Breast Augmentation

Attitudes about women's breasts have always been influenced by fashion trends.  In the twenties, women bound their breasts; in the forties, more volume was desirable; then, in the Sixties, a less restricted look was popular. Contemporary styles reflect a trend toward fuller, yet natural-looking lines. But regardless of your breast size, all healthy breasts have the same basic anatomy. When you're considering breast augmentation, it helps to know your anatomy so you can make informed choices with your surgeon’s guidance.

Breast Health

After breast augmentation, new breast health baselines must be established by you and your doctor.  Breasts with implants feel different during breast self-examinations and professional examinations and look different on a mammogram.

Breast Self-Examination

Dimples may mean a small tumor inside is tugging on your breast.

The best time for your breast self-examination is a week after your menstrual cycle begins.  Look in the mirror with your arms raised, and then lowered, hands on your hips.  Turn from side to side, checking for dimples, lumps and discharge from the nipple.

Feel for lumps while lying down or standing up, using three degrees of pressure - light, medium, and then firm - without lifting your fingers from the breast.  Lotion makes breast examinations lying down easy, and soapy water helps when you're showering.

Mentally divide your breast into several sections, and use the same pattern for every examination.

Using the soft pads of your middle fingers, feel your breasts in a circular motion.

Professional Examinations

In addition to your monthly breast self-examinations you should have a professional breast examination by your doctor on a yearly basis.  Inform any doctor who examines your breasts that you have had breast augmentation as the implants change the way the breast feels.

Understanding Your Options

If you have chosen to proceed with the operation of breast augmentation there are various decisions that you and your surgeon must make. Your surgeon will discuss these with you and obviously will make recommendations based on their experience and your particular needs. Take your time to consider the options before deciding on a procedure.  Clear up any questions before surgery is scheduled.

  • Breast Size and Shape

    The size that you aim for depends on your current size and shape and your stature.  It is important to realize that bust measurement is a number and a letter An even number represents the back size determined by the size of the torso and a letter that indicates the cup size determined by the size of the breast.  Since it is the breast that is being altered, do not expect to go from 34B to 38DD.  We can make you a “DD” cup, but the back circumference will probably not change.

  • Incision Location

    The location of your incision is based on your personal preference, your body type and your surgeon’s recommendation.  A periareolar incision (around the areola) means the scar may be concealed by the color and shape of the areola.  An Axillary incision (under the arm) means you will not have a visible scar on the breast itself, but there will be a fine, almost invisible scar under the arm which may be seen when the arm is lifted.  An incision placed in the inframammary fold may be hidden by the breast itself when standing, but can be seen when the patient is lying down.

  • Implant Location

    The implant may be located in front of the pectoral muscle (prepectoral) or behind it (postpectoral). If you have a moderate amount of breast tissue, over the muscle may be a good choice for you. If you have a small amount of breast tissue, under the muscle may be the better choice. Each location has different advantages for each woman. Your surgeon will help you make the decision as to which placement is best for your body.

    Prepectoral location is often more suitable if the breast is slightly droopy (or ptotic), or if you exercise with the upper body. Under the muscle can give a smoother line to the implant, but does have the disadvantage of movement and/or distortion with chest muscle compression. Your surgeon will discuss this alternative with you.

  • Type of Implant

    There are different types of implants available. Most implants are synthetic rubber shells filled with a saline (saltwater) solution. The outer wall of the implant may be smooth or textured (rough surfaced). Generally, rough surfaced implants do not need to be massaged post operatively. Smooth implants may need to be massaged to help prevent scar contracture (this is further explained in the section on capsular contracture). Your surgeon will recommend the particular type of implant that he feels is most appropriate for you. You should ask him about specific risks or complications related to the implant material and possible deflation of an inflatable saline implant.

On the day of surgery, the proposed implant site, the creases under the breast and the incision sites will be marked on your skin either in your hospital room or in the pre-op area outside the operating room.

In the operating room an incision is made according to the preoperative plan. A pocket is then made depending on the type of implant being used and the breast size you have selected.  The space in the pocket allows your breasts to feel soft.  An implant is inserted in order to achieve the look you have chosen.  Once the desired look is achieved, the pocket is closed. 

The incision is closed and your surgeon places either a surgical bra or bandage over the incision, depending on what seems best in your case.   Drain tubes are frequently inserted into the pockets to eliminate any blood which may collect.

Understanding Risks

As with any surgery, breast augmentation involves some risks and potential complications.  These are listed below and are separated into general risks which can occur with any surgical procedure, and risks specific to the breast augmentation operation.

