breast tissue at all. By providing this extra padding in these circumstances, one then substantially decreases some of the adverse effects like scar contraction. The breasts look more natural. Another advantage is that mammogarphy has been reported to be slightly more effective.

There are two locations or pockets made where the implant may be placed; the subglandular(in front of the pectoralis muscle but under the breast tissue) and the submuscular(behind the pectoralis muscle and the glandular tissue). The pectoralis muscle is the chest muscle that is commonly developed in body builders.

The subglandular placement is also popular mainly because of its ease. The disadvantage is that the outline of the implant may be more prominent or visible in very slim women. In these situations one can therefore sometimes detect a "step-off" appearance or "stuck-on look" of the breasts on the chest. In these situations you will be advised to have the implant placed submuscularly.

There are however some breast shapes that are better suited to the subglandular approach. These women typically have breasts that at one time were much larger that the present. When there is a very large volume decrease and there is little or no shrinkage in the size of the skin envelope surrounding the breast tissue, then the shape approaches that of an "empty bag". Under these circumstances it is sometimes better to place the implant in the subglandular position in order to allow the implant to fill out the skin envelope f the breast.

In the event that the skin envelope has stretched to the point where the nipple is below the breast fold, it may be necessary to reposition the nipple upward again and reduce the size of the skin envelope by means of an uplift or mastopexy. Again, this will be determined at the time of the consultation.

The decision, as to which location the implant should be placed in your case, will be discussed at the time of the consultation.

What type of anesthetic is used and how long does the surgery take?

The operation is performed under general anesthesia. The procedure takes approximately 90 minutes to perform.

Is it painful?

Pain, will be experienced following a Breast Augmentation. It is always difficult to quantify how much pain any one individual will experience. While some women find this procedure painful others report very little pain postoperatively. Placement of the implant behind the pectoral muscle is associated with a greater degree of pain, as it is necessary to release the muscle in order make space for the implant. It would be fair to suggest that most women experience a moderate degree of pain for the first five days, which will require regular painkillers and more importantly muscle relaxants. After a week however most women feel fairly normal.

What happens after surgery?

Your breasts will be somewhat swollen and bruised postoperatively. This is usually settles in about two to three weeks. Sometimes swelling may be slightly different between the two sides. This is normal and settles with time. However if a great difference develops between the two sides then you must contact us for advice.

Following a Breast Augmentation, the breasts may appear to be placed quite high up. This is normal. During the first two months postoperatively the implants will gradually lower and settle from the effects of gravity into a more natural position. Do not be alarmed if one side settles quicker than the other, as this sometimes occurs.

Following the operation you will have a light dressing in place which will need to be kept dry until the first post-op visit. You will need to take a muscle relaxant (Valium) for a few days. On the first post-op visit Dr. Loeb will teach you to massage breasts and place you in a soft bra.

What kind of after effects should I expect?

Changes in nipple and breast sensation (feeling) can occur in 2% of patients. Some patients may lose a lot of sensation while others report only a slight decrease, and some even report heightened sensation. In the majority of cases where sensation changes occurs, these are only temporary and soon recover. The recovery period can sometimes take up to 18 months to complete. In a small minority of patients, however, permanent loss of sensation may occur.

Breast-feeding can proceed following a breast augmentation providing of course that you are able to produce enough milk in the first place. You must understand that regardless of whether you have implants or not, all women cannot breast feed satisfactory.

Pregnancy: should you become pregnant following your operation then your existing breast tissue will be subjected to normal hormonal influences of this period and therefore your breast will enlarge and the skin will stretch accordingly. Likewise, once the pregnancy and any associated breast feeding ceases, your own breast tissue will then shrink down. It is impossible to predict to what degree these changes will occur, however, the breast implant volume will remain the same throughout these.

Rippling or wrinkling of the skin over the implant may occur in women who have little or no breast tissue. Saline implants have a slightly higher incidence of this happening than

the silicone implants. This has no medical implications in itself but can be cosmetically undesirable. This can occur in any location of the breast. In order to minimize this effect and if deemed appropriate at the time of the consultation, you may be advised that the best placement of the implant should be in the submuscular position as previously described. It is important to understand however that rippling or wrinkling can still occur even when this precaution is taken, and should this then occur it might be difficult or impossible to eradicate.

Palpation of the implants may occur in thinner women following breast augmentation. In these situations the implants are more likely to be felt at the lower part of the breast near the fold. Again this has no medical implications, although women who do not bear this is in mind may suddenly become worried about feeling a "lump" in their breast. In any instance of uncertainty it is always best to contact your surgeon to have this examined.

There is no chance of the implant exploding or bursting whilst traveling in an airplane, swimming, diving etc.

What are the scars like?

Scars are not a complication but a normal event after any surgery. Thankfully the scars in a Breast Augmentation operation are short and around the areola very hard to see. You should always expect these to start out red and even itchy but with time they should fade and flatten. This is the natural evolution of the healing process. However it is important to keep in mind that this may take up to one year to complete. You must understand however that no responsible can promise any scar's ultimate appearance.

