Basic Facts on Breast Implants
A Few Facts on Silicone
What are the alternatives to Silicone Gel?
Are there different shapes and consistencies of implants?
How do I choose which size of implant is the best for me?
Do Breast Implants cause Breast Cancer?
Does a Breast Augmentation affect the means to detect Cancer?
How long do implants last?
What does the operation involve?
What kinds of Incisions are there?
Where do you place the implant? In front of or behind the muscle?
What type of anaesthetic is used and how long does the surgery take?
Is it painful?
What happens after surgery?
What kind of after effects should I expect?
What are the scars like?
What could go wrong?
How long before I can get back to normal?
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 too 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 a 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.
It is important to understand that the outer shell or envelope of all breast implants is made of silicone. However, the actual filling substance can differ giving rise to various types of implants including saline (salt water), pure silicone gel which is divided into simple or cohesive gel (i.e. McGhan). The more recent sugar & salt gel (Hydrogel) and Soya oil (Trilucent) implants are currently not in use, pending further safety investigations.
Silicone gel implants are currently the most common type used. In Europe current sales figures show a distribution of 70% silicone, 15% saline, and 15% for alternative fillers such as Hydrogel and Soya oils. As modern silicone gel implants have been available since 1963, surgeons therefore have over 35 years of experience with these types of implants. This is more than any other type in use. Evolution has brought changes and improvements over the years with the introduction of textured surface envelopes made of newer formulations designed to minimise the "bleed" or diffusion of what is usually tiny amounts of the silicone oil fraction of the gel contents.
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 of the silicone gel content.
Many ladies considering this type of surgery will no doubt have heard of frightening stories about silicone toxicity or autoimmune/connective tissue disease, due to gel "bleed" or migration. As a result, breast augmentation has, in the last 8 years, received much unfavourable 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 Administration (FDA) in January 1992 imposed a ban on the use of silicone gel breast implants. The FDA concluded, "there was no evidence that silicone gel filled breast implants are unsafe, but there was insufficient evidence to prove safety". All the above was a result of pending law suits against the manufacturers of breast implants from women who had implants and were now allegedly suffering from a whole host of symptoms from a disease process arbitrarily termed "silicone related autoimmune disease". In fact a search of court records in America has revealed that no less than 216 separate complaints or symptoms have been filed in association with gel filled devices(a number unheard of with any other disease process or condition!)! Since this time there has been much activity and debate within the medical community to try to ascertain whether silicone gel breast implants are safe. To this end there have been many numerous statements issued and conclusions deduced. In summary some of these are:
In conclusion to these statements, it would be fair to accept that some women who have had Breast Augmentation surgery, may have subsequently developed at some point in their lives a connective tissue or autoimmune disorder. However as these disorders arise fairly commonly in individuals in the general population anyway, regardless of whether they have had breast implant surgery or not, is it not possible that they may have become ill anyway? This type of question can only be answered by careful statistical analysis and examining groups of individuals who have had silicone implants and then comparing them to similar numbers and types of individuals without breast implants. If it then appears that the group of women with silicone implants suffers a higher number of individuals with autoimmune diseases then a causal link can be established. However, at the moment, after examination of all the relevant data, it seems safe to say that there is no conclusive scientific evidence that silicone materials in breast implants increases the risk of connective tissue diseases or for that matter breast cancer.
Trilucent(soya oil) Breast Implants
The main concept behind the development of the Trilucent implants was to create a safe radiolucent (invisible to x-ray) product which would allow good visualisation of breast tissue with mammography. Trilucent implants are filled with highly refined, non-silicone, natural triglyceride soya oil that allows better penetration of x-rays through the implant. Although these implants appear to obscure the breast tissue to a lesser degree on a mammogram, one must always inform the radiographer of her implants.
One significant problem that is evident with the Trilucent implants, is the phenomenon of skin rippling. As the Trilucent implant is fluid filled some wrinkling of the shell should be expected. In patients with thin breast tissue, these wrinkles can show up easily as visible and palpable ripples. As saline filled implants are approximately 30 times less viscous than the Trilucent implant, this problem occurs even more frequently. Silicone gel filled implants on the other hand have a thicker composition and therefore this problem occurs less frequently.
Patient clinical trials with these implants were initiated in the UK in 1993. In total about 5000 women have had Trilucent implants. However on March 7th 1999, the Department of Health (DOH) advised practitioners that with immediate effect, no further Trilucent Breast Implants were to be implanted until further notice.