Generally speaking, any surgical procedure can be accompanied by the following three conditions:

  • Infection

    Infection is a significant risk in that the presence of a foreign body (i.e. the breast implant) can cause prolongation of the infection. Infection is rare, but should it occur, it may be necessary for the prosthesis to be removed temporarily (up to about six weeks) until the infection is controlled.  Once the implant is replaced however, the result should be indistinguishable from the opposite normal side.

    Special precautions are taken to limit the chances of infection and these include showering prior to surgery with antiseptic soap, intravenous antibiotics during the operation and a course of antibiotics following surgery. If pain and redness begins or increases after 24 - 48 hours this may indicate an infection and this should be immediatelyreported to your surgeon.

  • Bleeding and Hematoma Formation

    Excessive post-operative bleeding can be caused by a variety of factors.  One of these is the taking of blood thinning medications such as aspirin and we can give you a list of drugs that can cause this problem. You should not take such medications for at least 10 days prior to your operation.

    Some bleeding occurs after all surgery - it is natural. But excessive bleeding and hematoma formation are a problem.  To deal with this, your chest will be bound firmly for 24 hours after surgery and a small drain will be inserted into each side. The drains remain in place until they stop draining. They are an important indicator of what is going on inside your chest.

    • Bleeding and Hematoma Formation

      It is our experience that if bleeding does occur and a hematoma develops it can lead to abnormal thickening of the scar capsule around the implant (capsular contracture) or to an increased possibility of infection.  It is therefore appropriate that if bleeding does occur in the first 24 to 48 hours that the patient is returned to the operating room with removal of the implant and cleaning out of the abnormal blood which has accumulated. The implant is replaced immediately after the bleeding has been controlled and this usually results in no further problems. If excessive bleeding does occur, increasing pain will be experienced and the breast on that side will be abnormally swollen compared to the opposite side.  This is always in the early post-operative stage and should be reported immediately to your surgeon

  • Scarring

    A sequel of any surgical procedure is scarring.  Each and every time the skin is cut either by scalpel or laser, a surgical scar is produced.  The quality and appearance of scars vary widely with the individual’s healing process, the position of the scar on the body and degree of tension placed on the scar.  The types of scars a patient acquires are influenced by personal, familial and racial factors and cannot be controlled by your surgeon. 

    The incisions for the insertion of the breast implants can be placed under the arm, around the nipple or in the crease under the breast.  All incisions will leave a scar no matter how faint.

    The scar in the axilla (underarm) is well hidden when the arms are by the side or even at reasonable elevation.  However, if the arm is lifted completely above the head during the early stages of healing a red scar may be seen.  This can persist for up to six months.  When the scar eventually settles it usually looks like a crease in the skin.  This area can on occasion be prone to scar thickening.  However, this is rare.

    The scar around the nipple is, of course, not seen while the patient is clothed.  However, when the nipple is exposed the scar is sometimes seen as a white line on the lower border of the areola.  The visibility of the scar depends on the color of the areolar skin.  Scars are always white, so the darker the areolar skin, the more obvious the white scar.  Thickening of the scar in the area of the areola is extremely rare, but can occur.

    The scar in the crease of the breast is usually not seen when the patient is standing.  However, when you lie down the scar is easily seen.  While the scar is red (in the first 3-6 months) it can be quite noticeable.  Scars in this position have a higher chance of thickening (hypertrophy) and on occasions can become quite thick (keloid) and take several years to settle.  The scar in the crease under the breast is not actually in the crease but slightly above the crease on the under surface of the breast.

    The indications for using various incisions and the quality of the scar will be further explained to you by your surgeon

    Scarring also occurs in the deeper layers of skin and muscle.  This is more frequent when the skin and other layers have been separated and these deep scars can behave in the same way as skin scars, becoming thick, lumpy, raised and tender.  As with skin scars, this type of scarring will settle and mature with time, but the process may take many months.  The most noticeable areas where this deeper type of scarring can occur are the cheeks of face lifts and liposuction.  Massage and other types of treatment can help with maturing and flattening the scar, but time is always necessary.

Specific Risks

  • Capsular Contracture

    Any foreign implant that is inserted into the body is ultimately surrounded by a scar formed by the body to wall it off from the other tissues.  This occurs also with the breast prosthesis.  All scars shrink or contract to a certain degree.  If this occurs to excess in the breast, the shape of the implant may distort.  It usually becomes round or globular.  The breast may also feel hard to varying degrees.

