What surgery is available, and what techniques are involved?
Breast enlargement involves the placement of an implant under the breast tissue to increase the size and shape of the breast. The implants are usually inserted using an incision placed under the breast at the crease, but can also be put in via an incision in the armpit or around the nipple.
Breast implants can be placed either directly behind the breast and on top of the chest wall muscle (known as sub-glandular placement), or behind the breast and chest wall muscle (known as sub-muscular placement). Your surgeon will advise which is appropriate for you.
Behind the breast
The insertion of implants behind the breast is considered to be the simplest of the available enlargement procedures, and less likely to cause significant discomfort. This route is also effective for patients with some drooping of the breasts.
Behind the muscle
The insertion of implants behind the breast muscle provides more padding or coverage for the implant. This is can be helpful for slender patients and those with very little breast tissue as it reduces the chances of being able to feel or see the implant under the breast tissue.
Dual plane augmentation
Surgeons often combine these two routes, placing the implants partly behind the breast and partly behind the muscle. Through this combined approach, surgeons try to give patients the benefits of both techniques. This is called a dual plane augmentation. If implants are inserted behind the muscle, they are likely to move when the muscle contracts. This is called animation and is normal.
Diagram showing implant either directly behind the breast itself or beneath the muscle and behind the breast.
What does the operation involve?
Before and after photographs should be taken for your clinical record. This is helpful for you and your surgeon to plan the operation and to assess the result. Your face is not included in the picture and you will be asked for your consent to have these done. If your surgeon wishes to use these for any other reasons (e.g. teaching or publication) they must specifically ask for additional consent from you in order to be able to do that.
Breast enlargement surgery takes about one-and-a-half hours, and is usually done under general anaesthetic. You may be able to go home the same day, but many patients will spend one night in hospital. Postoperative pain should be well controlled. Your chest may feel tight and your breasts and ribs below your breasts may be tender. You will be mobile from day one and should be back to full exercise within six weeks. You are recommended to take around one to two weeks off work after the operation.
At first your breasts may look high and the skin may appear tight. This tends to settle down over the first six weeks, but you will not get your long term result for 3-4 months after the operation as a more natural shape emerges. Most patients are pleased with their surgery, but some find their new shape is difficult to get used to. You should be prepared for this possibility.
There is an unpredictability about how scars heal. Scars tend to be quite red in the first six weeks, changing to purple over next three months and then fading to white. Most patients will form good quality scars over time. Abnormal scarring can occur in breast augmentation surgery.
What type of implants should I have?
The outer layer, or shell, of all implants is
made of silicone. Some implants have an
additional polyurethane coating.
The shell can be filled with either silicone
gel or saline. Implants have been used for
breast augmentation since the 1960’s and
the evidence suggests they are safe to
use.
You should ask your surgeon exactly
which type and manufacturer of implant
will be used and why. Most patients will
be offered silicone gel filled implants.
They tend to feel the most natural, have a
range of shapes and are durable. Saline
filled implants tend to feel less natural,
folds or ripples may be more visible and
they have a risk of deflation. All other filler
materials have been withdrawn for use in
the UK.
The most important decisions to make
about your implants are their size, shape
and placement.
Implant size
Implants are supplied by volume. It is not possible to guarantee a cup size. At your preoperative consultation your surgeon will assess your chest wall, your existing volume of breast tissue and how much skin is available to accommodate the implant. Your surgeon will be able to give you an idea of which implant size is appropriate for you. Your own view is also important, since in most patients a range of implant sizes could be used.
Your surgeon will ask if you want an implant towards the larger or smaller end of that range. Your surgeon will not be able to discuss a precise cup size with you. The larger the implants that are used and the slimmer you are, the less natural looking your breast augmentation will be.
An implant which is out of proportion for your frame is more likely to cause complications such as drooping, stretching the breast tissues and being more easily felt.
Implant shape
Implants can either be round or teardrop shaped (also known as anatomical).
Round implants provide a bigger volume at the top of the breast, and are the same width as they are tall. With teardrop shaped implants, it is possible for the surgeon to choose the width and height separately thus enabling more control of the eventual shape. With either of these options, there are varying degrees of projection. Your surgeon will discuss the best shape option to fit your frame and your desired outcome.
Teardrop or anatomical shape implant
Round shape implant
Implant Texture
The outer surface of breast implants is usually made of silicone and can be either smooth or textured. There are varying degrees of texture available, from very fine to coarse. Some implants are also covered with a foamy textured surface of polyurethane.
There are two main reasons for texturing the outside of implants. The first is to reduce the formation of tight scarring, known as a capsular contracture, around an implant because this can distort the shape and cause pain. There are studies that give evidence for this advantage particularly when the implant is placed in front of the muscle.
The other is to reduce any unwanted movement or rotation of an implant. The more textured an implant, the less likely it is to move or rotate over time.
For this reason, anatomical or teardrop-shaped implants tend to be textured, because rotation of the implant can alter the overall shape of the augmented breast. If a round implant is being used any rotation is not noticeable.
A further potential disadvantage of a textured surface is that it appears to be related to an uncommon condition known as Breast Implant Associated Anaplastic Large Cell Lymphoma (BIAALCL).This is described in more detail in section 4 below.
At this time, smooth surface implants appear to have no link to BIA-ALCL but that is not to say it could never occur.
Smooth implants are almost always round rather than anatomical shaped. Because smooth implants don’t stick to the tissues in the same way as textured implants, they tend to move around within the breast and can take several months to ‘settle’ into their long term position. If smooth implants move too much then they can slip to the side of the chest when lying down (lateral displacement) or drop below the crease of the breast(bottoming out).
It is not a straightforward decision between smooth and textured implant sand your surgeon should help you decide which implant is best suited to your shape and desired outcome.
Are silicone implants safe?
Breast implants are made from medical grade silicone. If you have breast implants, small quantities of silicone can be taken up by your body and be found in the breast tissue and sometimes in the lymph glands in your armpit. There have been reports of silicone being found in other areas of the body. Although most people do not react to silicone occasionally the body can form some inflammation and extra tissue around silicone deposits. These are called silicone granuloma.
Over time the implant shell may fail and the silicone gel may leak out. Often this will not cause any change in the appearance as the implants have a silicone gel inside them that keeps its shape.
Many ruptures will be discovered by accident when investigating other breast problems such as a lump. Implant rupture can cause symptoms such as lumpiness and a change in shape of your breast.
If a rupture has happened, you will be advised to have the implants removed. This is to stop silicone being taken up by your body and forming granulomas as described above. At that operation you may choose not to have any more implants or you may have them replaced at the same operation or at a time in the future.
There is no association between breast augmentation and breast cancer.
Please see the notes below regarding Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA ALCL) and symptoms known as Breast Implant Illness.