As with any surgical procedure, the goals of breast augmentation surgery are simple: A safe procedure with the desired outcome for the patient. For breast augmentation, this means increasing the breast size, with minimal scarring to achieve a natural, pleasing and long-lasting look. Some patients may request a larger appearance, some smaller. The amount of augmentation is tailored to each patient.
Who is a Good Candidate for Breast Augmentation?
You are a good candidates for breast augmentation if you are in good physical health and have realistic expectations. As this is a purely elective, cosmetic procedure, you should have no major medical problems such as heart, lung or vascular disease and be on little, if any, medications. In order to improve healing, it is best to be a non-smoker.
As well, you must be prepared psychologically. Your expectations must be realistic – you must understand what surgery can and cannot achieve. As well, implants eventually wear out and may need replacement several times over their lifetime. Patients must be aware of this and the costs associated with replacement.
Also, the immediate recovery can be quite painful and physical exercise must be avoided for several weeks.
How Dramatic of a Change is Recommended?
Our Surgeons recommend a natural appearance to the augmentation. Most patients desire a one to two cup size augmentation and this is reasonable. Implant sizes most often range from 250 – 400 cc in size. Our Surgeons rarely place implants above this range as they can stretch the skin too much, look unnatural and can lead to back, neck and shoulder problems.
Preparing for Breast Augmentation Surgery
Breast augmentation requires a general anesthetic in our Surgeons opinion. In addition to being in good health and being a non-smoker, patients are required to have nothing to eat or drink after midnight before their surgery.
As well, breast augmentation can be very painful after the surgery, so patients are advised to take at least two weeks off of work and not plan to do any lifting or anything strenuous for at least 6 weeks after the surgery. If they have small children at home, they are advised to get help for this time period. They will require someone to drive them home after the surgery and it is advisable to have someone stay with them the first night after the surgery.
As well, they will require a sports bra that opens at the front with no underwire for the first 6 weeks after surgery.
What can I do to assist the recovery process?
The best thing you can do is to follow our Surgeons post-operative instructions carefully. Do no more nor no less than he instructs you, even if you feel great – the inside takes a long time to heal, even if the outside looks great. Keep your incisions nice and clean. He will instruct you on how to perform breast exercises to ensure the implant sits nicely in its newly formed capsule. Attend the scheduled follow-up appointments. Do not apply any creams to the incision until our Surgeons instruct you to.
Get lots of uninterrupted rest and drink plenty of fluids. Should you do all of this and listen carefully, you will have the greatest chance of achieving all of your surgical goals.
There is very little, if any, effect of breast implants on breastfeeding. One must consider two factors on how implants affect breastfeeding: the effect of the surgery itself and the effect of the implant.
Rates of being able to breastfeed after any type of breast surgery, including breast augmentation, can approach 70%, but the true rate is really unknown. The limited studies to date lead us to believe that women with augmented breasts have about the same chance of being able to breastfeed as women who have not had the surgery. In fact, about 70% of women who have not had breast surgery are able to breastfeed, while 30% of the general population cannot. Thus, the rates of being able to breastfeed after breast surgery are almost identical to those who have not had breast surgery.
To the best of our knowledge, there is no danger of breastfeeding an infant from a mother with breast implants. Cow’s milk and infant formulas have a far higher level of silicon, a silicone component, than mother’s milk. Breast milk is the best food for babies.
Impact of Pregnancy and Breastfeeding on Breast Implants
The only significant change that may occur over the time of a pregnancy is position of the implant. This is impacted mainly by the amount of weight gain and breast growth during the pregnancy or other life change. While impossible to predict accurately as everyone is different, usually the implants can migrate or move to a lower or more lateral (towards the sides) position. There is no significant effect of shape change on the lifespan of the implant – i.e., they are not at increased risk of breaking during pregnancy because of weight gain.
The outcome of a breast augmentation in any given patient is influenced by a number of factors. These factors, along with their effect, are listed below:
Implant Size – Larger sizes look more “fake”.
Implant Pocket – Sub pectoral are more blunted and natural appearing, but are more visible during exercise in athletes.
Incision Placement – Inframammary scars are the most visible, axillary scars are the least.
Implant shape – Round implants are a great choice for augmentation – no concerns regarding rotation, tear drop shapes can add more volume to the lower portion of the breast, and less to the upper portion, giving a more natural appearance of the breast.
Pocket dissection – Too large a pocket will cause the implants to shift and move, stretching the skin prematurely, causing an unsightly appearance. The pockets may also be too close together, too far apart, too high, or too low, again giving an unnatural appearance.
