Home      Mission Statement      Biography      The Patient Journey      Procedures      Pre & Post Op Photos      Practice Information      Links       Based at:        Spire Thames Valley        Hospital        Wexham Street        Wexham        Berkshire, SL3 6NH        01753 662241        Berkshire Independent        Hospital        Wensley Road        Coley Park        Reading        Berkshire, RG1 6UZ        0118 902 8130       For Appointments   Breast Augmentation Breast Augmentation is an increasingly popular procedure that has a reliable and predictable outcome. Your desire for a larger breast may be to create a breast that you never had, restore previous breast size and shape, or correct asymmetry. Surgery will enlarge your breast and change the profile of your upper body. Following augmentation many patients feel much better about themselves and they often feel more feminine with a greater ease in fitting attractive clothes. However an augmentation cannot be expected to resolve some of the deeper, perhaps psychological, issues that some patients attribute to their small breast size. When contemplating a breast enlargement there are many things for you to consider. You need to be fully aware of what is involved in the operation and it's aftercare, that you understand it's implications and risks and you need to be sure that your expectations of the procedure are realistic before you decide whether a breast augmentation is for you or not. In almost all cases the breast is enlarged by placing an implant behind the breast to increase volume and enhance the projection of the breast. The implants that we use have an outer silicone shell with various formulations of silicone being used as a filling material. There are other types of implants available with saline or salt water as an alternative filler. It is important to remember that an augmented breast is not the same as a natural breast and there will be differences in firmness and mobility between an augmented breast and a natural breast. Most of these differences are usually advantageous and are often the reasons why people seek a breast augmentation but it is important to remember that the breast in general will be firmer than normal and tend to sit on the front of the chest rather than fall to the side when lying. The difference varies from individual to individual and with a soft modern implant of modest volume compared to the host breast the differences are very difficult to discern.  The Consultation There are many things to consider before you decide to go ahead. It is important to explore why you want a breast augmentation and what your expectations are. We will discuss how the procedure is done, the different types of implants available, the reasons why we still have different implants, what you may expect after surgery, any special precautions you need to take and the potential complications that may occur. If you are unsure about anything, particularly after consultation, it is vital that we clarify any points for you before you make a final decision as to whether to proceed or not. Following your initial consultation I hope you will have enough information to decide whether to proceed or not. We will also have had the opportunity to examine you to make sure that a breast augmentation is suitable for you. I will then ask you to come back for a second consultation at which time we can discuss any further questions that you may have and we will also take the opportunity to size you to select the appropriate implant to be used. There will be no charge for this second consultation or other preoperative consultations if you want to discuss things further. Before surgery it is important that you have as much time as you need to consider all the issues involved and you should not feel constrained by finance.  Implant types We use implants that have an outer shell of silicone rubber and are filled with silicone gel. Implants are either round or teardrop shaped and have a smooth or textured surface. A round implant adapts to the shape of the breast and usually adopts a teardrop shape when standing. A tear drop or anatomically shaped implant mimics breast shape and helps determine breast shape. Early implants had a smooth surface but now almost all of the implants we use have a textured surface to reduce the risk of capsular contracture. Implants are filled with Silicone gel which is available in two main formulations. The standard gel is an oily gel which creates the softest implant available. A firmer gel, a soft solid gel, and is known as a "cohesive" gel. This gel is available in round and shaped implants. Silicone gel has a consistency and viscosity that is most like normal breast tissue. An alternative to silicone gel is Saline which is salt water. Saline filled implants are available but do not perform as well as silicone implants having a less natural feel and an increased complication rate.  Shaped or round The introduction of the firmer "cohesive" gel allowed a shaped implant to be developed which has led to a major improvement in the results that we can achieve. In appropriate individuals a shaped implant filled with a cohesive silicone gel allows the implant to dictate the shape of the future breast keeping the breast volume low and to the side rather then leaving a rounded breast. In general this means that the shaped implant is most suited for patients who have very little breast development when we need to create new breast shape with a natural tear drop appearance. The disadvantage is that this implant is a little firmer then the soft implant and is not so well suited for a patient who is looking for a restoration of breast volume later in life where volume has been lost following pregnancy, age, or weight loss. For these patients a rounded soft implant is often more appropriate.  