The shape and size of the breast can be changed by placing an implant either under the breast tissue or behind the muscle on which the breast lies (pectoralis major). Preferentially, we place the implant under the muscle, since this makes the upper edge of the implant less noticeable. If the patient has sufficient fat/glandular tissue to pad the implant adequately, then placement of the implant over the muscle can be considered. Implants are usually inserted through incisions in the inframammary fold (under the breast). Alternatively, the incisions may be made around the areolas (periareolar) or in the armpit.
Sometimes a girl’s breasts do not develop much during puberty. Women with very small or even almost absent breasts have hormone levels in the normal range and can often breastfeed successfully. The size of breasts is genetically determined. As is the case with most of the human physical features, the size of the breasts in the population is distributed in a bell-shaped curve. Most of the women have average sized breasts and only a minority has really big or really small breasts.
With ageing breast tissue gradually reduces (atrophy) and descends (ptosis), changing the shape of the breast. This effect is greater following pregnancy and in particular after a significant weight loss.
A breast implant is made of an outer shell (silicone envelope), which can be smooth or textured. The filling material can be salt water (referred to as saline), liquid silicone or so-called cohesive (stable shape) silicone gel of varying degrees of firmness. Implants can be either round or shaped like a natural breast, referred to as tear drop or anatomical implants. We usually recommend silicone cohesive gel implants. These implants tend to have a more natural look and feel, and have less chance of “rippling” (seeing waves of the implant through the skin). The implants that we use are all FDA (United States Food and Drug Administration) approved and have life time expectancy. FDA place stringent requirements regarding scientific documentation prior to approving a breast implant.
In women with very little breast tissue, the shape of the breasts will be largely dictated by the shape of the implant. A round implant can give too much fullness in the upper part of the breast and a pronounced cleavage. However, most women prefer a more natural look, usually achieved with tear drop implants.
The best way to do that is 3D simulation. During the consultation, you will express your wishes about the shape and size of the breast and concerns regarding the procedure. Enough time will be taken to answer your questions, so you will be well informed about the benefits and risks of the procedure. We will perform a detailed evaluation of the shape of the breasts (height, width, drooping, and symmetry), skin quality and the breast cage appearance. To help you choose the desired breast size, you will be able to try on special silicon sizers. Wearing them under a tight fitting t-shirt will provide a more accurate idea of the final result. Based on your wishes and the evaluation, we will finally agree on a suitable choice of implants.
Breast augmentation can be done under general, sedation with local anesthesia or local anesthesia only. Rarely women choose to be conscious during this operation, since there is a considerable discomfort with pure local anesthesia. Therefore, some kind of general anesthetic is always given. Thanks to modern techniques the anesthesia may be shallow (sedation) and supplemented with local anesthetic.
Patients usually stay overnight or if the surgery is performed earlier in the day they can leave the clinic in the evening. During the first week, painkillers are usually necessary to alleviate the pain, which could otherwise be rather intense, particularly with the submuscular insertion. Sport bra should be worn to give the breasts some support during the first week. Scars are taped using surgical tape during a two week period, and it is preferred that they are not exposed to the sun for at least six months. The patient can take a shower after a couple of days and a bath after two weeks. Any sporting activity should be avoided for at least two weeks, after which it is gradually reassumed. The breasts will initially look bigger due to normal postoperative swelling, which for the major part will subside in the first months. As your soft tissues, skin and muscle (in submuscular insertion) accommodate to the implant, the shape of the breast will continue to change subtly during this time. A final appointment is planned six months after the surgery in order to assess the end result of the surgical procedure.
Breast augmentation has for many years been the most popular cosmetic procedure which is a testimony to its safety and ability to attain a satisfying results in most patients. However, all surgical procedures carry certain risks, and this one is by no means an exception.
Postoperative bleeding can cause the blood to accumulate (haematoma) in the pocket around the implant. It is a rare occurrence (less than 1%) as all bleeding is carefully stopped with cautery and, if necessary, the drain is inserted during the procedure. The drain evacuates the blood and is usually removed on the following morning. In case of haematoma, it is necessary to reopen the incision, remove the collection of blood and stop the bleeding.
Breast augmentation is carried out in the utmost sterile conditions, and prophylactic antibiotics are used. Therefore, the infection rates are less than 0.5%. Any infection that occurs in the tissue around the implant can usually be treated with antibiotics, but may require surgical removal of the implant. The implant can usually be replaced only when infection has subsided completely in a few months.
