Mr Turton’s Information Sheet for Patients Undergoing Augmentation
Introduction on Breast Enlargement – Breast Augmentation
The terminology of breast enlargement is important to understand. It is colloquially referred to as a boob job, but we prefer the term breast enlargement and this is the term my patients use with me. When we write about breast enlargement on medical letters or in journals we use the term breast augmentation or augmentation mammoplasty.
We essentially enlarge the breasts to try to improve femininity. The breast has been the symbol of femininity since the earliest time. Often, to a woman, in her perception of her body and her concept of self, the size and shape of her breasts plays a dominant role. Whilst padded bras do give the illusion of increased breast size and they help superficially they can paradoxically cause increased problems for a woman once they are removed and the breasts assume their natural appearance. Breast augmentation has been performed for centuries but the techniques 100-years ago were pretty hopeless involving the transplant of a fatty growth, or the use of experimental materials that were not successful. All of this changed in the early 1960’s and for the last 55-years breast augmentation has become an established surgical technique that is proven to improve a woman’s body image and her perception of self with usually positive psychological effects.
Who chooses to have Breast Enlargement?
There are 2 main groups of women who request this operation. The commonest group of women are represented by mothers of children who were happy with firmer larger breasts before or during pregnancy, or who have found that subsequent to pregnancy and childbirth the breasts have decreased in size and seemingly deflated. This is often with emptiness in the upper half, causing a more scalloped appearance and sometimes combined with loose skin. The lower pole of the breast may overhang the crease under the breast. The second group is represented by young or middle-aged women who are yet to start a family or have decided not to have children, who wish to have breast enlargement as they consider their breasts to be of insufficient size, often disproportionately small to their frame.
How do I go about finding more information on Breast Enlargement?
Unfortunately, unless there is a significant underlying medical condition which has to lead to a deformity of the breast or a postoperative deformity that requires correction it is not possible to obtain augmentation mammaplasty on the NHS except in exceptional circumstances. There are numerous sources of information on augmentation from books, magazines, to articles posted on the internet, and these should be complemented by a good quality in depth consultation with the specialist surgeon who will perform the augmentation. Please use our consultation contact form to get in touch.
Mr Turton is happy for women to book to see him directly, but it is considered good medical practice for the surgeon to keep the patient’s general practitioner informed of any consultations and medical interventions that subsequently occur. He will write to your GP after each consultation unless you explicitly inform him that you do not wish this. Please provide this in writing at the consultation too. Mr Turton has produced this information to supplement your reading and provide a basis to enhance your understanding and for informed consent. Additional information from Allergan, one of the leading suppliers of implants maybe found here.
How do I select a surgeon for Breast Enlargement?
Not all surgeons will have the necessary skill, patient numbers, years of experience, or technical ability and artistry. Breast augmentation should only be performed by a Specialist Surgeon trained and experienced in the technique, such as Mr Turton. If your surgeon is expert they are also likely to have excellent feedback and few complaints. Check the “I Want Great Care” Web Site, which is independent, and see what is said about your surgeon. Read every single review you can find and research thoroughly. Be prepared to travel to find the right person.
Your surgeon must be on the GMC specialist register as a surgeon in a specialty that does this type of surgery. Your surgeon’s credentials for performing Cosmetic Breast Surgery can be verified on the Royal College of Surgeons web site which records all Specialist Surgeons who have Full Certification to carry out such procedures in the UK- check the credentials here. You will find that for Cosmetic Breast Surgery the background of your surgeon’s training should have origins in the specialty of plastic surgery with special interest in breast surgery, or be a Specialist Breast Surgeon who comes from a general surgery parent specialty. Mr Turton is a Specialist Breast Surgeon and his clinical workload relates entirely to breast surgery, reconstructions of the breast, surgery for women with breast disorders and all aspects of cosmetic breast surgery including complex cosmetic work.
Your Specialist Breast Surgeon should be a member of the Association of Breast Surgery, (ABS) and in addition to this the Department of Health now recommends that they are Fully Certified to perform Cosmetic Breast Surgery by the Royal College of Surgeons. The Specialist Information website lists more details about the surgeon’s ‘usual’ practice, and this is a very helpful site to check more about your consultant. They do charge you just £2.99 for access, but this is money well spent if you are not sure about your surgeon’s usual area of practice. The link to the Specialist Information web site is here. Further details might be found from reviewing their NHS practice too, for example regarding Mr Turton who is listed on the St James’s Teaching Hospital web site as being a Specialist in Breast Surgery- see link here.