    This hardening, caused by excessive contracture of the normal scarring phenomenon, can occur in between 5 and 35% of breast augmentation operations and can be influenced by the surgical technique as well as the type of implant used.

    Recently, rough surfaced implants have been noted to have a lower incidence of scar contracture, but there are other trade-offs as a result of using the rough surfaced implant. These include a wavy appearance of the skin around the margin of the implant and fuller projection of the implant. A smooth implant inserted into a large space will also have a low incidence of scar contracture, but it is necessary after the operation to manipulate the implant to maintain a large pocket and therefore a large scar surrounding the implant. If capsular contracture does occur, it can be accompanied by discomfort or pain and this may necessitate further operative treatment to release or remove the internal scar. If it is not causing problems then no further treatment may be necessary. The position of the incision usually has no bearing on the chance of scar contracture.

  • Loss of Nipple Sensation

    This operation may be accompanied by an alteration of nipple sensation.  Nipple sensation can be increased as well as decreased after surgery, but over a period of months the number of patients with permanent alteration of nipple sensation decreases to approximately 10%.  This seems not to depend on the site of the incision that is used, but is mainly due to stretching or damage of the nerve at the outer part of the breast while the cavity is being made.  There can also be a temporary loss of feeling of the breast skin particularly in the area beneath the nipple.  It is usually found that this sensation returns over a six-month period.  Our experience is that nipple sensation is unaffected in 70% of patients.  For 10%, sensation is enhanced.  In 20% however, nipple sensation may be diminished or even rendered numb.  Permanent numbness is however quite uncommon.

  • Implant Deflation

    The manufacturers of saline implants advise that there is a failure rate of the implant with subsequent deflation in the order of approximately 5% over 10 years.  Although clinical experience to date has not confirmed a failure rate of this magnitude, the manufacturers have obviously taken a cautious line.  It is unreasonable to expect that any mechanical device may not fail sometime.  Breast implants are no exception.  If the implant should fail either by valve failure or "cracking" of the wall of the prosthesis, the breast would deflate and the salty water would be absorbed into the body.  Saline is not detrimental in any way to the patient.  It is similar to the intravenous fluid given at operations and is eliminated from the body in the urine.

    The deflated implant would have to be replaced and this would require a further small procedure, re-opening the same incision line.  In advising of this complication, the manufacturers warn patients that breast augmentation with saline filled devices should not be regarded as a final or permanent procedure.

  • Asymmetry, Firmness and Discomfort

    These complications are usually a result of asymmetrical or excessive contracture of the scar or capsule which forms around the prosthesis internally.  The formation of the scar capsule is a normal biological response to the implantation of foreign material and excessive contracture can distort the shape of the breast. This can be in the order of 5-35% depending on the type of implant and procedure used.

  • Minor Displacements or Asymmetry

    Minor displacements leading to asymmetry of the implants are generally not different from the variations of the breasts considered to be within normal limits.  Quite frequently, minor asymmetries or even significant asymmetries of the breasts can be seen prior to surgery and doctor will frequently make a note of these.

    You can return to your activities at a slow, gradual pace. You may be back to work as soon as five to seven days after surgery and may begin light exercise in a week or so.

    Lifting and strenuous moving may be restricted for several weeks or longer. Follow the golden rule - "If it hurts, don't do it".

Breast Self-Examination

You should resume normal breast examination at three months after surgery. This is one suggested routine you may care to follow.  The best time for your breast self-examination is a week after your menstrual cycle begins. 

Look in the mirror with your arms raised and then lowered, hands on your hips. Turn from side to side, checking for dimples, lumps and discharge from the nipple.

Mentally divide your breast into several sections, and use the same pattern for every examination.

Using the soft pads of your middle fingers, feel your breasts in a circular motion.

Feel for lumps while lying down or standing up, using three degrees of pressure - light, medium, and then firm - without lifting your fingers from the breast. Lotion makes breast examinations lying down easy, and soapy water helps when you're showering.

Professional Examinations

In addition to your monthly breast self-examinations you should have a professional breast examination by a surgeon of family practitioner on a yearly basis. Inform any doctor who examines your breasts that you have had a breast augmentation.

If you are in the habit of having regular mammograms, it is a sound idea to have a repeat examination about six months after your operation. Surgery will change the radiological architecture of your breasts. A mammogram taken after surgery will serve as a useful comparison for future radiological investigations.

Although every effort has been made to explain the complications there will be complications that may not have been specifically mentioned. A good knowledge of this operation will make the stress of undertaking the operation easier for you to bear. 

The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery.