| | providing a woman has been informed accordingly, then ultimately she can decide which is best for her.
Are there different shapes and consistencies of implants?
There are different shapes and types of gel fillers with breast implants. Traditionally, all implants have been round.
The majority of all implants currently used are still round. Viewed from the front, they are circular and in profile,
they appear to be half moon shaped. More recently however a newer, cohesive silicone gel has been introduced which is also known as
the shaped or teardrop implant. As the composition of this gel is set, a shape has been produced which mimics the natural profile of
the breast. These implants are slightly taller than they are wide and are fuller in the bottom. There tends to be a smoother
transition from the upper chest wall to the top of the breast and not quite so much of a "step-off" as can sometimes be seen with the
round type implants. Therefore overall this tends to give a slightly more natural shape, although this very much depends on your
initial shape to begin with. In comparison, the round implants give the breast a slightly more circular or rounded appearance.
The disadvantages of the teardrop shape implants are that, not all breast shapes will benefit equally from this particular type of
implant. It will be determined at the consultation whether you would benefit appropriately from this type of implant. Another
disadvantage is that they are substantially more expensive than the standard silicone implants. The cohesive implant also feels
slightly firmer to touch, making the edges of the implant more palpable, and there have been reports of the implants moving out
of place within the pocket, with resultant loss of shape.
Even more recently however, a round silicone cohesive type implant has also been produced which has the advantage of not leaking
when the shell of the implant wears or tears. Another advantage in comparison to the previously mentioned teardrop implant is that
the round cohesive implant doesn't lose its shape within the pocket.
How do I choose which size of implant is the best for me?
Implants come in a wide variety of sizes and it is possible for any woman to comfortably carry a variety of sizes on her chest.
Most women have a rough idea as to how big they may want to be in terms of bra sizes. The objective during the examination is to
determine which size of implant will give the desired appearance. As you can imagine different size implants in different framed
women gives different results. The secret is to choose a size that will give you a more balanced, proportionate look overall and
more inline with your desires
It is important to understand however that ultimately, the limiting factor in choosing implant size is the space available beneath
your breast. It’s important to remember that as the volume of any breast implant increases, and then so does its width. Therefore
if you choose an implant that is excessively large, the edge of the implant may then extend around beyond the breast and potentially
even under the armpit. This would be undesirable for most people. In addition the potential for rippling (see below) and other
long-term adverse problems increases. The vast majority of women however have a realistic outlook of what they wish to look like,
and therefore it is not often that a surgeon cannot deliver the desired expectations to his patient.
Do Breast Implants cause Breast Cancer?
There is no evidence that silicone in breast implants causes cancer in humans. On the contrary, recent studies have shown that
implanted women seem to have up to 30% less breast cancer that the general population.
Does a Breast Augmentation affect the means to detect Cancer?
Perhaps the most significant concern over breast implants is the possibility of delayed detection of breast cancer with silicone
and saline filled breast implants. Both of these are radiopaque, meaning the implants obstruct the breast tissue viewing to varying
degrees on mammogram. Mammography techniques however have improved over the last few years enabling the radiographer to minimize the
amount of breast that is hidden by the implant. It is important however to realize that 10-20% of breast cancers are invisible to
x-ray, and therefore most breast cancers are still being discovered by self or physical examinations. In this respect, interestingly
enough, some clinicians feel that the implant can actually increase the ease of palpation.
A woman with breast implants should be on the same schedule of routine mammography as all other women. The radiographer should be
informed that she has implants and therefore special displacement (Eklund) views will be required for proper radiological evaluation.
How long do implants last?
Like all man made products, breast implants do not last forever. Despite being very robust and resistant to even extreme pressures,
they are susceptible to daily wear and tear over time. What this means in simple terms is that the outer shell or coating of the
implant eventually wears thin and ultimately disappears. If this happens then the contents of the implant leak out. This is usually
termed disintegration, leakage or rupture of the implant. Clinically however this may be difficult to spot. Occasionally one may
detect a slight flattening of the breast or an alteration of the shape, but this may only be very slight and hardly noticeable.
Capsule formation is the main reason that ruptures of an implant can sometimes be tricky to detect. As previously stated, a capsule
forms a type of "biological bag" encompassing any breast implant. Should leakage of the implant therefore occur, the contents will
still be contained in the same location by the body's own bag or capsule. Despite being difficult to detect clinically however,
thankfully an ultrasound scan will most times be able to accurately assess the condition of any implant when necessary.