The National Care Standards Commission is a new agency set-up by the government to ensure the regulation of cosmetic surgery in private hospitals and if you approach a surgeon offering augmentation mammoplasty in the private hospitals within Yorkshire they will have had to fulfill the requirements to be allowed to provide this surgery. It is obviously our opinion that any surgical intervention is better carried out by local experts rather than travelling far and wide. Mr Turton is a Specialist Breast Surgeon and performs Cosmetic Breast Surgery including breast augmentation (also referred to as breast enlargement or simply ‘boob job’), breast reductions, breast uplift (also referred to as breast mastopexy), correction of nipple inversion, tuberous breast deformity, breast asymmetry surgery, breast reconstruction, and breast liposuction. He is trained from the parent specialty of General Surgery (includes breast, oncoplastic and reconstructive breast, vascular, upper and lower GI, endocrine) and within this specialty trained further in breast, reconstructive breast, oncoplastic breast and cosmetic breast surgery. This specialist training reinforced his special area of interest in Cosmetic Breast Surgery which he has performed expertly at Consultant level since 2004. His practice is appraised annually, he is a full member of the Association of Breast Surgery and he is Fully Certified by the Royal College of Surgeons in the field of Cosmetic Breast Surgery.
Mr Turton is Director of the Leeds Breast & Cosmetic Clinic and treats private patients at the Leeds Nuffield Hospital and Spire Hospital Leeds. He has been carrying out all aspects of Cosmetic Breast Surgery since 2004 and has performed many thousands of breast operations.
Mr Turton was also one of the first UK specialists to be awarded Full Certification status in Cosmetic Breast Surgery by the Royal College of Surgeons. He is a Full member of the Association of Breast Surgery (ABS) and is a past member of the ABS Clinical Practice and Standards Committee. Mr Turton is also an active member of the Aesthetic sub-committee of the ABS who meet three times per year at the Royal College of Surgeons. This Aesthetic Committee serves the interests of the ABS members who have a special interest in Aesthetic Breast Surgery in the UK. In addition, Mr Turton’s NHS Consultant work is exclusively as a Specialist Breast Reconstructive and Oncoplastic Breast Surgeon. Even within his NHS work he routinely carries out aesthetic breast surgery with breast augmentation, breast reduction and mastopexy where required for congenital and developmental problems or in relation to reconstruction to obtain symmetry with the other breast. Mr Turton has been in continuous full-time employment as a Consultant Specialist Breast Surgeon at Leeds Teaching Hospitals Trust since 2004.
Pre-operative evaluation for Breast Augmentation
You will be seen by your consultant and various questions asked concerning your approach to breast augmentation. You will be asked why you wish your breasts to be enlarged, what size you would like them to be and if you had been pregnant previously the breast size that was attained.
The most common answer to the first question is that women wish to look better in their clothes and be in better proportion to the rest of their body, or be returned to the size they were prior to pregnancy. As far as the second question is concerned it is unrealistic to give an exact estimation of cup size following the procedure but a general opinion can be given. It is important to achieve a balance between what the woman wants and what is possible surgically given the limitations of the woman’s chest size and tissues etc. Finally, if the woman did not enjoy having larger breasts during pregnancy it is unlikely that a breast augmentation will be a positive experience.
Your medical and any previous surgical history will be taken and any medications that you currently use will be documented. Pre-existing illnesses, especially of any skin diseases, will be evaluated in more depth. Any smoking history past or current should be disclosed. You must detail all medications, herbal preparations and any allergies as the adjustment is often needed at the time of surgery.
After discussing the woman’s motivation and desire to final appearance a full breast examination will be performed. This will include a clinical check for any pre-existing breast lumps. The cosmetic assessment requires a trained eye and the experience of Mr Turton is invaluable here. The measurements taken will be recorded on and kept in the notes. In particular any asymmetry of the chest or back is noted as if there is some element of asymmetry of the breasts at the start of the procedure due to minor physiological differences (these are common), or development or skeletal deformity then this will obviously need to be recognised as it will always have some impact on the final results. Discrepancies cannot usually be greatly altered by conventional simple breast augmentation surgery and if you are concerned about asymmetry you may need additional surgery or further surgery at a later date. A balance is usually made by patients to accept their starting asymmetry to avoid additional costs, but if it is something that you feel would be difficult to cope with psychologically you should make this clear so that Mr Turton’s opinion can be explored as to the potential solutions and what they might entail. Asymmetries will, therefore, be demonstrated to avoid any dissatisfaction postoperatively. It is worth remembering that augmentation will not produce a perfect type cleavage with nipples pointing straight ahead unless that is what the woman started with.