Downsizing – Implants placed for a long time may just be too large for the patient. They can over-stretch the skin, causing a droopy appearance. Implants can be downsized and a breast lift performed, giving the patient a more youthful and appropriate breast shape.
Different sized implants – Patients with breast asymmetry or one breast a different size than the other, can have this corrected with implants of a different size.
Implant type – Saline implants are more adjustable and can be placed through a smaller incision but look and feel unnatural. Silicone implants, while requiring a larger incision, tend to look and feel more natural.
The risks of any surgery include, but are not limited to: infection, bleeding, scarring, the wound edges opening up, recurrence of the deformity, nerve damage and anaesthesia risks. These risks are small, but they are not zero.
There are other risks associated with Breast Augmentation surgery and some of them are listed below.
Rippling
Rippling may be defined as the appearance of little undulations or waves on the surface of an implant which resembles disturbed water. This rippling is apparent on the skin’s surface and is most often noticeable at the edges of the implants. Rippling is more commonly seen in subglandular implant placement because of traction between the implant, implant capsule and the skin. It is also seen with saline implants that are under filled and the folds of the implant become visible.
There is no inherent risk of rippling, it is mainly a cosmetic problem. There may be a theoretical increased rate of implant rupture because of the folds in the implant shell, but this rate is extremely small and not considered a significant risk for breast augmentation.
Capsular Contracture
Capsular contracture is defined as the “encapsulation of a breast implant by a fibrotic, contractile scar”.
All breast implants are encased by a breast capsule or scar. This is the body’s normal response to a foreign material within it. In the vast majority of cases, the capsule is quiet and does nothing to the implant. In cases of capsular contracture, the capsule contracts or shrinks, squeezing the breast implant. This can cause pain, disfigurement of the implant and quite possibly, rupture the implant.
Capsular contracture is a definite risk of breast augmentation surgery. The true rate of capsular contracture is unknown, but most Plastic Surgeons would quote a rate of around 5% or so. The exact cause of capsular contracture is not known, but some factors include bacterial contamination, silicone breast implant rupture or leakage, and hematoma or bleeding after surgery. Capsular contracture may happen again after additional surgery.
Methods which have reduced capsular contracture include submuscular implant placement, using textured implants, using saline implants, limiting handling of the implants and skin contact prior to insertion, prophylactic antibiotics, careful control of bleeding, and irrigation with antibiotic solutions.
Rupture
If left in place long enough, virtually all implants will eventually break. Think of implants as similar to parts on a car – they are subject to wear and tear and eventually will wear out. Implants will eventually need to be replaced.
The real question is how long do implants last. Studies indicate that the rate of failure of saline implants is about 1% per year. So if a saline implant has been in place for 7 years, the chance of it rupturing that year is about 7%.
The rupture rates of the newer cohesive gel silicone implants is not well known simply because they are newer. One recent study indicated that the rupture rate of implants was about 1% at 6 years after implantation, which, happily, is very low. Most Plastic Surgeons would say that a silicone implant should last about 10 – 20 years in most patients under most circumstances.
Should a saline implant break, it will be immediately noticeable as the size of the breast will rapidly decrease over a few hours. A silicone implant rupture, especially a cohesive gel one, is much more difficult to diagnose and often goes unnoticed for many years. This is because the volume remains constant and the gel stays within the implant shell, even if it is broken.
Other Causes of Disfigured Breast Implants
Capsular contracture is the most common complication that can cause physical disfigurement of the breast implants. Other complications that could potentially cause the implants to look unattractive include: hematoma (bleeding around the implant), seroma (non bloody fluid surrounding the implant), infection, rippling, implant rupture, and inadequate release or dissection of the breast implant pocket.
While most of the complications listed above are rare, they can happen. They all can happen even if the Plastic Surgeon did everything properly. In fact, experienced, meticulous Plastic Surgeons may have had patients with all of the above complications. This is just the nature of surgery. Of course, Plastic Surgeons who are not as meticulous as others may tend to have higher rates of complications than more conscientious Plastic Surgeons.
The placement of the breast augmentation incision is based upon three factors: Dr. O’Grady’s preference to achieve the surgical goals, which incision traverses and traumatizes the least amount of tissue, and patient preference.
There is no single incision that is perfect for every patient. Each has its own advantages and disadvantages. Factors which influence incision placement include: scar visibility, operative exposure, potential to injure vital structures including nerves, disruption of breast tissue, access for revision procedures, pre-operative breast size and type and size of implant.