Recommended Implants At the present time I recommend implants from Allergan's, Inspira and McGhan 410 range. Inspira implants are round implants that have wide range of sizes varying in volume, diameter, and projection. They are filled with a soft gel known as a "responsive" gel or a "cohesive gel" known as a "soft-touch" gel. The McGhan 410 implant is tear drop or anatomically shaped. To maintain its shape it is filled with "Soft Touch" cohesive gel. The shaped implant has an even wider range of sizes with variation in volume, width, height, and projection. With careful measurement and assessment we can select the correct implant from the matrix of sizes available to achieve the desired result. Although I consider these to be the standard implants that I use and recommend other implant types can be used if you have a particular request.  Sizing There are many factors that will determine the size of implant that we should use for your proposed breast augmentation. We are constrained by the size of the space that we can create to accept the implant and by the aesthetic proportions of your future breasts. If too large an implant is used the breast will look very rounded and is less attractive to many. Also the larger the implant that is used the greater its weight and therefore more stretching of the breast will occur in the future. Within these limitations the final decision is of course yours.  Choosing the correct size and type of implant for breast augmentation In deciding which implant to use we are looking at enhancing the shape and form of your breast to create an aesthetically pleasing breast which I believe is more critical to a successful outcome than mere volume. Everyone has an ideal shape and volume for their breasts in their mind and I hope that with careful sizing and assessment we can achieve this for you within the limits of feasibility. Choosing the correct sized and shape of implant is critical to achieving the result that you are looking for from your breast augmentation. We need to determine the dimensions and volume of the implant to be used. The volume of the breast implant added to your own breast tissue will determine your eventual cup size. As people have varied amounts of breast tissue and different shaped chests it is not possible to select a particular cup size of implant from the range available. Implant selection is primarily done by measurement to determine the dimensions of an implant that will give you the desired result. We then check that the volume of the selected implant is correct for you with the use of trial implants.  Buying a bra of your desired cup size. The first stage in sizing is for you to buy a bra of the size you would like to be. This should be a full cup sports bra which you will also need following surgery. The band size, which is your chest circumference in the infra-mammary fold, will not change with an augmentation. It is useful to be measured formally so that you are wearing the correct band size and then select your desired cup size. It is not unreasonable to buy bras of more than one cup size, to try them on at home, and potentially return those that you find do not 'fit' your requirements! With the bra that you have selected pad it out at home to check that the profile of your upper body that this creates is correct for you. You should also try on various items of clothing from your wardrobe to ensure that your selected cup size is creating the desired effect for you.  Your sizing appointment Once you have selected your desired cup size we should see you back in clinic for your sizing appointment. This is also an opportunity for you to ask any further questions that you might have about the procedure, its implications and its aftercare. We will start by measuring the dimensions of your breast. If we are using a round implant this will indicate the maximum size of implant that it would be realistic to expect to be able to insert under your breast. If we are using a tear drop shaped implant we will then assess the dimensions of your proposed augmented breast which will indicate the size of implant to be used. With the tear dropped shaped implant our base measurement is the width of the proposed breast that we want to create. We then select the height of the implant based on your stature, and your chest wall contour. We then select the projection of the implant based on the amount of breast tissue that you have and the cup size you would like at the end of the day. The implant is then selected from the matrix of implant sizes. This will give us a small range of implants that would be suitable for you. We then check that the volume of implant that we have selected is appropriate for you by using trial implants inside your sports bra. With trial implants in place it is your opportunity to decide whether the proposed increase in size is too much or too little for you. We will then be able to select the proposed implant, make a final decision as to whether this implant should be placed underneath the breast only or underneath the muscle as well and proceed to the next stage, which is surgery. By sizing your breast in this way I find that we select the correct implant in the vast majority of patients. Occasionally, however, the space that we can create underneath your breast is smaller than the implant selected. Under these circumstances it is better to use the next size smaller to avoid a round and bulbous breast. I will have discussed this with you pre-operatively and if you are very keen to use the selected implant, and accept that the breast may be more rounded than ideal, we will of course do this for you.  