Specific Considerations with Breast Enlargement Surgery
Ptosis – ptosis (sagging) is the medical term for nipples that have dropped below their original position. There are various grades and in the worst cases, they can actually be pointing directly at the floor. Breast augmentation cannot correct anything other than the mildest case of ptosis. If a ptosis correction is requested then an alternative procedure known as a mastopexy would be required which can occasionally be combined with an augmentation, albeit with certain increased risks. This, however, leads to additional incisions and hence scarring around the nipple and often lower breast (see photos of mastopexy or reduction on Mr Turton’s website), dependant on which technique is required. Care should be taken to discuss this with your surgeon should you wish the nipple position to be altered. Some women are happy to live with a degree of looseness and ptosis so long as the volume of the breast can be returned with the augmentation. So long as they understand that in a bra they will have good volume and projection but once the bra is removed they will have the downward deflection of the nipples as before. At all times it should be emphasised that we are aiming to achieve what the woman wants and not some preconceived idea of perfection. If you do not have ptosis then you will not have to worry about this, although it can develop later after augmentation and sometimes it can occur just in one breast causing asymmetry. Future weight changes, hormonal changes, the presence of implants and simple ageing can all contribute unpredictably to the way the breast behaves as you get older. This can affect women who do not have implants but is generally more obvious after augmentation.
Breast Implant size
Consideration is taken into account of the patient’s desires. Between 125 and 150 ml of volume will very approximately increase the bra size by about 1 cup. Although there are many other considerations eg: the base size of the implant, the shape of your chest wall, the thickness of your current breast tissue, skin and breast tissue elasticity, the shape of the implant, whether it is placed behind or over the muscle, previous pregnancies and breast size, as well as your current starting point. All should all be considered by your surgeons and taken into account when discussing implant size with the patient. A round implant will give a fuller appearance in the upper part of the breast (this can give a more artificial look where desired, but can also look very natural in the context of the right starting point, and the right profile and size of implant chosen by your Specialist). There are also anatomically designed implants that give a less pronounced fullness in the upper part of the breast, although these don’t suit everyone, they can work very well with patients who are very thin and flat chested. You should ask your surgeon to discuss the various merits of each of these with you prior to selecting an implant. Reviewing pre-and post-op pictures from Mr Turton’s website and printing off the post-op pictures that you feel are most in line with your desires can assist the discussion. A bio-dimensional assessment will be performed by Mr Turton, to provide you with an implant size that fits your frame and therefore is more natural and in proportion, as is desired by the majority of patients these days.
Breast Implant type
The implants have an outer silicone shell but virtually all cosmetic breast implants have silicone gel inside. They can be saline-filled but these do not feel as natural. It must be stressed that previous concerns about silicone have proved unfounded in the Independent Review Groups Reports, with no evidence of autoimmune problems, but your surgeon will discuss things with you in more depth and ask any questions that you have. Natural oil based implants are no longer recommended. The UK market is dominated by silicone filled implants as these give a more natural look and feel. Mr Turton will use one of the high cohesive silicone gel implants, which are far superior to runny silicone (see the section on the Natrelle Cohesive and BLite implants). Mr Turton has an extensive experience with different implant manufacturer’s implants. He has particular experience and expertise with the full spectrum of anatomically shaped (tear drop) and round implants of different profiles and LVC measurements, and their correct placement (see pre- and post-op photos).
Positioning of the Breast implant
The implant can be placed either directly under the breast in a “sub glandular” position or partially under the muscle of chest wall known as the “subpectoral” position or “dual plane”. Generally for women with very little existing breast tissue a submuscular approach is recommended to reduce the palpability of the upper edge of the implant, or to mask visible rippling which might only appear when you sit forwards. Every woman obviously represents an individual case and you should discuss the various advantages and disadvantages of each approach with your surgeon. The sub-muscular position affords a better ability for mammograms to visualise your breast tissue later, although they are still less sensitive than when performed without implants. The breast tissue is partly obscured by cosmetic implants on mammograms. Sub-pectoral positioning can sometimes look less natural, especially if the implant is wrong for your frame. During forced pectoral muscle contraction the upper pole of the breast and the cleavage area will flatten when the implant has been positioned behind the muscle (sometimes referred to as animation of the breast as it makes the breast move). Sometimes the sub-pectoral position can stop the implant filling the overlying envelope of the breast as well, if the envelope is quite loose to start with. Although it is not uncommon for the breast to look and move unnaturally when contracting the pectoral muscles, giving a distorted appearance, this is only really visible if you do this deliberately or when wearing just a bra or are undressed! Sub-pectoral positioning may help lower capsular contraction rates and it is the preferred position for smooth shelled implants which are a popular choice for their lowest risk of ALCL. Some patients prefer sub-glandular positioning as it is less painful and the recovery is quicker, and they “reserve” the sub-pectoral position for later in life when they may have revisions. It is good to have a detailed balanced discussion about this with Mr Turton.