What could wrong?

All surgery carries some uncertainty and risk. When a breast augmentation is performed by a qualified Plastic Surgeon, complications are infrequent and usually minor. Complications include infections, hematoma, and skin necrosis. Infection can occur despite our normal routine of administering antibiotics at the time of surgery as well as post-operatively. This happens about one percent of the time. Signs such as pain, redness, swelling, or fever, following augmentation should be reported immediately to the doctor. Infection not reported could easily compromise the success of any surgery. If infection were to be serious and fail to respond to antibiotics, removal of the implants would be required and replacement would not be done until the infection had cleared.

Bleeding, as a result of a leak in a blood vessel will give rise to swelling and bruising of the breast. If this is slight then your body will be able to absorb it in time. If it is significant (termed hematoma and occurs 1% of the time) then it may be necessary to drain this. Your surgeon will be able to assess this.

Decreased sensation is reported in less than 2% of patients, the bigger the implant and the smaller the patient the greater the chance of nerves being stretched or injured.

Capsular Contracture(Hardening)

This is the most common complication of breast implants. A capsule or capsule formation is a layer of scar tissue that normally forms around any artificial material placed in the body. It is important to realize that this the natural response of the body to foreign material. Most times this capsule is so soft that it is virtually undetectable and therefore does not affect the implant in anyway. Capsular contracture or hardening occurs when this layer of scar tissue thickens and shrinks around the implant, squeezing it so that it starts to feel firm, or in some cases, quite hard. Most capsular contractures experienced today stem from the smooth shell silicone implants placed some years ago. The capsule contracture rate in the past was 30-35%.

With the onset of submuscular implant placement, the problem of capsular contracture has been significantly reduced, now being between 6-8%. Breast massage is extremely important to prevent early contracture. You will be instructed on this post-operatively.

The cause of capsular contracture is not totally clear, but seems to be multifactorial. It is important to realize that there are degrees of contracture and that the majority of women who develop this hardening, develop it only to a mild extent. In the minority however, it may be severe enough to be bothersome, even painful and may cause distortion of the breast. The condition may occur in one or both breasts.

Capsular contracture is most likely to occur in the first few months post-operatively. Nevertheless it can happen anytime. Unfortunately at this time there is no effective way to totally prevent capsular contracture if it going to occur. However as mentioned previously, encapsulation is no longer the problem that it was. Having mentioned all the above, it is important to note that capsular contracture is not in itself a health risk other than its possible interference with mammography.

There are two ways to reduce or relieve the firmness of a contracture. These are the closed and open capsulotomy. In the closed capsulotomy, the firm implant is manually squeezed tightly from the outside, in attempt to disrupt or tear the scar envelope. when successful the result is instantaneous and the implant immediately feels soft. The tear resistance of the scar envelope however varies from woman to woman. Some tear easily but in others the scar is so tough that it cannot be torn. In others, only a partial tear is possible which can lead to a small outpouching of the implant with a resultant unsightly appearance. A closed capsulotomy may also result in bruising, bleeding, or even rutpure of the implant itself. If rupture occurs then you will need surgery to remove and replace it. In light of these unpredictable outcomes, closed capsulotomy is rarely done.

The other method, which is much more controlled and thus the preferred method, is the open capsulotomy, performed under general anesthesia. In this procedure the old incision is reopened and the thickened capsule is removed or loosened. The implant is then reinserted again into the breast pocket. Sometimes steroid are added to the pocket to reduce scar tissue. Active massage is important within post-op. Unfortunately, even after a successful capsulectomy, there is always the possibility of recurrent hardening.

How long before I can get back to normal?

Although you can gently walk about and do very light duties from the next day, please avoid stretching or lifting during the first 7-10 days. Depending on your job many ladies go back to work after this time. Obviously if this involves excessive stretching and lifting you are then advised to refrain from a further 10 days. Upper arm exercises and swimming can begin after 3 weeks. When exercising always try and wear a good sports bra. Driving is allowed after 1 week. Sexual activity can be commenced at around 3 weeks although at this stage only very gentle handling of the breast is advised. More vigorous handling can be commenced only after 2 months!

Summary

The chances are excellent that you'll be happy with your surgery. Most patients understand the advantages and benefits of this type of surgery. However, despite assurances by competent Plastic Surgeons and the FDA, many women are still concerned about safety aspect of silicone and implants in general. If this is your case, you have no alternative other than to err on the side of caution and either not undergo breast augmentation or alternatively choose an implant, which you feel happy about.

If you decide to proceed, the decision as to what type of implant to use ultimately rests with you. A surgeon can only inform and advise what implant he feels is best. Unfortunately, the perfect implants has yet to be made and as already described there are some drawbacks associated with all implants. One must therefore try to balance all these against the benefits, by trying to examine any evidence in a rational and impartial way. There are breast implant website, which can be useful in making your decision. One good one is breastimplantsafety.com.