The Operation The next stage is coming in for surgery. I will see you immediately before the operation which is another chance for you to ask any questions. I will then mark the incision site with you awake and standing. Surgery is usually performed under general anaesthesia and most people stay in hospital overnight following the operation. I usually leave a small drain in the wound which is removed before you leave hospital. The wounds are closed with absorbable sutures which are left buried under your skin and in the deeper tissues and therefore there are no sutures to remove. Steri-strips or suture tapes are also used. A band of tape is placed across the upper and lower parts of the breast at surgery which should remain in place for a week to stabilise the implants. A bra that you have used for sizing can be worn over these dressings on discharge from hospital and we will usually see you again a week later when all dressings will be removed.  Access Incisions There are three types of incisions in use;           Infra-mammary fold           axillary           peri-areolar My preferred incision is beneath the breast in the future infra-mammary fold. The incision is actually made below your present infra-mammary fold as skin is drawn up onto the breast by the implant. The infra-mammary fold incision gives the best access to the space that we need to create for the implant. The infra-mammary fold incision allows the implant to be placed in any of the layers or planes that we may want to position it in. It also allows careful control of bleeding and accurate placement of the implant. The axillary incision is underneath the arm. When using this incision the implant can only be placed under the muscle. The space to accept the implant is created by feel rather than direct vision and involves tearing of tissues with increased damage to them. The incision around the nipple (peri-areolar) finds less favour with patients in Northern Europe and North America. If you have a large areolar, access can be as good as when using the inframmary incision but there is an increased risk of damaging feeling to the nipple and infection with contamination from the glandular and ductal system of the breast.  Placement of the implant An implant is not an exact replica of the breast. The natural breast thins out towards it edge with a margin which is often difficult to define or feel. An implant has a much more obvious edge to it and this edge needs to be disguised by the body's tissues to prevent it from being seen and/or felt. Many patients will be familiar with images of people who have breast implants where the outline of the implant can be clearly seen in the upper part of the breast. With appropriate placement of the implant this can be avoided. In most people there is enough tissue in the upper part of the breast which is either subcutaneous fat or breast tissue to disguise the upper part of the implant when the implant is in the subglandular or sub mammary plane. However if you are very thin we may need another layer of tissue to disguise the implant and we then use the muscle on the chest wall called the pectoralis major. The implant is then in the submuscular or subpectoral plane. The implant can be placed in one of several layers; underneath the breast only - subglandular plane, underneath the muscle - subpectoral plane, underneath the breast in its lower half of the and muscle in the upper half of the breast - dual plane underneath the breast and the covering layer of tissue on the muscle known as the fascia - subfascial plane. The easiest procedure to recover from is a subglandular placement. Lifting muscle of the chest wall in a subpectoral placement is more painful for you as a patient and will take you a few days longer to recover. However if submuscular placement is required to disguise the implant this is a disadvantage worth putting up with. Another disadvantage of placement underneath the muscle is that the muscle may become attached to the implant with excessive movement of the implant with arm and shoulder movement. To minimise this effect yet still gain the advantages of a subpectoral placement the dual plane technique is now used where muscle cover is required. In this technique we place the lower part of the implant underneath breast tissue only which maximises the projection achieved and then the upper part of the implant is placed under the muscle to disguise the implant. This method detaches muscle from the breast tissue reducing the incidence of unwanted mobility but maintaining advantages of submuscular plane placement. Occasionally in favourable circumstances we may do a subfascial placement. This raises a thinner layer of tissue from the surface of the muscle to help smooth the contour of the implant but does not disturb the muscle itself. Determining which plane to place the implant in is decided by your physique, choice of implants, and your wishes. This will of course be discussed with you before surgery. The firmer implant, particularly if it is anatomically shaped, will need more disguise than a soft round implant and therefore is more likely to be placed underneath muscle rather than the breast only.  