On the 6th of June 2000, the Medical Devices Agency issued a further hazard notice advising women to consider having their Trilucent Breast Implants removed. This was due to preliminary data suggesting that the filler used in Trilucent breast implants may breakdown in the body to create products that may be harmful. As a result further investigations are pending.
This is the latest type of implant produced in the quest for a filler substance that is harmlessly absorbed and excreted if the shell leaks or breaks. This is made from a sugar and salt-water gel. Although very close to imitating the feel of silicone gel type implants, the Hydrogel implants nonetheless are slightly firmer to touch. In addition the gel can sometimes feel slightly lumpy compared to the smooth quality of the silicone implants. Although skin rippling is less likely with the Hydrogel than the other Trilucent or saline filled implants, it does have a slightly higher incidence to exhibit this than the silicone gels.
Unfortunately, like the Trilucent implants, due to a lack of long-term studies and data, the Medical Devices agency have decided as of the December 2000 to stop the implantation of these implants until these concerns have been addressed.
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.
More recently however a newer, cohesive silicone gel (McGhan type 410) has been introduced which is also known as the shaped or teardrop implant. As the composition of this gel is set, compared to the more fluid gel of the round implants, a shape has been produced which mimics the natural profile of the breast. These implants are slightly taller than they are wide and are fuller in the bottom. There tends to be a smoother transition from the upper chest wall to the top of the breast and not quite so much of a "step-off" as can sometimes be seen with the round type implants. Therefore overall this tends to give a slightly more natural shape, although this very much depends on your initial shape to begin with. In comparison, the round implants give the breast a slightly more circular or rounded appearance.
In addition, as a result of the thick gel composition of the cohesive implant, in the unlikely event of any rupture or breakage of the shell, leakage of the contents does not occur as it would in the standard silicone gels. The disadvantages are that, not all breast shapes will benefit equally from this particular type of implant. It will be determined at the consultation whether you would benefit appropriately from this type of implant. Another disadvantage is that they are substantially more expensive than the standard silicone implants. The cohesive implant also feels slightly firmer to touch, making the edges of the implant more palpable, and there have been reports of the implants moving out of place within the pocket, with resultant loss of shape.
Even more recently however, a round silicone cohesive type implant has also been produced which has the advantage of not leaking when the shell of the implant wears or tears. Another advantage in comparison to the previously mentioned teardrop implant, is that the round cohesive implant doesn't lose its shape within the pocket.
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 the Specialist 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 patient.
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.
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 few years enabling the radiographer to minimise the amount of breast that is hidden by the implant. It is important however to realise 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.
Like all man made products, breast implants do 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 eventually wears thin and ultimately disappears. If this happens then the contents of the implant leak out. This is usually termed disintegration, leakage or rupture of the implant. Clinically however this may be difficult to spot. Occasionally one may detect a slight flattening of the breast or an alteration of the shape, but this may only be very slight and hardly noticeable. Capsule formation(see above) is the main reason that ruptures of an implant can sometimes be tricky to detect. As previously stated, a capsule forms a type of "biological bag" encompassing any breast implant. Should leakage of the implant therefore occur, the contents will still be contained in the same location by the body's own bag or capsule. Despite being difficult to detect clinically however, thankfully an ultrasound scan will most times be able to accurately assess the condition of any implant when necessary.
There are many quoted figures as to how long ultimately any implant lasts before disintegrating. An average figure is probably in the order of 20 years. There are however variations in the wear and tear amongst different individuals. A women therefore who subjects herself to extreme physical exercise for many hours a day on a regular basis with resultant excessive movements of her breasts (i.e. aerobics instructor, marathon runner, regular horse riding etc.) will naturally subject her implants to more wear and tear over a given period of time, than someone who does very little exercise. In the first situation it would be reasonable to assume that the implants may disintegrate sooner than in the latter case.
In order therefore to have a proper assessment of the state of your implants it is best advised to have your implants examined by a specialist on a regular basis from about 10-15 years after your operation and an ultrasound performed as necessary.
The main principle in the operation of Breast enhancement surgery is the creation of a pocket behind the breast which will accommodate a breast implant. There are however a number of details in the approach to this surgery which one needs to understand beforehand.
There are generally 3 types of incisions used for inserting the breast implants.
The inframammary incision, is made under the breast at the fold or crease line. The incision is about 4 cm in length. This is the most 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 of 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 that pocket.
Another method is the peri-areola incision, which is made around the edge of the areola (the darker skin around the edge of the nipple). The disadvantage is that the scar is not hidden by any folds, and subsequent scarring may interfere with milk expression in breast-feeding.
The third method is the 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.
Regardless of where the incision is placed it is important to remember that a 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.