Breast Augmentation – The Operation
You must not smoke either before or after surgery ideally from 6-weeks before to 6-weeks after. Smokers have higher rates of all complications both in the short and long term. All nicotine products must be completely avoided. The operation is performed under a general anaesthetic and in Mr Turton’s practice is always conducted by an experienced Consultant Anaesthetist as safety is his priority. Various approaches are available for the placement of the implant. The commonest approach is by placing the scars underneath the breast in what is called the inframammary position. This is generally considered the one required for the placement of silicone implants as they do not compress enough to be squeezed through holes in either the armpit or around the nipple. It is associated with the lowest complication rate. Your surgeon should discuss the surgical approach with you prior to the operation. Mr Turton has very careful and skilled technique for breast augmentation that has been refined from years of experience and will help optimise the best cosmetic result for you and reduce the risk of subsequent complications. The stitches used are dissolvable. Mr Turton uses three layers of sutures, with the deepest strength layer designed to be reabsorbed slowly by the body and usually complete by 6-months. The top layer is a fine cosmetic suture just under the skin surface to optimise your scar.
Following the procedure, the wounds will be dressed with white adhesive strips called steristrips and over this, a semi-waterproof dressing will be placed. This will protect your wound, but Mr Turton prefers that you just take shallow baths for the postoperative 1-2 weeks to keep the dressings dry. A Tubigrip support is pulled up over the breasts at the end of the operation so that no sports bra is needed at this time, as this is generally preferred to prevent possible implant malposition from an ill-fitting bra. The Tubigrip and “stabilising band” should not be removed, but left on even when having a shallow bath (and kept dry!). They should be comfortable and not excessively tight. The Tubigrip is often placed as a double layer for the first post-operative night, and then pulled out to a single layer and the bottom trimmed the following morning so that it isn’t as tight. An overnight stay is generally always recommended as Mr Turton believes this to be the safest way to look after you and for your reassurance. Antibiotics are given to cover the procedure and for a period of 3 days afterwards.
Returning Home after Breast Enlargement Surgery
You normally need regular combination analgesia with sub-muscular augmentation for the first four days (eg a common combination is: Paracetamol, Ibuprofen, Tramadol all taken every day for four days before decreasing). The patient is advised that she should restrict her arm movements for the first 7 days trying to keep her elbows close to her sides. On the eighth day she can resume routine non-strenuous activities but should still restrict arm movement; She can usually drive a car again a little earlier than this if it is not uncomfortable to do so. However, she must avoid lifting her arms above shoulder height. She will be reviewed at around one week after surgery in the dressing clinic and then at around two weeks after surgery in the outpatient’s department. At the end of 2-3 weeks, you will be advised when you can start to wear a sports bra. Usually, by 6-weeks, you can start to wear an underwired bra, thought you may consider continuing to wear the sports bra at night (which may help reduce breast sag in the long term if you keep it up). If all is well you can resume most normal activities including light exercise at 6-weeks, except when a shaped (anatomical) implant has been used when the period of restriction is far longer to reduce the risk of implant rotation. Swelling usually resolves by 3 weeks but can take 6-8 weeks with subpectoral placement and for implant settling to occur. It is worth remembering that exposure of the scars to ultraviolet light will produce permanent pigmentation in the scar. It is therefore advised to avoid tanning booths and exposure of the scars to the sun until the scar has gone a white colour, which can take 6-12 months or occasionally two years.
It is very important not to poke around the scar area with your fingers and under no circumstances scratch the area. Doing so can initiate inflammation, protrusion of the suture ends and cause a deep infection leading to implant removal.
Routine massage of the implants (as is described for smooth shell saline implants) is not recommended or required and may encourage capsulation, seroma formation or chronic inflammation. Please do not do this under any circumstance. Please also ensure any sexual breast contact is gentle.
Keeping the scars taped with a thin strip of low allergy tape such as Micropore™, for 3 months can help reduce stretching of the scar whilst it matures, and hence help to keep it as imperceptible as possible. However, some patients develop a tape allergy and this makes the skin itchy and red and it must be discontinued immediately if that occurs. If you have a tendency to form thickened or raised scars there are silicone gels that can be used which might be beneficial. Otherwise, Dermatix gel can be used from 2-weeks and applied twice daily for 12-months for the reassurance to get the best maturation possible. Some patients just use “bio-oil” for around 3-months.