There are many quoted figures as to how long ultimately any implant lasts before disintegrating. An average figure is probably
in the order of 20 years. There are however variations in the wear and tear amongst different individuals. A women therefore who
subjects herself to extreme physical exercise for many hours a day on a regular basis with resultant excessive movements of her
breasts (i.e. aerobics instructor, marathon runner, regular horse riding etc.) will naturally subject her implants to more wear and
tear over a given period of time, than someone who does very little exercise. In the first situation it would be reasonable to assume
that the implants may disintegrate sooner than in the latter case.
In order therefore to have a proper assessment of the state of your implants it is best advised to have your implants examined by a
specialist on a regular basis from about 10-15 years after your operation and an ultrasound performed as necessary.
What does the operation involve?
The main principle in the operation of Breast enhancement surgery is the creation of a pocket behind the breast, which will
accommodate a breast implant. There are however a number of details in the approach to this surgery which one needs to understand
beforehand.
What kinds of Incisions are there?
There are generally 3 types of incisions used for inserting the breast implants.
The inframammary incision is made under the breast at the fold or crease line. The incision is about 4 cm in length.
This is the most common incision, and the natural fold of the breast usually hides the scar quite well. It will probably always be
covered by any clothing-even the smallest of bikini tops. Because the incision gives immediate access to the space where the implant
will be placed it is possible to very accurately create the size and shape of the pocket for the implant, and the carefully control
the position of the implant within that pocket.
Another method is the peri-areola incision, which is made around the edge of the areola (the darker skin around the edge of the nipple).
The disadvantage is that the scar is not hidden by any folds, and subsequent scarring may interfere with milk expression in
breast-feeding. The third method is the axillary incision, which is made in one of the crease lines of the armpit. This is used less
often because it is more difficult to get proper placement of the implant in some patients, and if there is a problem in the future,
an additional incision on the breast may be required. Although some patients thinking about this surgery may believe this approach is
the least conspicuous, in truth this may not always be the case, particularly in light of sleeveless open type clothing that expose
the armpit area quite readily and frequently. Regardless of where the incision is placed it is important to remember that a scar will
always be present. The scars normally settle quite well and become less conspicuous with time. However no surgeon can ultimately
predict the appearance of any particular scar.
Where do you place the implant? In front of or behind the muscle?
There are two locations or pockets made where the implant may be placed; the subglandular (in front of the pectoralis muscle) and the
submuscular (behind the pectoralis muscle). The pectoralis muscle is the chest muscle that is commonly developed in body builders.
The first location is the subglandular placement of the implant. The disadvantage is that the outline of the implant may be more
prominent or visible in very slim women. In these situations one can therefore sometimes detect a "step-off" appearance or "stuck-on"
look of the breasts on the chest. In these situations you will be advised to have the implant placed submuscularly.
There are however some breast shapes that are better suited to the subglandular approach. These women typically have breasts that at
one time were much larger than the present. When there is a very large volume decrease and there is little or no shrinkage in the size
of the skin envelope surrounding the breast tissue, then the shape approaches that of an "empty bag". Under these circumstances it is
sometimes better to place the implant in the subglandular position in order to allow the implant to fill out the skin envelope of
the breast.
In the event that the skin envelope has stretched to the point where the nipple is below the breast fold, it may be necessary to
reposition the nipple upward again and reduce the size of the skin envelope by means of an uplift or mastopexy. Again, this will be
determined at the time of the consultation. This sometimes is performed at the same time with the augmentation or in borderline
situations at a secondary time a couple of months after the augmentation(when most of the swelling is gone) .Dr SKarparis will
evaluate the final outcome and will advice you if an uplift is worthwhile to be performed.
The second location is the submuscular placement between the muscles of the chest wall and the rib cage. Submuscular placement
increases the padding overlying the implant offering more coverage and camouflage to the shape of the implant. This is particularly
helpful in women bearing very little or no breast tissue at all. By providing this extra padding in these circumstances, one then
substantially decreases some of the adverse effects on the appearance mentioned above. Another advantage is that mammography has been
reported to be slightly more effective. The disadvantages are that there may be a bit more pain, or discomfort, after surgery and
that the breast will move with certain actions of the muscle.
The decision, as to which location the implant should be placed in your case, will be discussed at the time of the consultation.
