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| Glasgow Nuffield Hospital |
Beaconsfield Road
Glasgow
G12 0PJ
Tel: 0141-334 9441 |
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| Ross Hall Hospital |
221 Crookston Road
Glasgow
G52 3NQ
Tel: 0141-810 3151 |
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| NHS Correspondence: |
Canniesburn Plastic Surgery Unit
Glasgow Royal Infirmary
84 Castle Street
Glasgow
G4 0SF
Tel: 0141-211 5646 |
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Breast augmentation involves the insertion of an implant into the chest wall to enhance the size of the breasts. The implants are inserted into a pocket either below the breast tissue or below the pectoral muscle, or in some cases partially under each. Implants may be round or anatomically shaped; their surface may be smooth or textured; the contents may be silicone or saline, and there are advantages and disadvantages with each option. Some implants are more expensive than others; if you are looking for state of the art breast enhancement or simply the most cost effective solution and the best value for money, we can find a product to suit your needs.
I like to use state of the art implants which carry with them a lifetime warranty; the implants I prefer are the Allergan Inspira Soft-Touch range if I am using round silicone implants. These implants are cohesive gel, which means the implants will never leak silicone. The implants are also biodimensional, which means I take measurements of you at the time of consultation and I ask you what your requirements are. Using a combination of measurements and desired results, together we choose an implant that has the right width and projection for you. These implants are round but, if after your consultation, together we feel you would benefit from anatomical implants, I would use the McGhan 410 range, which are also biodimensional. For round or anatomical saline implants I tend to use the Allergan range, again because of their shell technology which I believe to be very high quality.
Different surgeons will use different implants for various situations, and most will be more than happy to justify what they're using and why. This can sometimes be an important part of the discussion during the consultation and at the end of the consultation both your surgeon and you should be happy with the choices made.
There is a lot of information you should know about breast augmentation. So please read on to find out more. You can also download a brochure on breast augmentation here. |
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| POCKET PLACEMENT |
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The implants need to be placed within a pocket. There are three types of pocket and the best place to put the implant depends on the characteristics of the breast being enhanced, the implant being used and the desired look. We will discuss this at the time of your consultation.
Submuscular Pocket
The submuscular pocket is often referred to as "under the muscle", as the pocket is made under the pectoral muscle of the chest wall. This pocket is often used in women who have minimal breast tissue so that the top of the implant is hidden under as much of your own tissues as possible to prevent a sharp take off of the breast and to reduce the chances of the implant being felt or seen. However, it can lead to the muscle being pushed forward on top of breast tissue which slides down as time goes by. This can lead to a “double bubble” problem where there are two bulges on the chest wall which may need further surgery for correction.
Subglandular Pocket
This pocket is often referred to as one which is made "on top of the muscle". The "sub" part of subglandular means "under" and the "glandular" part refers to the breast itself. So, the subglandular pocket is made under the breast, on top of the muscle. This pocket is often used when there is already a reasonable amount of breast tissue in someone who has little projection but is generally flat. It can also work well in someone who already has a reasonable breast volume but simply wants to be larger and is also used when someone wants to have an enhanced look following their surgery. It can also be used in someone who has a low take off and some concavity in their upper pole who wants to have an enhanced look
Dual Plane Pocket
The dual plane pocket is one that is made partially on top of the muscle and partially under the muscle. It involves splitting and releasing the muscle at exactly the right point so that you can have the benefits of having some of the implant above the muscle and some of the implant below it. This is often used in women who have a low take off and little tissue in the upper pole of the breast. By using a dual plane approach, what we achieve is to get the upper part of the implant hidden by the muscle but we prevent the appearance of two bulges in the breast (the double bubble effect) because of the low take off of the breast tissue by placing the lower part of the implant above the muscle. It is only possible to use an inframammary crease incision for the dual plane approach but in some people this is the best way of achieving the most natural look. |
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| INCISIONS |
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The incision is where the surgeon makes the cut in the skin so that the implants can be inserted. A breast augmentation may be performed using a number of incisions: the incision used depends on patient preference, the type of implant used and after a discussion of the advantages and disadvantages of the various incisions.