Infra-mammary Fold Incision for Breast Augmentation
The most common placement of scar is the infra-mammary fold (IMF) incision, which is in the breast fold at the base of the breast. It offers the best exposure and operative control, least disruption of breast tissue and risk to vital structures. Its main disadvantage is that is leaves the most visible scar.
Peri-Areolar Incision for Breast Augmentation
The peri-areolar incision is located at the edge of the areola from the 3 o’clock position to the 9 o’clock position. If offers very good exposure with a more camouflaged scar than the IMF incision. Disadvantages include increased exposure of the implant to breast bacteria, altered nipple sensation and limited access size to place larger implants.
Axillary Incision for Breast Augmentation
The axillary incision is located in the armpit. It offers absolutely no scar on the breast itself and no violation of breast tissue at the implants are slid in underneath the pectoralis major muscle. However, visualization is very poor and the technique is done mainly by feel. This can be improved with an endoscope, but this adds cost and time to the procedure. Access to the lower part of the breast is poor and revision surgery is difficult. As well, there is a greater chance of injuring some of the nerves that supply the breast. Furthermore, only saline implants can be placed through this incision. On rare occasions, a very small cohesive gel implant can be placed, but this is indeed very rare.
Our Surgeons have performed surgery on patients using all three of these incisions. They can help determine which is the best incision for you.
The placement of the breast implant is entirely patient dependent. This means that the placement is tailored to individual patients based on their needs, lifestyle and anatomy.
Submuscular Placement
Implants are generally placed in one of two areas relative to the breast. The first and perhaps most common placement is submuscular. Submuscular refers to placement underneath or deep to the pectoralis major muscle (the “pecs”). In this pocket, the muscle covers the upper 2/3 of the implant, while only the overlying breast tissue covers the lower 1/3.
Breast implants are usually placed underneath the muscle (sub pectoral pocket) in the majority of patients because of the advantages of this plane. These advantages include: lower rates of capsular contracture, better appearance of the implant edges, and maximal nipple sensation preservation. Disadvantages include: increased post-op pain, distortion of the implant shape with pectoralis muscle contraction (i.e. in weightlifters), unable to address moderate droopiness without a breast lift.
Subglandular Placement
The other area of placement is subglandular, meaning underneath the breast tissue itself, but on top of the pectoralis major muscle. This pocket is also known as “pre-pectoral” placement of the implant. The pectoralis major muscle covers none of the implant.
In certain patients, most notably those with a bit of breast droopiness or ptosis, a sub glandular plane may be more desirable. Advantages of this placement include: easier plane to dissect, less post-operative pain and ability to compensate for a small amount of droopiness. Disadvantages include: increased rates of capsular contracture, increased bleeding during surgery and slightly greater chance of exposure to breast bacteria.
Breast implants are very safe. In fact, no other medical device has been studied as much as the breast implant. A comprehensive report released by the Institute of Medicine of the National Academies of Science in June of 1999 examined 2000 peer-reviewed studies and 1200 data sets and reports. Its findings indicated that there was no evidence that breast implants were responsible for any major diseases of the body, including autoimmune disease, cancer, or neurological problems. As well, there is no danger in breast-feeding babies from women who have breast implants.
When Breast Implants Rupture
Should breast implants rupture, the breakage may be immediately visible or may not be apparent for years. For example, saline implants rapidly deflate when they break. The body absorbs the salt water (saline) from the breast implant fairly rapidly over a day or so. Silicone implants, however, may be ruptured for years before being noticed. Often, a rupture is only suspected on a routine mammogram and diagnosis is confirmed with either an ultrasound or MRI. Most ruptures (over 90%) of implants occur within the scar capsule around the breast and do no leak into the surrounding tissue. Only a small minority of ruptures result in any significant leakage of the silicone in the surrounding tissues.
Do You Need to Replace a Ruptured Breast Implant?
Usually the reason ruptured implants are replaced is that patients are symptomatic. They can experience pain, tenderness, swelling or have an undesirable breast shape. However, experience has shown that only a small minority of patients ever have symptoms from a ruptured breast implant. The other main reason for removal is that many patients may not like the idea of having a broken implant in them and opt to have the implant removed or replaced. This is entirely up to the patient.
The human body is made up of about 60% water with a low salt content, thus there are two main types of breast implants commonly used for breast augmentation in Canada today. They are saline implants and silicone implants.
