Breast Augmentation

Overview

Some women want fuller breasts. Some want back the volume they lost after pregnancy, breastfeeding or a large weight loss, and some want two breasts of clearly different sizes to match more closely. Breast augmentation is the operation used for all three. The volume comes either from a breast implant placed behind the breast tissue, or from fat transfer, where the surgeon removes fat from another part of your body by liposuction and injects it into the breasts.

This is elective surgery, which means there is no medical need for it. A surgeon can describe a likely change in size and shape. No surgeon can promise a particular result, because your skin, breast tissue and healing all affect how things settle.

Implants are also a long-term commitment. They need checking over the years, and many women need at least one further operation at some point.

Who needs it

The women who are usually suitable for breast augmentation are:

• Adults in good general health, with a stable weight.
• Not pregnant or breastfeeding. Surgeons usually wait several months after breastfeeding ends, so the breasts have settled.
• Non-smokers, or willing to stop for several weeks before and after surgery. Smoking slows healing and raises the risk of wound problems and infection.
• Making the decision for themselves, with no pressure from anyone else.

Age rules differ by country. In the United States, for example, silicone gel implants are approved for cosmetic augmentation from age 22 and saline implants from age 18. The hospital you choose follows the rules of its own country.

A surgeon may advise against surgery or ask you to wait. Common reasons are poorly controlled diabetes, a bleeding problem, an infection, or a breast lump that has not yet been investigated. Some surgeons also ask how you feel about your body more generally, and may suggest speaking to a counsellor first if the worry seems larger than any change an operation could make. That is good practice.

What the surgeon will want to know

For a first opinion, the surgeon usually asks for your age, height, weight, medical conditions, current medicines (including blood thinners and supplements), smoking, any previous breast surgery and any family history of breast cancer. Depending on your age and history, you may need a breast ultrasound or a mammogram (an X-ray of the breast) before surgery, so that any existing problem is found first.

How it is done

The operation is done under general anaesthesia, so you are fully asleep, and usually takes one to two hours.

Implants or fat transfer

Implants allow a larger change in size and are the more common choice. Fat transfer gives a modest increase. The body reabsorbs part of the fat, so a second session is sometimes needed, and you need enough spare fat elsewhere. Transferred fat can also form small oil cysts or calcium deposits that show on later mammograms. Radiologists can usually tell these apart from anything worrying.

Implant types

• Filling. Silicone gel implants contain a thick, cohesive gel. A leak may cause no symptoms, which is why regular scans are advised. Saline implants contain sterile salt water. If one leaks, it goes flat within days and the body absorbs the water.
• Surface. Implants have either a smooth or a textured shell. Most cases of BIA-ALCL (explained below) have been linked to textured implants, and many surgeons now use smooth ones.
• Shape and size. Implants are round or anatomical (teardrop shaped). The surgeon suggests a size based on measurements of your chest and the tissue you have.

Before you leave, ask for your implant card. It records the manufacturer, model, size and lot number, and you will need it for future care and in case of a product recall.

Where the cut goes and where the implant sits

The most common cut is in the crease under the breast. Others go along the lower edge of the areola (the darker skin around the nipple) or in the armpit. All of them leave a permanent scar, which usually fades over a year or more.

The implant sits either partly beneath the pectoralis major (the large chest muscle) or above the muscle, directly behind the breast tissue. Your surgeon explains which suits your tissue.

Risks, in plain terms

• Bleeding or a haematoma (a collection of blood) that may need a return to theatre, and infection, which sometimes means removing the implant.
• Capsular contracture. The body forms a layer of scar tissue, called a capsule, around every implant. Sometimes it tightens, making the breast firm, painful or misshapen, and further surgery may be needed.
• Rupture, rippling, or the implant moving out of position.
• Changes in nipple or breast sensation, which can be permanent.
• BIA-ALCL (breast implant associated anaplastic large cell lymphoma). This is a rare cancer of the immune system, separate from breast cancer, that develops in the capsule or the fluid around an implant. It usually appears years after surgery as swelling on one side, a lump or pain. Treatment usually means removing the implant and the whole capsule. The US Food and Drug Administration (FDA) has also reported rare cases of squamous cell carcinoma and other lymphomas in the capsule. It does not recommend removing implants in women who have no symptoms.
• Some women report wide-ranging symptoms such as tiredness, joint pain and poor concentration that they connect with their implants, often called breast implant illness. Research on this continues.

Recovery and how long you stay

Many hospitals keep you for one night, and some do the operation as day surgery. You wake up with dressings and a supportive bra. The chest feels tight and sore for several days, and tablets usually control the pain.

Surgeons usually ask you to avoid heavy lifting, raising your arms above your head for long, and strenuous exercise for about four to six weeks. Your own surgeon sets the exact limits.

Plan for about 7 to 10 days in the country in total. That allows for a consultation and tests before surgery, the operation, and a wound check before you are cleared to fly. If you ask us to, we keep copies of your implant card and operation notes for follow up, and after you go home your coordinator sends any later scan reports to the surgeon who operated.

Caring for implants over the years

• For silicone gel implants, the FDA advises a first ultrasound or MRI five to six years after surgery and then every two to three years, even without symptoms. Advice in your home country may differ.
• Keep up normal breast screening. Tell the radiographer about your implants before every mammogram.
• See a doctor about any new swelling, lump, pain or change in shape, however many years later.

Questions to ask your surgeon

1. Do you recommend implants or fat transfer for me, and why?
2. Which implant would you use (filling, surface, shape, size and manufacturer), and will I get the implant card?
3. Where will the cut be, and where will the implant sit?
4. What happens if I get capsular contracture, a rupture or an infection, and who pays for further surgery?
5. Is there anything in my health history that makes you hesitant?
6. How will this affect breastfeeding and future mammograms?
7. When can I fly, and when can I go back to work and exercise?
8. Which scans should I have at home, and when?

You can leave a consultation without booking a date. An elective operation can wait until you are sure.