There are two locations or pockets made where the implant may be placed; the subglandular (in front of the pectoralis muscle) and the submuscular (behind the pectoralis muscle). The pectoralis muscle is the chest muscle that is commonly developed in body builders.
In the U.K. the subglandular placement is probably the most common location used. 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 than 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 of 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 second location is the submuscular placement between the muscles of the chest wall and the rib cage. Submuscular placement increase the padding overlying the implant 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 on the appearance mentioned above. Another advantage is that mammography has been reported to be slightly more effective. The disadvantages are that there may be a bit more pain, or discomfort, after surgery and that the breast will move with certain actions of the muscle.
The decision, as to which location the implant should be placed in your case, will be discussed at the time of the consultation.
The operation is performed under general anaesthesia and usually requires an overnight stay in hospital. The procedure takes approximately 45 minutes to perform.
Pain, will be experienced following a Breast Augmentation. It is always difficult to quantify how much pain any one individual will experience. Whilst some women find this procedure extremely 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 cut 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. After a week however most women report a considerable improvement in their symptoms and in fact do away with any regular painkillers.
Your breasts will be somewhat swollen and bruised postoperatively. This 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 also 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 for 2 weeks. At two weeks your dressing will be removed and the wound inspected and lightly cleaned. There are no stitches to remove, as these are internal and dissolvable. Always remember to read and follow the postoperative instructions that will be given to you.
Changes in nipple and breast sencation(feeling) can occur. Some patients may loose sensation entirely, 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 satisfactorily.
Should you become pregnant following your operation then your existing breast tissue will be subjected to the 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. Hydrogel 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 minimise 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 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 travelling in an aeroplane, swimming, diving etc.
Scars are not a complication but a normal event after any surgery. Thankfully the scars in a Breast Augmentation operation are short, being about 4 cm in length. You should always expect these to be red, raised, lumpy and even itchy to begin with 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 two years to complete. Daily massage of the scars during this time period is advised to expedite and facilitate this process. You must understand however that no responsible surgeon will ever be in a position to predict any scars ultimate appearance. Although as mentioned, scars do fade and improve in time it is not very often however that these are ever characterised as being only "hairline" in nature.
All surgery carries some uncertainty and risk. When a breast augmentation is performed by a qualified Plastic Surgeon, complications are infrequent and usually minor. Still, individuals vary greatly in their anatomy, their physical reactions, and their healing abilities, and the outcome is never completely predictable. These include infection, haematoma, 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 hospital. Infection not reported could easily compromise the success of any surgery. If infection was to be serious and fail to respond to antibiotics, removal of the implants would be required and replacement would not be effected until such time as 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 haematoma, and occurs 1% of the time) then it may be necessary to drain this. Your surgeon will be able to assess this.
Skin necrosis or skin decay occurs when there is not enough blood to supply the skin. This could happen if the surgeon were to select an implant size too that was too large for the pocket created. This is extremely rare .
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 realise that this is 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 any way. Capsular contracture or hardening occurs when this layer of scar tissue 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 textured shell implants, the problem of capsular contracture has been significantly reduced, now being between 6-8%.
The cause of capsular contracture is not totally clear, but seems to be multifactorial. It is important to realise that there are degrees of contracture and that the majority of women, who do 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 and to a different degree either side.
It may develop any time, even years later although it is most likely to happen in the first 3 years after surgery. Unfortunately at this time there is no effective way to prevent capsular contracture if it is 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 an 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 rupture 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 infrequently done.
The other method, which is much more controlled and thus the preferred method, is the open capsulotomy, performed under general anaesthesia. 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. Unfortunately, even after a successful capsulectomy, there is always the possibility of recurrent hardening.
Although you can gently walk about and do very light duties from the next day, please avoid any stretching or lifting during the first 7 to 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 for a further 10 days. You can usually commence light lower limb exercise after three weeks. Upper arm exercises and swimming can begin after six weeks. When exercising always try and wear a good sports bra. Driving is allowed after 1 week. Sexual activity can be commenced at around 4 weeks although at this stage only very gentle handling of the breasts is advised. More vigorous handling can be commenced only after 2 months!
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 British Plastic Surgeons and the UK's Department of Health, many women are still concerned about the 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 do 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 implant 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. Patients should never allow themselves to be swayed by any form of media hype or scare mongering.
IF YOU REQUIRE FURTHER INFORMATION OR WOULD LIKE TO MAKE AN APPOINTMENT WITH ANDIE, OR WITH A SPECIALIST PLASTIC SURGEON PLEASE CALL ANDIE McLean’s Clinic on: 01525 40 30 40