To gain the best possible results from aesthetic surgery requires careful patient selection. Not all procedures are suitable for all patients, therefore it is impossible to offer anything other than very general advice before seeing a patient. It is certainly better to have no procedure than an inappropriate one. To undergo aesthetic surgery is a major decision requiring appropriate discussion and thought.
Cosmetic Procedures
Breast Augmentation

Breast augmentation is a procedure designed to increase the size of the breasts, usually for women either with naturally small breasts or whose breasts have diminished in size following pregnancy. The procedure involves the insertion of a prosthesis (implant) behind the breast, not within the breast tissue, to give it more bulk and projection.

Breast augmentation has a very long history. In 1962 specific breast implants consisting of silicone gel contained within a silicone envelope were introduced in America but even before that a variety of materials including fat grafts and injections of substances such as beeswax had been used – generally with very unsatisfactory results. Since 1962 breast implants have evolved and improved but by far the most commonly used remain of a silicone construction. A great deal of data about the behaviour of silicone implants in the body has been gathered over the last 45 years or so and to date there is no evidence to suggest that they have done or do harm and neither do they have any association with any specific disease process. Their licence was withdrawn for a period in the USA because of concerns about auto-immune or collagen disease, otherwise known as human adjuvant disease (HAD) being associated with silicone breast augmentation but an extensive investigation over a prolonged period concluded that the two were not related. Silicone breast implants are now licensed once more in the USA – the licence was never withdrawn in Europe. There is certainly no association between breast augmentation and breast cancer, if anything women who have had an augmentation have a slightly lower incidence of breast cancer than the population at large (though this difference does not reach statistical significance), presumed to be because of a smaller than average volume of breast tissue.

The shell of breast implants is constructed of silicone and generally has a roughened, or textured, surface which keeps them softer in the body more reliably than a smooth surface does. The filler material is either saline (salt water) or more commonly silicone gel which, in turn, may be of a treacly consistency or semi solid like “jelly” served at children’s tea parties. The latter is known as cohesive gel and has the specific advantage that the implant can be made in a variety of shapes and chosen to suit specific anatomy. Saline has the same consistency as water and so is less satisfactory than silicone because it is more likely to be felt through the skin or cause irregularities known as rippling but it does have a place in certain individuals. Unlike all other implants the saline type are filled by the surgeon at the time of the operation so that they may be inserted “flat” and then inflated once inside the body which enables a very small incision to be used. The disadvantage, however, is that there must necessarily be a valve to fill them through which is potentially a weak point for leakage.

In summary, both silicone and saline implants have been very closely studied, have a long track record and are well understood. Other types are introduced from time to time, often marketed directly to the public but with little or no scientific data to demonstrate their effectiveness or safety. The “Trilucent” implant was a good example. It was filled with soya bean oil and sold in the lay press as being “natural” and “transparent” to x-rays. It was eventually withdrawn because some patients had noticed inflammation and swelling of their breast which was associated with leakage of the implant. There were also real concerns about the long-term stability of the soya bean oil and patients in whom these implants were used were advised to have them removed. Unfortunately, in the UK, “implantable medical devices” are regulated by a different body (the MHRA) from pharmaceuticals and require much less scientific information to be collected before their clinical use is permitted. In a market, such as breast augmentation, which has become so commercial this is a real concern re-inforced by the recent scandal about PIP implants (which I have never used). I have anxieties also about the current vogue for “injections” into the breast – historically this has never proved satisfactory and we have no long-term information about the behaviour of contemporary materials within the breast itself.

Which implant is right for me?
The choice of exactly which size and shape of implant to use is not a simple one and is best reached in discussion with the patient to take in to account individual wishes and circumstances. It must be remembered that one should not attempt to over stretch the skin since this will produce a very unnatural appearance and a breast which does not move normally. In general, patients who have had children are likely to have more scope for enlargement than those who have not since the breast tissue and skin will have been stretched during pregnancy and/or breast feeding. From a corsetieres point of view the measurement of breast size is the bra “cup” size not the “inches” dimension which rather represents a measurement of the chest beneath the breasts. It should also be borne in mind that cup sizes are not uniform from one bra manufacturer to another. Because of these various factors the planning of the post-operative breast size must necessarily be an approximation. The implants themselves are measured by volume (cc’s). Placing them inside a bra pre-operatively is little help in gauging post-operative size since when the implant is inside the body the skin tension and that of the tissue surrounding it will have a significant effect, so that an implant of a particular volume will not necessarily produce the same change in cup size in two different women – this will depend on their anatomy. Volume is not the only variable and there are now many different ratios of width to height to projection producing a wide range of implant shapes which must be considered in each individual case. In general, however, following discussion, it is usually possible to predict reasonably accurately what would be achieved by the operation.

Which implants are best?
Manufacturers and their quality control vary. I use only implants that are licensed for use in the United States, i.e. approved by the FDA. The manufacturers who are so approved are Allergan, Mentor and Silimed.

How long will an implant last?

Although they are all durable and made to a high standard, they cannot be considered 'lifetime devices'. Any woman undergoing a breast augmentation should assume that at some future date it will need to be revised or adjusted, either because her anatomy has changed (e.g. because of pregnancy and breast feeding) or because the implant 'wears' with time and, therefore, needs to be replaced. This time interval is currently not defined, but it is known that the older the implant becomes, the more likely failure (i.e. leakage) becomes. It is impossible to predict for certain the behaviour of any implanted material over the course of a patient's lifetime and, although statistics are being gathered constantly to improve our knowledge, patients must accept that there is always a degree of uncertainty in the long term.

Where are the scars?
Implants may be inserted by different routes which will leave the scar in different locations. The commonest is via an incision on the under surface of the breast close to where the breast and chest meet, this incision will usually be approximately 5cm (2") long. An incision beneath the armpit may be used, which may be limited to only 2cm (1") in length, but only if a saline filled prosthesis is being employed, the implant being inflated once it is in position. Thirdly it is possible to carry out the operation through an incision around the lower half of the areola (the pink disc surrounding the nipple) so long as it is of sufficient diameter. The choice depends on the physical characteristics of the patient and also, of course, on their personal preferences and this can be discussed.

Behind the breast or behind the muscle?
Once inside the body the implant may be placed behind the breast (submammary) or behind the pectoralis major muscle (submuscular). Each has advantages and disadvantages and the choice is, to a large extent, dictated by anatomical features. In many patients a combination of the two known as a biplanar placement may be preferable. This puts the upper part of the implant, where the breast tissue is thinnest, behind the muscle to disguise it and create a smooth “take off” from the chest, but the lower part behind the breast only to avoid the tendency of the muscle to push the implant upwards. These various options will be discussed at the consultation.

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