Inframammary Fold Incision
An inframammary fold (IMF) incision is one placed near the region where the breast tissue meets the chest wall. This incision is usually very well hidden after the procedure and for most implant sizes the length of the incision is limited to a few centimetres. For inserting very large silicone implants, the incision may have to be longer and you should discuss this with us at your consultation. These scars will only be seen from underneath and when placed well, they will be in line with the inframammary crease, meaning they will be very well hidden.
Periareolar Incision
A periareolar incision is one placed around the lower half of the nipple/areolar region as a semi-circle just inside the outer border of the areolar and is only suitable for women with large enough areolars to accommodate the size of the implant being inserted. If you are having saline implants inserted then it is quite rare for the areolars to be too small to use. Although periareolar incisions usually heal very well and are often barely visible, incisions around the areolar will always be seen by someone who is looking very close to the breast. There is always the risk that an incision does not heal with an almost invisible scar, and a prominent scar on the areolar may not be the best position for a prominent scar.
Armpit Incision
An axillary incision is also known as an armpit incision. Usually saline implants only can be inserted this way; silicone implants need to be squeezed and pushed too far into the chest with an axillary incision, whereas saline implants can be inserted into the pocket and inflated once they have been pushed through the small incision. The advantage of the incision is that there is no scar on the breast, however, there is a greater theoretical risk of bleeding and infection after this type of incision. In addition, the scar usually takes longer to fade in comparison to periareolar and inframammary fold scars.
The Tuba Incision
A TUBA is a trans-umbilical-breast-augmentation. In this, the incision is placed near the belly button (the umbilicus), a tunnel is made using a blunt dissecting instrument and a saline implant passed into the breast pocket. The implant is inflated once it is in place. The advantage of this incision is that there is no visible breast scar at all, however, special instruments are required and the implant placement is a little more imprecise in comparison to some of the other methods of pocket creation. Imprecise pockets can lead to asymmetry after the operation which may have to be corrected using one of the other incisions (eg the inframammary fold incision). Please note that I do not perform breast augmentation surgery using this technique.
Other Incisions
A nipple lift or breast uplifting procedure can be performed at the same time as a breast augmentation. In these cases, your incisions will be placed all the way around the nipple and may go down the breast and along the inframammary fold at the same time - either as a round incision, a lollipop shaped incision or an anchor shaped incision. The type of incision during a combined lift and augmentation depends on how much lift needs to be done, whether the size of the nipple needs to be reduced at the same time and how much of the shape of the breast needs to be changed. |
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| IMPLANT TYPES |
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Breast implants come in three different varieties: the shape, the surface material texture and the filler. All implants have a silicone outer coating and implants of each type come in various different sizes.
Implant Shapes
Implants may be round or teardrop (anatomical) shaped. Both types have their advantages and disadvantages and the shape of implant can be discussed at the time of the consultation.
Implant Textures
Implants can be smooth or textured. Textured implants have a rough surface and smooth implants have a smooth texture. Textured implants have a lower risk of developing capsular contracture, which is explained in the risks section.
Implant Fillers
Implants are commonly called silicone implants or saline implants and this refers to the fluid used to fill the implant. All implants have a silicone shell, but the filler material can differ. The most common filler materials we use nowadays are silicone or saline. Saline implants are filled with salt water at the time of the operation and a valve within the implant reduces the risk of saline leaking out of the implant causing deflation. Silicone implants have been extensively tested for safety and the independent government report on this can be found here. Different types of silicone are also available - some implants have thicker silicone within them, and the silicone will not leak out of the implant even if the implant ruptures. Other implants use softer silicone gel. These implants are more affordable and feel softer but can potentially leak silicone into your breast. You can see a few of the different implant types at your consultation. |
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| SIZES |
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Choosing the right implant size is a matter of balancing what you already have with what you want and what we can use. We will measure you during your consultation and these measurements will determine the size of the implant we should use, the pocket placement (ie below the muscle or over the muscle) the shape of the implant and the incision placement. The amount of nipple droop (or breast ptosis) will also tell us whether you need to think about any other procedures to reshape the breast at the time of implant placement or at some other time in the future.
Breast augmentation surgery is obviously designed to make your bra size bigger. One of the common questions at a consultation will be to find out what size you are just now and what size you would like to be. Although your surgeon will be able to give you a size which is roughly in keeping with what you want, there are usually never any guarantees of exact size. In fact, different bra manufacturers will have different sizes to fit the same person.
All this means that you will usually be able to have a breast size roughly within the region of what you are hoping to achieve.
Your surgeon may perform various measurements as part of the consultation. These may help you and your surgeon decide what implant sizes are best for you. |
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The distance between your nipple and the bone at the bottom of your neck |
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The width of the nipple-areolar-complex |
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The width of the breast itself |
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The distance between the two nipples |
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The distance between the nipple and the bottom of the breast |
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The amount of pull present within the skin of the breast |
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The thickness of the tissue at the top of the breast |
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The height of the inframammary fold |
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The point along the chest wall where the breast begins to take off |
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All these measurements will tell you and your surgeon what size of implant to use, what pocket to use, what incision to use, whether the same implants need to be used in each side and whether there is already some degree of asymmetry between the two sides.
Breast implants don't come in cup sizes, but they do come in volume or weight sizes. The bigger the implant, the greater the cup size increase you can expect to see after your operation. The bigger your bra band width that you currently use, the bigger the implant size you will need to increase your cup size by one letter.
Different surgeons will use different ways of deciding together with you what's best for your requirements. One way of deciding is to talk about implant dimensions. In other words, if we know how wide your breast already is, and if we know the measurements of the implants, then we can match this to how much of a size increase you want. If you do not have enough pull of skin within your own breast, you may not be able to have as large an implant inserted as you may want. In these cases, you might need two operations to go bigger in stages. The vast majority of women, though, will be able to have a single operation to help them achieve their aims. |
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| SUPERSIZE ME! |
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Most women want a very natural look and one that is in harmony and balance with the rest of their body shape and size, often wanting to look as if they haven't had an operation, and also looking as if they don't need an operation.
Some women, however, want a very enhanced look. In these cases, we can offer a range of expandable implants where the skin can be repeatedly stretched after the implant is inserted by pumping a salt water solution into the implants until the skin is stretched to its limits. This is then repeated until the desired size is achieved. If this is something you would like, please note that you will need to visit Glasgow probably around six or eight times for your consultation, surgery, and expansions. With the newer ranges of breast implants, it is now possible to choose an implant based on desired projection, available skin for projection and current breast base dimensions. These "biodimensional" implants are also cohesive gel, carry a lifetimer warranty against manufacturing defects, and can be used for greater choice and accuracy. Skin laxity is determined at the time of consultation, and if enough laxity is already present, then the projection achieved with the extra high projection biodimensional implants may be greater than the projection from expandable options.
The exact method best suited to you will be discussed during the consultation and a decision will be made together on how best to take things further.
Breast enlargement surgery is also known as breast augmentation, breast enhancement, inserting breast implants, and having a boob job. Currently the most common means of breast augmentation is by inserting breast implants into the chest to make the breasts appear larger. In the future, plastic surgeons may be able to grow fat cells and implant them into the chest wall, but currently this is not performed for thin women who are looking for cosmetic enhancement. Usually both sides are but sometimes only one side needs to be treated if someone has two breasts that are very different in size. |
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| RECOVERY |
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Your breast augmentation will probably be performed under general anaesthetic and you will probably stay in hospital overnight but certainly until you are comfortable enough to go home. When you do go home you will need to take pain killers for a few days until the discomfort settles down. The first day of the operation is the worst and you may well need help with day to day activities for a few days. Some women still feel some twinges of discomfort for a few weeks after the operation, but most women are back to normal tasks within a few days. If you are taking time off work, you may be able to go back after a week and you can go back to high impact activities after 4-6 weeks. Most women are back to doing most of their normal day to day tasks within a couple of days, in my practice.
For the first few days after the operation, take it easy. You should try and keep your wounds dry and clean, though it is sometimes impossible to keep them away from water completely. If you have an absorbent dressing, then this should be changed if it gets wet. After a bath or shower, you may want to dry your wounds with a hairdryer on a cool setting (so as not to burn your delicate healing skin) before applying any more dressings, if still required.
If we have told you to wear a bra, then you should wear it constantly for the time period advised (often 4-6 weeks). You can take off your bra for an hour at a time once or twice during the day, but you should really wear it constantly at night time.