What type of anesthetic is used and how long does the surgery take?
The operation is performed under general anesthesia and usually requires an overnight stay in hospital. The procedure takes
approximately one hour to perform.
Is it painful?
You will experience some pain following a Breast Augmentation. It is always difficult to quantify how much pain any one individual
will experience. Whilst some women find this procedure painful others report very little pain postoperatively. Placement of the
implant behind the pectoral muscle is associated with a greater degree of pain, as it is necessary to cut the muscle in order make
space for the implant.
It would be fair to suggest that most women experience a moderate degree of pain for the first five days, which will require regular
painkillers. After a week however most women report a considerable improvement in their symptoms and in fact do away with any regular
painkillers.
What happens after the surgery?
Your breasts will be somewhat swollen and bruised postoperatively. This usually settles in about two to three weeks. Sometimes
swelling may be slightly different between the two sides. This is normal and settles with time. However if a great difference
develops between the two sides then you must contact us for advice.
Following a Breast Augmentation, the breasts may appear to be placed quite high up. This is also normal. During the first two
months postoperatively the implants will gradually lower and settle from the effects of gravity into a more natural position. Do
not be alarmed if one side settles quicker than the other, as this sometimes occurs.
Following the operation you will have a light dressing in place which will need to be kept dry for 2 weeks. At two weeks your
dressing will be removed and the wound inspected and lightly cleaned. There are no stitches to remove, as these are internal and
dissolvable. You can have a shower (not bath) 4 days after the surgery (your doctor will also advice you).
What kind of after effects should I expect?
Changes in nipple and breast sensation (feeling) can occur. Some patients may loose sensation entirely, others report only a
slight decrease, and some even report heightened sensation. In the majority of cases where sensation changes occurs, these are only
temporary and soon recover. The recovery period can sometimes take up to 18 months to complete. In a small minority of patients,
however, permanent loss of sensation may occur.
Breast Feeding can proceed following a breast augmentation providing of course that you are able to produce enough milk in the first
place. You must understand that regardless of whether you have implants or not, all women cannot breast feed satisfactorily
Pregnancy: Should you become pregnant following your operation then your existing breast tissue will be subjected to the normal
hormonal influences of this period and therefore your breast will enlarge and the skin will stretch accordingly. Likewise, once the
pregnancy and any associated breast feeding ceases, your own breast tissue will then shrink down. It is impossible to predict to what
degree these changes will occur; however, the breast implant volume will remain the same throughout these.
Rippling or wrinkling of the skin over the implant may occur in women who have little or no breast tissue. This has no medical
implications in itself but can be cosmetically undesirable. This can occur in any location of the breast. In order to minimize this
effect and if deemed appropriate at the time of the consultation, you may be advised that the best placement of the implant should be
in the submuscular position as previously described. It is important to understand however that rippling or wrinkling can still occur
even when this precaution is taken, and should this then occur it might be difficult or impossible to eradicate.
Palpation of the implants may occur in thinner women following breast augmentation. In these situations the implants are more
likely to be felt at the lower part of the breast near the fold. Again this has no medical implications, although women who do not
bear this in mind may suddenly become worried about feeling a "lump" in their breast. In any instance of uncertainty it is always
best to contact your surgeon to have this examined.
There is no chance of the implant exploding or bursting whilst traveling in an airplane, swimming, diving etc.
What are the scars like?
Scars are not a complication but a normal event after any surgery. Thankfully the scars in a Breast Augmentation operation are short,
being about 4 cm in length. You should always expect these to be red, raised, lumpy and even itchy to begin with but with time they
should fade and flatten. This is the natural evolution of the healing process. However it is important to keep in mind that this may
take up to two years to complete. Daily massage of the scars during this time period is advised to expedite and facilitate this
process. You must understand however that no responsible surgeon will ever be in a position to predict any scars ultimate appearance.
Although as mentioned, scars do fade and improve in time it is not very often however that these are ever characterized as being only "hairline" in nature.
What could go wrong?
All surgery carries some uncertainty and risk. When a breast augmentation is performed by a qualified Plastic Surgeon, complications
are infrequent and usually minor. Still, individuals vary greatly in their anatomy, their physical reactions, and their healing
abilities, and the outcome is never completely predictable. These include infection, haematoma, and wound healing problems. Infection
can occur despite our normal routine of administering antibiotics at the time of surgery as well as post-operatively. This happens
about one percent of the time. Signs such as pain, redness, swelling, or fever, following augmentation should be reported immediately
to the hospital. Infection not reported could easily compromise the success of any surgery. If infection was to be serious and fails
to respond to antibiotics, removal of the implants would be required and replacement would not be effected until such time as the
infection had cleared.