Aftercare On discharge from hospital you will be wearing your sports bra over the dressings. We will provide you with pain killers to relieve any post-operative pain. After a general anaesthetic you should not drive for 48 hours. We will encourage you to take regular walks and maintain general mobility. You shouldn't smoke. We usually see patients at a week following surgery to remove all dressings and wound closures. You may then resume normal skin care and you should apply a proprietary moisturising cream to the wounds. We will usually ask you wear a firm sports bra for 3 months following surgery. You should wear this at all times for the first month and may then leave it off at night for the second and third months. Towards the end of this period you will not do any harm wearing a normal bra for special occasions and particular clothing but for everyday use please continue with the sports bra. If you have had round implants placed in the submuscular or subpectoral plane we will provide you with a firm elasticated band to wear across the upper part of the breast for three weeks following surgery. This will help stabilise the implants and prevent them from riding too high. In the early stages following breast augmentation you will find the breasts are rather swollen and prominent in the upper part. This will improve as the implants settle into their natural position. Providing you are wearing a bra you can return to normal activity as comfort allows apart from running or jogging which we ask you to avoid for the first three months following surgery  Recovery In general exercise freely within the limits of discomfort following these guidelines; You should not drive for 48 hrs following a general anaesthetic. You should not smoke until the dressings have been removed when the wounds will be healed. As soon as you can you should be doing lots of walking. Introduce lower and upper body work after a few days increasing, within the limits of any discomfort to a full exercise regime at 2 weeks except high impact work. Impact work can be introduced at 6 to 8 weeks providing you are wearing good support but we would discourage you from running or jogging on the road for 3 months. The implants that we use have a textured surface to reduce the risk of capsular contracture. How this actually works is not known but It is believed that it is important that a mechanical bond develops between your body and the implant. The vigorous movement of high impact work may interefere with this bond hence the advise to avoid jogging.  Complications Although breast augmentation is a reliable procedure a small minority of patients do experience complications. The operation is performed under general anaesthesia and you must consider the risks of a general anaesthetic.  General Operative Risks As an operative procedure there is a risk of excessive bleeding and infection. If an excessive amount of blood accumulates in the cavity surrounding the implant we will advise a return to the operating theatre to remove the blood clot and prevent its re-accumulation. Infection is fortunately a very rare complication following breast augmentation. If infection does occur and it is not possible to control it with antibiotics it may necessary to remove the implant.  Sensory changes in the Nipple In approximately 5% of patients there will be altered sensation in the nipple. The nipple may be more sensitive, similar to the heightened sensation in pregnancy or feeling may be reduced. Changes in sensation are usually temporary and recovering over a few days or weeks but loss of feeling may be total and permanent.  Capsular Contracture or Hardening When an implant is placed inside the body the body will lay down a layer of scar tissue around it. This scar tissue has the ability to contract and this capsular contracture can cause undue hardening of the breast. As the scar tissue contracts the implant is squeezed. The implant is fluid filled and cannot shrink so that as more pressure occurs the implant adopts a spherical shape and becomes firmer. Capsular contracture is usually not of significance if it just leaves the breast firmer than ideal. If capsular contracture is more severe it can actually cause distortion of the breast and pain. If this occurs patients usually elect to undergo revisional surgery which involves removal of the implant, release or excision of the capsule, and re-implantation. Wrinkling of the implant shell can also occur. This is a folding of the silicone shell which can be felt as a "lump" in the breast. A "lump" due to wrinkling rapidly disappears with light pressure only to appear elsewhere in the breast. This movement is accompanied by a popping sensation.  