We may insert drains after the procedure and we may ask you to wear a supporting bra for a while after your operation. Your support bra should be wireless with firm supporting cups - something like a shockabsorber sports bra is usually fine. Wired bras are very supportive, but they can sometimes press against the bottom of the implant or the site of the surgical wound, and be more uncomfortable than non-wired bras.
You should buy a couple of sizes, as the breast size changes over the course of a few months after the operation. The bra may be needed so that the implants can be supported in place while the bruising and swelling gets better. The implants will drop down over time and a well supporting
bra will help prevent this. You might only want to buy one bra of each size in the first instance, and only buy more once you know you are filling a particular manufacturer's size.
Occasionally we will tell you not to wear a bra for a few weeks. This may be because the implants have been placed behind the muscle and muscle appears to be quite strong - wanting to push the implants upwards and outwards. Sometimes we will apply an upside down bra to the top of the implant or place a pressure dressing at the top of the implant to help keep the implants from riding upwards. This is more commonly done after placing the implants behind the muscle.
If we have placed drains into the chest at the end of the operation, these will be removed, usually the following day, before you go home. They can help reduce bruising and help remove some of the excess air and fluid in the implant pocket. Not all patients will need drains and many surgeons will only use drains for the operation if there seems to be a little excessive bleeding during the operation. |
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| WHAT YOU NEED TO KNOW ABOUT BREAST AUGMENTATION |
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| The majority of people who have breast augmentation are very happy with the results. However, there are risks with any procedure and there are specific problems you should be aware of with breast augmentations and these include (but are not limited to): |
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Infection |
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Blood clots |
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Scarring |
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Asymmetry |
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Wound healing delays |
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Nipple hypersensitivity |
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Nerve injury leading to sensory reductions at the nipple |
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Size issues - some women feel they should have been made bigger or smaller after their augmentation procedure |
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Implant palpability |
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Implant wrinkling |
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Implant deflation (in cases of saline implants) |
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Implant migration and movement |
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Implant extrusion |
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Implant rotation (in cases of anatomic implants) |
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Difficulty with mammogram interpretation |
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Changes in the way breast lumps are investigated and treated |
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Capsular contraction (the formation of a hard painful or distorting area of scar tissue around the breast implant) |
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Silicone leakage (in cases of non cohesive silicone gel implants) |
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Galactorrhoea (the inadvertent production of milk) |
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Further surgery: all implants have a life-span that is limited and finite. In many cases, the patient lives longer than the implant. All women with breast implants should therefore prepare themselves for further surgery during the course of their life. |
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All the natural effects of having larger breasts - bra strap marks, drooping of the breast tissue with time, development of prominent veins, etc. |
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| Capsular Contraction |
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This is the most important long term complication that you need to know about, and you may need another operation several years later because of this. Whenever we insert a foreign material into your body, your body recognises that implant as being foreign. Your body then creates a wall of scar tissue around the implant and this is perfectly normal. This happens with all types of implants - for example hip replacements, plates and screws for broken bones and, of course, breast implants.
What is not normal is for this wall of scar tissue to thicken as the years go by. The thickness of the scar tissue increases and increases and then it starts to contract. Eventually it becomes hard and round. This changes the shape of the implant and you can sometimes start feeling the wall of scar tissue. When this happens, we call this capsular contraction. Because it can feel uncomfortable and look different you may want to have another operation to remove and free up the capsule and replace the implants. |
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| Capsulectomy and implant replacement |
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| If a capsule forms and is sufficiently severe enough to warrant treatment, an operation is performed called a capsulectomy and implant replacement. This is where the scar tissue around the implant along with the implant itself is removed and the implant is replaced. Sometimes it is necessary to make a new pocket or change the size or type of the implant when replacing it. It is a more complex operation than simply inserting a breast implant and the recovery time is a little longer. |
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| Infection |
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Although infections after breast augmentation surgery are rare, when they do occur it can be very troublesome. The early signs are redness and discharge around the wound site and feeling unwell with flu like symptoms. If caught early, then infection can sometimes be treated with antibiotics, but if the infection cannot be treated with antibiotics, then the worst case scenario is that the implant will need to be removed and the infection allowed to settle. Several months later, another implant can be inserted.