Capsular contraction can develop as a mid- or long-term complication (please see the next question). Very rarely mechanical wear and tear causes the silicone envelope to rupture. Although this is usually not dangerous, implant will have to be replaced or removed in due time.
Implants can sometimes rotate in the pocket. With round implants this is not problematic, as they are shaped symmetrically. All tear drop implants are designed with textured coating to stimulate the adherence to the breast tissue and prevent rotation. If it happens despite this preventive measure, the volume shifts and distorts the shape of the breast. The rotated tear drop implant might have to be corrected surgically.
The weight of the implant may affect the age and gravity related changes of the breasts. Large implants might stretch and weaken the breast envelope and cause a premature sagging.
The patient contemplating breast augmentation must clearly understand that in many cases, implants are palpable in the lower-outer part of the breast. This happens more often in very skinny patients with large implants. Rippling can be another problem when soft tissue cover is on the small side. The rippled edges of the implant can sometimes be palpated and seen in the lower area of the breast, despite the submuscular placement. Fat transfer (lipofilling) can be done to cover the rippled implant.
The augmented breasts may have an operated-on look. The rule of thumb is, the smaller the implants, the more natural the look of the breasts. If palpability and natural look are very important issues you might want to reconsider breast augmentation.
Breast augmentation leaves scars on the breast or in the armpits. The scars mature over 12 or more months, and are seldom noticeable after this period. However, the appearance of the scars does vary between individuals.
Unsatisfactory cosmetic results are avoided through meticulous surgical planning. More information about breast implant complications and corrections can be found at breast revision surgery.
Implants can in rare cases cause symptoms of autoimmune disease and BIA-ALCL (breast implant associated - anaplastic large cell lymphoma), a cancer of the immune system. So far about 400 cases were described (FDA report,March, 2018) and about 5-10 milion implants inserted. More information on offical page of the FDA.
Depending on the quality of the implants, they can rupture or start leaking (gel bleed).
When any foreign material is inserted, the body makes a protective coating around it. It is similar to the scar tissue on the skin surface after an incision or other wound. In case of breast implants, this is usually a thin membrane that remains undetectable externally. However, if the reaction to the implant is excessive and the membrane becomes much thicker, it is referred to as a capsule. Similar to a hypertrophic scar a capsule around the implant can become firm and contracted. The newer designs of implants have features to reduce the likelihood of this happening. Capsular contracture occurs to some extent in around 5 % of patients and usually starts more than a year after surgery. It can be painful and lead to an abnormally hard feel of the implant. The contracture can displace the implant upwards and distort the breast.
Surgical treatment with widening of the implant cavity and removal of the capsule might be needed. Implants can be placed in a different position with a fresh pocket created under the muscle. Occasionally a change of implants is warranted. Polyurethane implants, associated with a lower rate of capsule formation might be considered.
Breast augmentation does not usually interfere with breast feeding, and it has been confirmed by the scientific studies there is no silicone in breast milk.
Nipple sensitivity can be temporary reduced. This is more common if the incision around the areola has been used. Sensitivity usually returns in the first few months, but can be permanent in isolated cases.
Special radiographic views must be taken to minimize the interference of breast implants in mammography (screening method for breast cancer). This is a routine practice in most radiology departments. The ability to detect a breast cancer in patients who have had implants is not reduced. Neither does having a breast augmentation interfere with breast self-examination, physician breast exams, ultrasound or MRI.
If you are over 40 years old or have a history of breast or ovarian cancer in your immediate family, it is advisable to have a preoperative mammogram before breast augmentation. We will perform a complete medical history at your consultation and make recommendations for breast imaging or other referrals, if necessary.
With the right indications there is no age limit. There is no specific age that is considered too old. Physical health is much more important than the age.
With regard to the minimal age, it is recommended that at least 7 years have passed since the first menstruation and that breasts have not grown in size for the last 2 years. Usually the patient has to be 18 to be reasonably assured the breasts have developed fully and the patient can sign her own consent form.
Minimally and moderately sagging breast can usually be sufficiently filled and lifted with suitably large implants alone. However if, there is significant breast sagging (ptosis) a breast augmentation is combined with a breast lift (mastopexy) in a procedure named augmentation mastopexy. A breast lift removes the excess skin creating a more youthful breast contour, and lifts the nipple and areolas to a higher position on the chest. A breast augmentation enhances the breast volume and creates a more balanced appearance.