Special consideration/side effects/complications with Breast Implant Surgery
Pregnancy should preferably be avoided for 6-months after the procedure. It is normally possible to lactate and sometimes breast feed after breast augmentation but a small number of women will find that they are unable to do so or that the volume of milk has reduced. It should be remembered that some of these women may not have been able to breastfeed even without an augmentation. The antibiotics given during the procedure may make the oral contraceptive pill ineffective. Barrier contraception should, therefore, be used until an uninterrupted pill cycle is restarted.
In the first few hours after surgery, Haematoma or bruising is the most common complication. This is the same after most surgical procedures and occurs in less than 1% of patients undergoing augmentation mammoplasty under Mr Turton’s care. It normally appears within the first 24-hours and is associated with a sudden obvious increase in breast volume with a tight feeling and discomfort. Small haematomas can be treated conservatively and will settle. However larger haematomas are usually treated by evacuation under anaesthetic on the same day. Avoiding moving around excessively as you come round from the anaesthetic is important to reduce the risk of this occurring.
The nationally reported deep infection rate leading to implant removal is reported at 2%, which means 2 in every 100 patients. In over 1000 breast implants placed for primary augmentation, Mr Turton has never had an infection leading to implant loss.
Minor wound healing problems may occur more frequently and minor infection with redness at the suture line would be treated as infection even if there are no other signs, and this would still be extremely uncommon at less than 2%.
If an implant becomes infected the breast would swell and you would likely feel shivery, unwell, and have a temperature. That would require urgent medical care to treat and remove the implant to prevent serious sepsis forming which could be dangerous. If an implant had to be removed for infection it would be left out for a period of months. This would produce a marked asymmetry if only one breast is affected. It is possible to place an implant subsequently, but there is an increased risk of infection with the second procedure. Not smoking is of particular importance.
ALCL stands for Anaplastic Large Cell Lymphoma. In 2011, the American regulatory Agency (the FDA) identified a possible association between breast implants and the development of ALCL, a rare type of non-Hodgkin’s lymphoma. It was estimated in 2011 that the FDA was aware of approximately 60 cases of ALCL in women with breast implants, out of approximately 5-10 million women who had received breast implants worldwide. The incidence is likely to rise with time but is still considered rare and as of 2016 only 300 cases had ever been reported worldwide since records began. In the UK our regulatory agency (the MHRA) have asked that all surgeons report cases of ALCL since 2011. As of 2017, around 30 such cases had been recorded in the UK, which confirms this to be a rare problem. Nonetheless, it is likely to be of media interest and to be discussed more in the future. In the cases reported to date, there are cases that have occurred in the commonest used macro textured implants such as Allergan Natrelle with Biocell macro texture. It is too early to say for certain whether it can affect all implant types but there is data to suggest different rates with different textured surfaces from different manufacturers. For example, smooth round implants seem largely immune from it if a patient has never had a textured implant- there have not been any cases of ALCL around a smooth surface silicone implant in this setting, anywhere in the World as of 2017. However, the complications from smooth round implants if placed over the muscle (sub-glandular position) are higher with a greater occurrence of capsular contraction. If smooth implants are placed under the muscle, there seems to be a similar occurrence or only slightly higher incidence of capsular contraction compared to textured implants. Mr Turton recommends this sub-muscular position for smooth implants and his patients always opt for this approach.
One theory about the development of ALCL is that minute traces of bacteria get trapped on the textured implant surface (a biofilm) and cause a chronic inflammation that stimulates the adjacent white blood cells in the tissue (the T-cells) and that over time and with the right genetic changes this can trigger the development of ALCL. But no one knows for sure and it may be a rare type of bacteria that has not yet been discovered. The frequency of occurrence does seem different in regions of the World, and overall as mentioned earlier, as of 2016, only 300 cases had ever been recorded World Wide. The numbers will increase each year and eventually we will now the frequency rates. Studies published in 2017 and early 2108 suggest that with macro textured Biocell implants the risk is between 1 in 1000 and 1 in 10,000; with micro texture Siltex it is 1 in 30,000 to 1 in 60,000.