A breast implant is made up of essentially two components: the shell or outer liner, and the inner filling. The shell of both types of implants is made of silicone elastomer. It is flexible, strong and evokes a minimal reaction from the body. What differs between the two implants is the filler.
What is Saline?
Saline is sterile salt water. The human body is more than 60% salt water, thus saline is most commonly used intravenously to prevent dehydration. Saline has no negative impact on the body’s internal systems.
What is Silicone?
Silicone is often confused with the element silicon but they are very different. Silicone is a composition of various inorganic rubbers made by linking silica atoms. It is what many baby products (nipples, pacifiers, etc) are made out of and there is even such thing as “food grade” silicone used in kitchen products and bake ware which can be broken down by the body. Silicone is an inert material (it does not react to other substances) is very durable, can sustain very high temperatures and is hypoallergenic.
Saline Breast Implants
The filler in a saline implant is salt water or saline. The Plastic Surgeon placing the implant can control the amount of saline in these types of implants and thus these implants are somewhat adjustable at the time of the breast augmentation. If these implants break, only salt water leaks into the body. Because they are inserted empty and then filled after they are placed, the incision is often smaller than when using a silicone implant. Medical literature also shows that they have lower rates of capsular contracture compared to gel implants. However, these implants do not feel as natural as a silicone implant. As well, they are more prone to rippling and under filled implants can often have a sloshing sound during movement. As well, when they do break, the entire breast deflates, resulting in a noticeable breast asymmetry.
Silicone Breast Implants
The other type of implant is the silicone gel implant. The filler in this implant is made up of silicone gel. Newer implants have a cohesive gel filling that retains its shape, even when the implant shell is broken. The main advantage of this type of implant is that it feels very natural and is most consistent with native breast tissue. Disadvantages include gel leak, higher rates of capsular contracture, slightly larger incisions and that an implant rupture is more difficult to diagnose.
Can A Breast Implant Rupture or Deflate?
Yes. All implants can rupture and deflate. If left long enough in the body, eventually all implants will fail. Think of them as parts on a car. Eventually, they will need to be replaced. They wear out. Factors which impact on rupture include: age of the implant, when the implant was made (some early versions are very tough, some very weak), the presence or absence of capsular contracture, folds in the implant, and trauma (i.e. a large fall or car accident).
In 1895, the first breast augmentation was performed by Czerny who transplanted a benign fat mass, known as a lipoma, into a position underneath the breast gland in a woman desiring augmentation. Other such transplants, or fat grafts, were subsequently performed. However, the results were unpredictable and the appearance was poor. Complications such as the fat dying, chronic, draining wounds as well as the fat masses being absorbed by the body plagued these initial attempts and they fell by the wayside.
The first attempt at breast augmentation with foreign materials was made shortly after Czerny tried his fat transplant. In 1899, paraffin wax was injected into the breast with disastrous results. Persistent swelling and inflammation, death of tissue (necrosis), chronic draining wounds and, most notably, blindness resulted. The insertion of glass balls followed in the 1930s and polyvinyl alcohol sponges in the 1950s. Glass balls broke and the sponges degraded, causing breasts to become hard, distorted and painful. In the early 1960s, liquid silicone was first injected into the breast, with the same disastrous results of paraffin wax injections. Note that this is still done in some parts of the world. Please DO NOT consider this a viable means of breast augmentation!
The Invention of the Breast Implant
The first silicone breast implant was introduced in 1962 and was offered by Dow Corning in the open market in 1963. It consisted of a thick silicone rubber shell with a thick, viscous gel filler. It was extremely well made and almost indestructible – breakage was almost unheard of. However, because the shells were so thick, these implants were very prone to high rates of thick, tough scar formation around the implant known as capsular contracture. The capsule around these implant would often shrink, deforming the implant, causing a considerable amount of pain. These types of implants, known as the First Generation Implants, were in use from 1963 to 1972.
The Second Generation Breast Implant was introduced in 1972 in an effort to reduce the rate of capsular contracture and continued in production up until 1987. Shells were thinner and the gels less viscous or thick to give the implant a much more natural feel. Texturing of the breast implant surface was also introduced in the mid 1980s to help reduce contracture. The rates of capsular contracture decreased dramatically, but the shells were too thin and the rupture rate increased significantly. Studies showed that 90% of the implants ruptured at 10 years after implantation.
