SURGERY ADVANCES

Improved implant shell technology: The current implants shells are very much thicker than their predecessors, and have a sophisticated texturing process on their surface to lessen the risk of the potential long term complication of capsular contracture. Some heavily textured devices have also created several “new” problems including double capsules, late seromas and BIA-ALCL – a rare type of lymphoma seen with some textured implants – if this is of any concern to you, please raise it at consultation

Bio-dimensional approach: The modern approach to breast enlargement, using specific measurements on each patient’s chest to help select the most appropriate implant. In essence, it involves taking a few simple chest measurements, the most important of which is the pre-existing breast width, and using this data to establish the base print of the implant. Once this is established, one can look at the various degrees of projection, which may vary from low to extra-high. The system is not “absolute”, but is a useful guide for implant selection.

If you wish, numerous before and after pictures will be shown to you, to give you some idea of the effect of the breast augmentation, but it is important to realise that the biggest determinant of your result is what you start with!!! What the operation achieves is an enhancement of your existing shape; the better the pre-op shape – the better the post op result! Patients of 40 years or above requesting any aesthetic breast surgery are encouraged to have a mammogram before the surgery, if one has not been done in the preceding year.

I most often use round (as opposed to shaped / “anatomic”) moderate-plus or high profile, cohesive, textured or smooth silicone gel prostheses (Mentor – USA, or Motiva. Depending on each patient’s chest measurements, which would include soft tissue pinch thickness / cover, the implants may be placed either in front of (pre-pectoral / subfascial), or partially beneath, the chest wall muscle (“dual plane”). In general, the thicker the existing breast tissue, the more likely I am to suggest placement in front of the chest muscle / sub-fascial, and vice versa for very thin patients with little soft tissue cover. Should we decide upon placing the implant in front of the muscle, I always use the “subfascial” approach, which was first described by Dr Ruth Graf of Brasil. The pectoral fascia is a thin but fairly tough covering over the pectoral muscle, and may give the implants placed in front of the muscle, better support, or at least maintain the breast fat in a more stable form. Either way, I do the augmentation surgery via a small (5cm) incision in the breast crease, which leaves a very acceptable scar that fades over a few months to become barely visible in most cases.

The operation is done under deep IV sedation, by a certified anesthetist, and long acting local anaesthetic is infiltrated into the breast. This ensures a safe and comfortable procedure, of which you will have no conscious recollection.

The operation itself takes between 1 and 1.5 hours, and generally you are discharged the same day; i.e. there is no need for overnight stay in the hospital.

To limit the chance of infection, antibiotics are given IV during the operation, and the implants are soaked in a special “cocktail” of antibiotics prior to placement. To date, I have had no infections after this operation that required implant removal, although this is an inherent risk when using prostheses of any sort. Most people are very happy with the results of this quick procedure.

Q3. What about the possibility of breast cancer?
A3. Large studies have shown that having breast implants neither increases your risk of developing breast cancer, nor delays the diagnosis of cancer, nor negatively affects the outcome should you develop cancer in the future. We routinely use breast implants to reconstruct breasts after patients have had a mastectomy for cancer. BIA-ALCL has been seen with macrotextured implants predominantly – these were recently recalled and are no longer on the market worldwide.

Q4. What about mammograms – can I still have them if I have implants?
A4. Yes, although you would need to tell the radiographer that you have breast implants. Often, in addition to a mammogram, the radiologist will perform and ultrasound / sonar examination of the breasts.

Q5. What about anatomic or teardrop shaped implants – don’t they give a more natural result?
A5. In short…. No! Whilst conceptually a good idea, anatomic implants have not lived up to initial expectations. No cosmetic benefit over standard, round implants have been noted in the vast majority of patients presenting for cosmetic breast augmentation, and some very definite potential disadvantages have emerged, including rotation of the implants, a larger access incision needed to place them, and they are generally firmer than round implants. They may have a place in breast reconstruction after mastectomy, but a very limited role in cosmetic breast enlargement, in my opinion.

Q6. Do you use cohesive implants?
A6. Yes – Both Mentor & Motiva breast implants are filled with cohesive, medical grade silicone gel (gummy bears). I use both textured and smooth surface implants. Websites: www.mentorwwllc.com/global-us/Breast.aspx , www.motivaimplants.com

Q7. Is it necessary to have the implants replaced routinely after a certain period of time?
A7. No. I usually recommend that a routine “check-up” be performed 10 years after the surgery, but if at that time, you are happy with the size, shape and feel of your breasts, there is no need for a routine “trade-in” of the implants for a new pair.

Q8. What about the armpit incision for breast enlargement – do you use it?
A8. No – I prefer the incision to be placed in the breast crease (under the breast). The reason is that this incision is the most versatile for implant placement; the implant can be placed either in front of, or partially behind the chest muscle, and I have the most control over the exact seating of the implant, allowing me to place it accurately. The armpit incision may leave you with a conspicuous scar (albeit not on the breast) that may be visible in strappy tops, and may result in implants that are “high riding” (i.e. the implants do not rest on the breast crease, but somewhat higher, which looks very unnatural)

Q9. Could I have saline implants? – I have heard they are better than gel implants.
A9. I do not like saline implants, but will place them if you wish. In the early 1990’s there was a silicone scare in the USA, and so, although the saline implants do not feel nearly as natural as the silicone ones, they came into common usage because of this scare, not because they were better in any way. They slosh, may leak, and do not feel natural at all. Since the early 1990’s numerous scientific studies have validated the safety of modern cohesive gel implants.

Q10. Which is better: Under the muscle or on top of the muscle?
A10. Both are very acceptable methods of placing the implants – neither is more correct than the other, and each has distinct advantages and disadvantages. I use a bio-dimensional approach to best ascertain the implant size, and placement there-of with respect to the chest muscle. Each patient is therefore assessed on their own merits.

Q11. What about using one’s own fat to do a breast augmentation?
A11. Previously “banned” this is now enjoying a renewed level of interest, with the resurgence of enthusiasm in fat grafting in general. Whilst I have done many fat grafts to the breast in the reconstructive setting, I rarely do this in a primary augmentation patient. Using gel implants is still currently the gold standard for breast augmentation and the procedure against which all others are measured. In broad terms, fat grafting for cosmetic breast augmentation is still in its infancy. Most patients with small breasts are slim in general and hence have very little “donor material” in terms of fat that can be lipo-suctioned for transfer to the breast. Generally, only small volumes of fat can be transferred at any one time, hence only a modest enlargement can be achieved at best, and indeed, more than one surgery may be required to achieve a satisfactory volume of augmentation. Nevertheless, this may be an option in a small, select group of patients seeking modest enhancement, and who have fatty deposits elsewhere on the body which can be harvested for transfer, and who are reluctant to have gel implants.

Q12. Have you ever used P.I.P or Allergan implants and what should I do if I know that I have them in place?
A12. I have never used implants manufactured by the French company P.I.P. The problem with these implants is that inferior grade silicone was used as a fill material and they are much more likely to break up in the body. My advice is to have a screening breast sonar (ultrasound) and mammogram and if there is any doubt as to the integrity of the implant shell, prompt removal is advocated. Allergan has withdrawn its biocell textured implants globally – I have never used them.
Many organisations have issued statements on this subject – perhaps also look at www.isaps.org