The reason to inform you about something so rare is that Mr Turton feels that patients should be given as full information as possible, and it would likely be more worrisome if you had not heard of it before and then to learn about it through the media. It is important you are informed and if you are worried about ALCL you should discuss this with your Specialist. From the cases of ALCL that have been reported where they present with a seroma we know that ALCL is treated by removing the capsule from around the implant (a capsulectomy), and removing the implant too. At this early stage, it is entirely curable. Late cases where it has spread or formed a mass can be fatal like cancer. The key thing is understanding it is rare but very important. Late problems with implants are far more usually caused by capsular contraction, or rupture and rarely minor trauma, infection or seromas. All of these can present with symptoms that may have overlap with this rare condition of ALCL, and it will be more common in the future to take a fluid sample from around the implant if a sudden effusion occurs to look for the very rare case of ALCL that might be the cause. Please see my dedicated page on my web site about ALCL.
There is no link between breast implants and conventional invasive breast cancer, and we know from extensive research that the frequency of breast cancer is no different in patients with cosmetic breast implants compared to the general population. Please feel free to ask more about this if desired.
Approximately 15% of all patients undergoing primary augmentation will have a permanent alteration in sensation on one or both sides. This can involve the nipple, the areola (the brown skin surrounding the nipple), or more commonly some of the skin on the breast itself usually across the lower pole. It may be less sensitive or totally numb. It would be considered permanent if it is still present after a year and even removing the implant will not bring it back. Women should, therefore, be honest about the importance they place on nipple stimulation on their sex life. If it is important to the women then they should consider whether this operation would be advisable given the risk of nipple sensation loss.
Capsular Contracture and Removal of Implants
A contracture is a tight fibrous capsule that the body forms around the breast implant causing it to become less natural looking. Approximately 1:4 women will develop some form of contracture around the implant. Whilst most women will not realise there is a thick capsule that has formed, occasionally the contracture becomes so bad that the implants require removal. The incidence of contracture is falling with only 15% of women who choose the newer textured prostheses being affected, over 5 years, but follow-up data in this group remains immature. As heavy texture is associated with a higher risk of ALCL, micro texture and smooth implants are options. Sub muscular smooth implants probably develop capsular contraction at similar rates to sub glandular texture implants, but there are no good studies that have been conducted. Pregnancy and breast feeding after augmentation can cause capsular contraction. This may be because of bacteria from sub-acute infections. Prophylactic antibiotics should be considered for invasive procedures such as deep root canal dentistry if you have implants. There have been various conservative treatments suggested that women could try to reduce the general risk of capsular contraction including the use of antioxidants such as vitamin E, however, nothing is foolproof and a certain percentage of patients will develop contracture no matter what they do or how many times they undergo revision procedures. Women should be aware of this before undergoing breast augmentation. However, a small amount of capsular contracture is very common and often accepted by other women undergoing this procedure. If a capsular contraction occurs you should have it removed fully if possible if having replacement implants. This can cause the breast shape to change and drop with more looseness. If you ever have the implants permanently removed in the future after augmentation than breasts will usually look worse than if you had never had them in the first place, with droop and emptiness.
Micropolyurethane covered silicone implants are thought to have the lowest capsular contraction rates, but there can be other down-sides.They are harder to place, and usually, a longer incision is required to get them in. Silimed manufactured these but they have recently had their licence withdrawn for their polyurethane implants as powdery silicone was found on the implant surface. They are still available from Polytech. There is a theoretical excess risk of breast cancer of 1 in a million with these implants, which is of negligible significance compared to the normal rates of breast cancer of 1 in 8 in a woman’s lifespan. However the heavily textured surface of a polyurethane implant has a higher association of BIA-ALCL (breast implant lymphoma) and although rare at 1 in 1000 to 1 in 10,000, needs to be considered when making decisons.
One modern theory on capsular contracture is that some occurrences are caused by microscopic contamination of your implant by bacteria from the environment or from your skin or the nipple ducts at the time it is placed in the operating theatre. Mr Turton therefore uses an intricate 14-point protocol to reduce this risk, comprising items such as nipple shields, glove changes, alcohol-chlohexidine skin preparation, no-contact implant placement, use of the Keller funnel, betadine, gentamicin, cefuroxime triple antibiotic/antispeptic rinse. Mr Turton has recorded a very low capsular contraction rate in his patients and has never had a case of BIA-ALCL.
Unsightly ripples may appear in the skin on the outside and inside of the breast particularly when the breast is in a dependent position (eg when bending forwards or bending down). This can be due to adherence to the underlying implant, thin tissue coverage, and because implants aren’t 100% taut or solid like a rubber ball. Submuscular (under the muscle) rather than sub glandular (under the breast) positioning reduces this complication and is recommended if there is little natural breast tissue to cover the implant. It is not always possible to prevent this.