A happy medium was struck and the Third Generation of breast implant was developed in 1988 and is still in use today. The silicone shell is thicker and much stronger. It is often made of three or four layers of silicone elastomer to reduce rupture rates and prevent silicone from leaking out. Breast implant failure rates have significantly decreased and the problems of the earlier generations appear to have been solved. A very recent study has shown that rupture rates are as low as 1.1% in patients after 6 years of implantation. As well, shell technology has improved so that the amount of inflammation around the implants is less and the capsules appear to be thinner, thus reducing the potential for capsular contracture.
The Modern Breast Implant
Over the last ten years, the gel filling in silicone breast implants has improved to a new cohesive gel filling. This type of filling remains intact and is much less likely to leak out even if the implant breaks. Unlike older gel implants, which contain a thick, syrup-like gel, a cohesive gel implant contains a filler similar to that of Jell-O or a gummy bear. Thus, the filler in a cohesive gel implant is much less likely to ooze out in a sticky mess and retain its shape, even if ruptured. This offers obvious advantages, the most prominent being that if these implants are ruptured, they may go years before actually needing to be replaced. These are the types of breast implants most commonly used in breast augmentation today.
What Is BIA-ALCL?
BIA-ALCL is Breast Implant-Associated Anaplastic Large Cell Lymphoma, a T-cell lymphoma that can arise around breast implants placed for either reconstructive or cosmetic indications. Currently, the cause of BIA-ALCL is not clearly understood.
Is BIA-ALCL A Type Of Breast Cancer?
BIA-ALCL is not a cancer of the breast tissue itself, but a type of cancer that develops around the scar tissue from the implant, and in some cases, can spread throughout the body. It is a type of Lymphoma, not Breast Cancer.
Is BIA-ALCL Common?
It is estimated that there are 35 million women worldwide who have breast implants. The true incidence of BIA-ALCL is hard to estimate. To date, the estimated incidence rates in scientific literature range from 0.03% to 0.003%, or 1 in 3,817 to 1 in 30,000. Publications referenced here include patient populations with breast implants and patients specifically with textured breast implants.
What Causes BIA-ALCL?
International health regulatory agencies are proactively working with implant manufacturers to study BIA-ALCL. To date, no specific risk factors have been identified, however implant texture, genetics, and bacteria have been implicated and are undergoing further study.
What Are The Symptoms Of BIA-ALCL?
BIA-ALCL is most commonly reported at an average of 8–10 years following implant placement. The first symptoms are usually a swelling of the breast—often caused by fluid building up around the implant. Other symptoms can include pain, lumps, and unevenness between breasts.
Is BIA-ALCL Treatable?
Yes. When diagnosed early by a surgical specialist, BIA-ALCL can be treated, often successfully. In most cases, BIA-ALCL can be treated by removing the breast implant and surrounding scar capsule, however, additional treatment may be necessary depending on the individual. In cases where the disease has spread throughout the body, rare cases of death have been reported.
What Types Of Implants Are Associated With BIA-ALCL?
BIA-ALCL has been associated with both saline and silicone implants, round and anatomic implants, all gel types, and all projections, as well as implants for both reconstructive and cosmetic purposes.
What Are Textured Implants And How Do They Affect My Risk Of Developing BIA-ALCL?
Breast implants have different surface textures, including smooth or textured. For cases reported to date, BIA-ALCL has been seen most often in patients with textured implants, however the overall risk of developing BIA-ALCL with textured implants is low. To date, the estimated incidence rates range from 0.03% to 0.003%, or 1 in 3,817 to 1 in 30,000.
What Do I Do If I Have Textured Implants?
If you are not experiencing any problems, international health regulatory agencies (i.e., United States Food and Drug Administration [FDA], Health Canada, United Kingdom Medicines and Healthcare Products Regulatory Agency [MHRA], France’s Agence Nationale de Se´curite´ du Me´dicament [ANSM], Australia’s Therapeutic Goods Administration [TGA]) do not recommend removal of the implants or any changes to your routine medical care.
What Can I Do To Protect My Health?
It makes good sense to monitor your breast implants. Perform regular breast self-examinations to make sure they feel normal. Consult your healthcare provider if you notice swelling, pain, lumps or asymmetry after the surgery sites are fully healed. If you have breast implants, your surgeon will advise you on aftercare and regular follow-ups.
Is There Anything I Should Do If I Have Breast Implants?
If you have breast implants, there is no need to change your routine medical care and follow-up. You should follow standard medical recommendations, including regular medical examinations as scheduled by your doctor. If you notice any changes, contact your health care provider promptly to schedule an appointment.