Often a surgeon will ask you to attend the hospital or clinic around a week after the operation, for a quick wound check to make sure that any early signs of trouble can be dealt with promptly. |
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| Blood Clots |
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| Blood clots can occur after any surgery. If a blood clot forms within the breast where the implant has been inserted, this is usually spotted in the first 24 hours after the operation. If this happens, you may need to go back to the operating theatre to remove the blood clot; the implant itself is not affected by this. A different type of blood clot can form in the legs after any operation (or indeed any period of prolonged immobility, such as an aeroplane journey, or prolonged operation). These blood clots in the legs can break off and fly into the lungs causing breathing problems. Although rare, if this does happen it can happen around a week or so after the operation and you should seek emergency treatment for this. Drink plenty of fluids and keep your legs mobile after any operation to reduce the risk of blood clots in the legs (also known as DVTs, or deep venous thrombosis). |
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| Scarring |
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| Any operation or any cut in the skin leads to scarring. Most scarring after a breast augmentation is well hidden within natural crease lines and tends to heal very well. Rarely, scarring can be a problem and in these cases, it will be a problem a few months after the operation. If you do have scar problems, then you might want to apply creams or ointments recommended by your surgeon, or he may want to give you injections into the scar to help reduce some of the itch and pain associated with some of the more abnormal scars. Scars may also darken if exposed to too much sun or tanning booths after an operation, so you should protect your scars from these after such an operation. You can also develop scars within the blood vessels below the breast and these can sometimes present as painful cords (these are called Mondor’s cords); treatment of these is with anti-inflammatory medication and you should speak to your surgeon before starting these. |
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| Asymmetry |
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| Everyone is a little different on each side before the operation, and these differences are often accentuated after the operation. For those women who have a considerable degree of asymmetry between the left and right breast before the operation, we can often insert implants of different sizes to compensate for some of the differences. Your left and right sides will always be a little different but these differences can be more noticeable
after a breast augmentation. Also, whenever we do an operation on two sides, the rate of healing varies, even though we do the same operation using the same techniques on both sides. As a result, sometimes the two sides can heal at different rates over the course of time. We generally will see the final result six months after the operation. |
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| Wound Healing Delays |
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| Rarely, the wound may unzip, leading to infection and implant exposure. Your surgeon may choose to resuture the wound or to allow the wound to heal with dressings. The implant may also need to be removed in rare circumstances. |
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| Nipple Hypersensitivity |
| After an augmentation, the nipples can increase in their sensitivity. It may be uncomfortable to touch the nipples or they may become quite prominent. This usually settles over a few weeks, and during this time, nipple protection may help reduce the discomfort. Nipples can also become less sensitive. |
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| Nerve Injury |
| The nerves that supply the skin of the breast and the nipple run close to where some incisions are made and where the pockets are made. These nerves can often be irritated during the operation, which can sometimes lead to reduced sensation around the nipple and the skin of the breast. This is often a temporary problem, but can take up to six months to return. In rare cases, the loss of sensation around the nipple can be permanent. |
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| Size Issues |
| Some women feel they should have been made bigger or smaller after their augmentation procedure. Often this can be avoided by discussing size issues in detail with your surgeon beforehand. However, sometimes it can be difficult to know exactly what size you will be after the augmentation, because implants don't come in cup sizes and all bra manufacturers are different. The vast majority of women, however, are absolutely delighted with their appearance afterwards. There is also a balance between maintaining a natural look and the augmented look, with larger implants looking more augmented than natural. |
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| Implant Palpability |
| There is always a risk of being able to feel a breast implant. Even though we can use various methods to try and make sure we reduce the chance as best as possible, there will be times when you will be able to feel the implants in some parts of your breast at some times. Feeling a firmness may either be the implant or the beginnings of a capsular contraction. If you are unsure about something that you are feeling, you should ask your plastic surgeon. |
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| Implant Wrinkling |
| There is always a risk of being able to see a breast implant. Even though we can use various methods to try and make sure we reduce the chance as best as possible, there will be times when you will be able to see the implants in some parts of your breast at some times. This is, of course, very similar to being able to feel an implant, and so you should expect to either feel or see your implants at some stage. |
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| Implant Deflation |