Palpable Implants (edges, knuckling, folds, kinks)
Occasionally the top or edge of the implant can be felt as a definite step or fold under the tissue. Submuscular placement reduces this problem but in athletic individuals can lead to cosmetic problems when the chest muscles (pectorals) are tensed. In addition to alternative implant positions, the newer biodimensional implants (also called “anatomical” or “shaped”) have a less pronounced “take off” than the round prosthesis and have a stiffer gel. Whilst they give less fullness in the upper and inner cleavage they can give a more natural shape to your augmentation. These may be particularly appropriate for women with little breast tissue in the upper part of their breasts, where the tissue thickness as measured with callipers on a pinch test is 20mm or less. You should ensure your surgeon discusses these points with you. Folds can appear over time, with capsulation.
Deflation / Replacement
With saline implants (rarely used by Mr Turton expect as part of initial stages of some breast reconstructions where these are called tissue expanders) there is the risk of sudden deflation and even with silicone implants, no women should regard her initial augmentation as necessarily being life long. It is possible that at some stage the silicone implants will have to be adjusted or replaced, although this is often 10-15 years or perhaps longer after the initial augmentation and may be due to contracture or other cosmetic problem rather than just deflation, rupture or gel “bleed” (the name given to the slow diffusion of silicone out of its covering). Given the continued development of new implant designs, it is difficult to predict the expected lifespan but it is certainly longer than with the older designs. With saline implants, deflation can occur slowly or the prosthesis may rupture causing a dramatic deflation. With silicone implants, any loss of integrity in the outer shell is generally compensated for by the fact that the body forms a capsule around the silicone and this is referred to as “intracapsular” rupture. This was not uncommon with the older implant designs and is normally asymptomatic. With the more modern high cohesive gels, it is extremely unlikely that any silicone would travel any distance from this capsule unless the rupture was left for a considerable time. The inside of the high cohesive type is more like a jelly baby rather than runny silicone, but a prolonged period of rupture can see some more liquid type silicone come from the surface. I specifically recommend the use of high cohesive implants. I also recommend that even if you have had no problems with the implants you have them replaced every 10-15 years. The rupture rate is thought to be around 10% within the first 10-years after augmentation.
It should be remembered that having breast implants does not stop the usual involution (shrinkage of breast glandular tissue with thinning) that occurs following pregnancy or with advancing age. Indeed correcting the aesthetic problems caused by these processes is often the reason women request implants in the first place. USS can be used to look for rupture but MRI is more accurate. However, no test is 100% accurate- Mr Turton has operated on patients where the test has suggested a rupture but there hasn’t been one and vice versa. Patients with breast symptoms should be referred to the breast clinic by their GP for urgent assessment.
Scarring and Pain
Obviously, there is always the risk of overgrowth of the scar known as over granulation or extremely rarely Keloid scarring. If the scar is hidden under the breast this becomes less of a problem but it can be quite dramatic. In over 99% of cases, the scar is usually very fine and fades beautifully over the course of a year. Very occasionally women can get an uncomfortable chronic ache on one side or another after augmentation and is almost certainly related to deep scar tissue or trauma to sensory nerves. Most patients report that the breast implants feel part of them by 6-weeks after augmentation and that they are not aware of them.
An unexpected result can occasionally occur leaving a less than optimal cosmetic result. One example is the double bubble appearance. It is slightly more common with pre-existing ptosis (sagging), and with shaped implants are placed under the muscle that are too big or the breast or where there is a constriction to the tissue in the lower part of the breast. It is also more common where the crease under the breast is very well defined as the condensed tissue (fascia) fails to expand naturally over the lower part of the implant. Although it may improve spontaneously over a number of months you may need to pay for revisional surgery.
It is possible that small lumps may appear over the implant due to the reaction of the body to foreign materials such as silicone. However, any lump occurring in the breast whether it has been augmented or not should be appropriately investigated urgently through the NHS breast clinic. Your GP would normally refer you using the “2-week rule”.
If an implant moves too far to the side or becomes too low falling beyond the crease under the breast, it is referred to as lateral or inferior malposition. It means the implant is in the wrong place. It can occur due to problems during surgery- eg when the incision was placed in the armpit it was much more common to find the implant was malpositioned as the surgeon couldn’t check the placement as accurately. However, as gravity affects breast tissue and implants weigh more heavily in the pocket causing tissue stretch, malposition can gradually occur over time although this is uncommon. This may lead to a bottoming out appearance. Corrective surgery will not always work effectively as it can occur again and is also associated with the costs of revisional surgery. Choosing implants that are too big or too heavy will encourage malposition. There is some evidence that the micro polyurethane coated anatomical implants are associated with a lower rate of rotational malposition (personal communication) but there are some difficulties with initial insertion through small incisions. The BLite lighter weight implants are around 30% lighter than standard silicone implants and although they are more expensive being a premium product, patients can consider them for their breast enlargement.