Bleeding, as a result of a leak in a blood vessel will give rise to swelling and bruising of the breast. If this is slight then your
body will be able to absorb it in time. If it is significant (termed haematoma, and occurs 1% of the time) then it may be necessary
to drain this. Your surgeon will be able to assess this.
Skin necrosis or skin decay occurs when there is not enough blood to supply the skin. This could happen if the surgeon were to select
an implant size too that was too large for the pocket created.
Capsular Contracture (Hardening)
This is the most common complication of breast implants. A capsule or capsule formation is a layer of scar tissue that normally forms
around any artificial material placed in the body. It is important to realize that this is the natural response of the body to foreign
material. Most times this capsule is so soft that it is virtually undetectable and therefore does not affect the implant in any way.
Capsular contracture or hardening occurs when this layer of scar tissue shrinks around the implant, squeezing it so that it starts to
feel firm, or in some cases, quite hard. Most capsular contractures experienced today stem from the smooth shell silicone implants
placed some years ago. The capsule contracture rate in the past was 30-35%.
With the onset of textured shell implants, the problem of capsular contracture has been significantly reduced, now being between 1-2%.
The cause of capsular contracture is not totally clear, but seems to be multifactor. It is important to realize that there are
degrees of contracture and that the majority of women, who do develop this hardening, develop it only to a mild extent. In the
minority however, it may be severe enough to be bothersome, even painful and may cause distortion of the breast. The condition may
occur in one or both breasts and to a different degree either side.
It may develop any time, even years later although it is most likely to happen in the first 3 years after surgery. Unfortunately at
this time there is no effective way to prevent capsular contracture if it is going to occur. However as mentioned previously,
encapsulation is no longer the problem that it was. Having mentioned all the above, it is important to note that capsular contracture
is not in itself a health risk other than its possible interference with mammography.
There are two ways to reduce or relieve the firmness of a contracture. These are the closed and open capsulotomy. In the closed
capsulotomy, the firm implant is manually squeezed tightly from the outside, in an attempt to disrupt or tear the scar envelope.
When successful the result is instantaneous and the implant immediately feels soft. The tear resistance of the scar envelope however
varies from woman to woman. Some tear easily but in others the scar is so tough that it cannot be torn. In others, only a partial
tear is possible, which can lead to a small outpouching of the implant, with a resultant unsightly appearance. A closed capsulotomy
may also result in bruising, bleeding, or even rupture of the implant itself. If rupture occurs then you will need surgery to remove
and replace it. In light of these unpredictable outcomes, closed capsulotomy is infrequently done.
The other method, which is much more controlled and thus the preferred method, is the open capsulotomy, performed under general
anesthesia. In this procedure the old incision is reopened and the thickened capsule is removed or loosened. The implant is then
reinserted again into the breast pocket. Unfortunately, even after a successful capsulectomy, there is always the possibility of
recurrent hardening.
How long before I can get back to normal?
Although you can gently walk about and do very light duties from the next day, please avoid any stretching or lifting during the
first 7 to 10 days. Depending on your job many ladies go back to work after this time. Obviously if this involves excessive
stretching and lifting you are then advised to refrain for a further 10 days. You can usually commence light lower limb exercise
after three weeks. Upper arm exercises and swimming can begin after six weeks. When exercising always try and wear a good sports bra.
Driving is allowed after 1 week. Sexual activity can be commenced at around 4 weeks although at this stage only very gentle handling
of the breasts is advised.
Summary
The chances are excellent that you'll be happy with your surgery. Most patients understand the advantages and benefits of this type
of surgery. If you do decide to proceed Dr Skarparis can inform and advise you what implant he feels is best. Unfortunately, the
perfect implant has yet to be made and as already described there are some drawbacks associated with all implants. One must therefore
try to balance all these against the benefits, by trying to examine any evidence in a rational and impartial way. Patients should
never allow themselves to be swayed by any form of media.
 These notes are for guidance but you must realize that every patient is different with a different healing capacity. You should contact your surgeon in case of any specific concerns.
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