| Saline implants are filled with salt water (saline). Although they have protective mechanisms to prevent the saline from leaking out of the implant, if this does occur, then the implant will deflate over the course of the next few days and your breast size will shrink. You will need another operation to fix things, and many women take the opportunity to have an operation to change both breasts at the same time. The risk of a saline implant deflating is around 5%. |
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| Implant Migration |
| Breast implants need a few months to settle into their final position. During this time they move around inside the body by a small amount. Occasionally, they can move into the wrong position, and they can be lower, higher, more outwards or more inwards than desired. In these situations, you may need another operation, though your surgeon will probably want to wait several months for the implants to settle into their final position before considering another operation to readjust the implant pocket. |
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| Implant Extrusion |
| Very rarely, the stitch line will open up and you will be able to see the implants. This is extremely rare, but in these situations, the implants need to be removed, and reinserted around 6-12 months later. |
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| Implant Rotation |
| Anatomical implants are shaped like a tear drop. They need to be placed in a pocket which is exactly the right size so that the implants can stick down into their position as quickly as possible. Your surgeon may also use a drain to help remove some of the excess space that may need to be created to insert such an implant. Although anatomical implants (in some women) may produce a more natural looking appearance, they will not look natural if they rotate. |
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| What You Need To Know About Mammograms |
| A mammogram is an X-ray which is taken to look for breast cancer. Although putting in implants doesn't increase your risk of getting breast cancer it can make it harder to detect. You should know that a mammogram will not see the whole of the breast if you have implants. When you are having a mammogram you should tell your radiographer that you have breast implants (if they don't already ask you), as they will use special views to have a better look at your breasts with the X-rays; they may also take two pictures rather than just one. The only way to completely see your breast tissue is by performing an MRI scan on the breast, but this is not something that is routinely performed for breast cancer screening, and there may be a cost associated with this if you are wanting a full screening to be performed. Women with breast implants are not at any greater risk of getting breast cancer. |
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| What You Need To Know About Breast Lumps |
| If you do ever get a breast lump, the tests you have may be different because you have implants. In particular, you may not have tests which risk rupturing or piercing the implants and you may have a different type of scan to find out more about the lump. Women with breast implants are not at any greater risk of getting breast cancer. |
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| Silicone Leakage |
There are different forms of silicone that can be used to fill a breast implant. Cohesive silicone is a more solid silicone, and non-cohesive silicone is a more liquid silicone.
Cohesive gel implants do not leak silicone, but non-cohesive implants can leak silicone into the surrounding tissue. Also, some women have gone abroad for treatment and have returned with liquid silicone within their breasts, which causes problems and needs to be removed. If you have non-cohesive silicone breast implants, then these may leak silicone and if you have problems with firmness inside the breast because of this, you may need another operation to fix this. |
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| Galactorrhoea |
| Galactorrhoea is the inadvertent production of milk and is quite a rare complication. Usually it is temporary but occasionally treatment with hormones may be needed to suppress milk production. |
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| The Need For Further Surgery |
| All implants have a life-span that is limited and finite. All women with breast implants should therefore prepare themselves for further surgery during the course of their life. Also some women may want to have another operation a few years after having one breast augmentation (for example, a further enlargement or a breast uplifting operation, or treatment for prominent breast veins, etc) |
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The Effect Of Larger Breasts
After making your breasts larger, you may start suffering all the natural effects of having larger breasts - bra strap marks, drooping of the breast tissue with time, development of prominent veins, etc. Wearing a well supportive bra will help reduce this, but nothing completely stops the effects of gravity and time. |
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| General Anaesthesia |
| Since the operation is usually performed under general anaesthesia, there are also risks of a short general anaesthetic. Modern anaesthesia techniques are safer than ever before and it is very safe indeed to have a short anaesthetic, particularly when your anaesthetist is an experienced hospital consultant with an excellent safety track record. It also helps if you are as fit as possible, and you should stop smoking if you are smoker. |
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| EXPLANTATION |
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| Some women want their implants removed and not replaced. In these cases we would remove the implant along with all of the surrounding capsule of the implant to remove all elements associated with implant insertion. At the same time it is sometimes necessary to remove some of the skin of the breast to prevent too much drooping but even when this is done, a second operation is often required a few months later to remove some of the skin excess that develops after an implant has been inserted. |
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