Subsequent Breast Investigations
It is easier to investigate an augmented breast that has had a subpectoral implant (rather than sub glandular) placed as obviously the breast tissue is pushed forward by the muscle. Even with sub-glandular implants, it is usually possible to perform breast examination and a breast biopsy so long as the investigating clinician is aware of the presence of implants. However, implants do interfere with mammography and specialist views are required. Screening mammograms are less sensitive at detecting breast cancers in women with breast implants. A woman should inform her mammographer that they had implants in place so that the proper studies can be done. It is slightly easier to perform mammographic views on a subpectoral implant than on a sub-glandular implant. Prior to augmentation if the woman is of a more mature age or there are any significant risk factors mammography may be performed as a screening investigation. Mr Turton can usually arrange a private screening mammogram in women over 40 who have not got any breast symptoms or lumps for approximately £250.00
Any woman considering augmentation mammoplasty should consider the following points as regards the recent negative publicity over silicone breast implants.
- There is strong evidence that implants do not cause breast cancer.
- There is no evidence that breast implants delay cancer detection if the appropriate investigations are performed.
- ALCL is a rare type of lymphoma that is definitely associated with textured implants. The highest risk so far reported was in Australia at around 1 in 3500 women.
- There is no further evidence that silicone implants cause any form of autoimmune disease or rheumatic disorders.
- There is no evidence that any significant silicone is found in a mother’s breast milk
- The silicone gel of an implant does not normally spread diffusely throughout the body in any detectable amount even if the implant is broken, unless local spread is neglected. The gel can be forced into the surrounding local tissues and produces a non-specific local inflammatory response.
- A general change in the cosmetic appearance may occur with time and you should assume that revisional surgery will be needed at some point in the future.
- A degree of breast sag can occur early after an implant has been placed and initial fullness can therefore decrease- tissue stretching is more common in women whose breasts had become much bigger during a pregnancy. Tightening the skin again is called a ‘mastopexy’ and is an option but involves scars around the nipple, down the front of the breast and across the crease, so as to remove the loose skin.
Breast augmentation remains a viable surgical intervention for women who appropriately select this procedure and are counselled concerning its possible effects. If there is any doubt we recommend that you discuss the options with your specialist.
- If you can feel your ribs in front, underneath or beside your breast you will be able to feel the edge of your implant.
- If feeling the edge of an implant shell could be a problem, do not have an augmentation.
- If you are thin or have very little natural breast tissue you will be more likely to feel your implant or to get rippling. Sub-muscular placement is more likely to reduce this unwanted problem.
- The larger your implant the worse your breast will look over time. A larger implant will stretch your tissues over time and cause more tissue thinning and sagging than a smaller implant. Visible “rippling” may also occur if you chose a large implant relative to your current breast size.
- No augmentation will provide a totally natural breast. Patients often have asymmetry and this persists or can look more noticeable after augmentation.
- It is vital that you arrive at a realistic expectation of what can be achieved with the various breast implants.
- Two weeks before surgery we encourage consumption of pineapple (mainly the core part). This is because there is evidence of an anti-inflammatory effect due to Bromelein contained in pineapple. Always disclose all gels, tablets and medication that you are taking including herbal remedies some increase the risk of haematoma (bleeding) and must be avoided prior to surgery-
- Any anti inflammatory drugs: like Ibuprofen, Neurofen, Diclofenac and aspirin.
- Herbal remedies and vitamins: St John’s Wort , Vitamin E, Vitamin C, Gingko Biloba, Echinacea, Garlic, Willow Bark Products.
- Others: antidepressants, warfarin, steroids, vioxx, or pain killers
- 2-weeks before surgery please avoid: Avocado, Ginger, Broccoli, Garlic, Vegetable oils, Nuts & seeds (high concentrations of vitamin E)
- Please ensure that any issues have been discussed with your surgeon to your satisfaction prior to undergoing breast augmentation.
Note: This information is for general guidance only and represents the views and opinions of Mr Turton, Consultant Breast Surgeon. It should in no way be regarded as either definitive or representing the views of any other surgeon, doctor or institution.
Further useful information is available on the internet from Allergan, one of the leading manufacturers of breast implants, and from the Department of Health detailing safety issues and complications relating to breast augmentation and implants: https://www.gov.uk/drug-device-alerts/medical-device-alert-breast-implants-report-cases-of-anaplastic-large-cell-lymphoma-alcl