Reducing the risk of capsular contracture There is increasing evidence that scar tissue production around an implant is increased in the presence of mild infection and tissue damage. To minimise the risk of capsular contracture I think it is important to adhere to any very strict regime of meticulous asepsis and delicate surgical techniques. Strict aseptic conditions must be followed including the use of lamina flow air enclosures in the operating theatre. The nipple of each breast is isolated from the operative field with a waterproof dressing. Prophylactic antibiotics are given during surgery. The tissue should be dissected carefully and not torn when creating the space for the implant. Meticulous attention to bleeding should also be undertaken to reduce the accumulation of fluid around the implant and drains are left in the wound to remove any remaining fluid. Textured implants are used and have been shown to significantly reduce the incidence of capsular contracture.  Breast Cancer There is no detrimental change in the incidence of breast cancer in those patients who have breast implants. Some studies actually show that the incidence of breast cancer is lower in patients who have been augmented which is probably an affect of selection rather then a protective effect of the implant.  Mammograms An implant throws a shadow on the breast when a mammogram is taken. At the age of 50 you will be contacted and entered into the National Breast Cancer Screening Programme with regular mammograms. Providing you tell the radiographer that you have implants further views can be taken to maximise the volume of breast tissue imaged. Unfortunately because of the technique of mammography not all the breast will be imaged when the implant is in place but this does not appear to have a clinical significance in the outcome of breast cancer. The presence of an implant does not impair palpation of the breast tissue, ultrasound scans, or MRI scans.  Rotation of the implant Rotation of a shaped implant can occur causing abnormal distortion of the breast. It is probably due to the implant being placed in too large a cavity and not being stabilised adequately in immediate post-operative phase with tape.  Safety Of Silicone As you may be aware there have been major concerns about the safety of silicone. Silicone rubber and silicone gel are derived from the mineral silica which is the commonest element on our planet. Concerns about the safety of silicone led to the withdrawal of silicone filled implants from the market in the United States in the early 1990s. Following extensive research no causal link has been found between silicone and a variety of diseases that were claimed to be caused by the leakage of silicone. The regulatory authorities in the United States are now allowing the use of silicone filled implants under carefully controlled conditions. The regulatory authorities in the United Kingdom did not feel that it was necessary to withdrawn the implants and this decision has been justified in the light of today's knowledge. Withdrawing the implants would have denied many women the benefits of silicone implants, particularly when they are used from breast reconstruction. Silicone can now be considered to be entirely safe as a material. This does not mean that silicone implants are entirely safe but the risks are related to the operation and the presence of a non-biological device rather than due to toxicity of silicone.  Implant Rupture Silicone if a very durable material and does not degenerate significantly over the time of a human lifespan. Implants are, however, man made devices and there is a rupture rate. The risk of a rupture is very small (around 1% - 2%). If rupture does occur you will notice a change in shape of your breast. You will no doubt want the implant replaced but this is not a surgical emergency as you will not come to any harm if the implant is left ruptured for even a few months.. As we move about the silicone is continually undergoing a modest degree of flexion and movement. This process may eventually cause rupture but laboratory testing of the implants with simulated wear patterns has suggested that the average implant will outlive its recipient. However as man made devices there is a failure rate which is the cause of implant rupture. If an implant does rupture there may be some migration of silicone. This can cause a local inflammatory reaction, which can be uncomfortable but is not dangerous. If you are particularly concerned about the implications of the leakage of silicone a cohesive gel implant may be the better option for you, as in the unlikely event that this implant ruptures the solid silicone does not leak.  Breast massage This used to be advised for patients following breast augmentation surgery but we would now advise against this to allow a good bond to develop between the implant and your body. To help the prevention of capsular contracture the use of a textured surfaced implant reduces the incidence of capsular contracture by influencing the structure of the scar tissue capsule that the body will form around the implant. The exact mechanism of this not well understood at the moment.  Lifespan of an implant Implants are durable and long lasting. If an implant is performing well and maintaining good shape there is no justifiable reason for changing it. The risk of surgery to change the implant after some years is greater than leaving the implant until or/if a problem occurs. Institutions that recommend change after 10 or 15 years are gaining significant financial benefit from doing a procedure that is not required and has significant risk.  Further Information 'Breast Implants:' Information for Women Considering Breast Implants Government Publication from the Medicines and Healthcare Products Regularity Agency (MHRA). www.mhra.gov.uk Allergan website: www.thenaturallook.co.uk     Copyright © John Dickinson 2007 Designed by Medical Media Ltd