Which implant and which operation?
This is the question that causes patients most confusion and concern. We at the Aesthetic Breast Surgery Centre have an approach that individualises both the surgical technique and implant choice to the patient. The most important thing we work together on is your desired outcome in terms of shape and size. We then work through what can reasonably be achieved based on your underlying breast and chest wall shape and size as well as your tissue quality, occupation, exercise requirements etc.
There are many different approaches to the surgery and many different implants available. Each can have an influence on the final outcome and it is the experience of over 15 years in this surgery that enables us to work closely with you to pick the right implant and technique. No one technique and no-one style of implant will suit everyone. Also a round implant does not always give a round breast, and alternatively an anatomical implant does not always a tear drop shaped breast!
Shape vs Volume
When breast augmentation first came into being the only option available was to increase the volume of the breast without giving consideration to the shape of the breast. Our approach is to firstly consider your desired breast shape . Very broadly we have described 3 different shapes:
Texan
 
This shape is characterised by the upper part of the breast being filled in a gradual slope towards the collar bone.
This can vary from subtle to a very full breast
 
Gold Coast
 
This is characterised by a step to the upper part of the breast from the chest wall. The upper part of the breast is noticibly rounded as opposed to having the straight slope of the ‘Texan.’
 
This can vary from subtle to a very full breast
French
This is the most ‘natural’ of looks with a soft sloped curve from the chest wall to the breast mound.
 
It helps us to know what your ideal outcome in terms of shape would be. That of course does not always mean that it is achievable but we can work with you knowing your ideals and explaining what might and what might not be attainable and where we have to compromise. It is essential for us to understand the outcome you would not like to have. There are also some situations that an implant will not ‘fix:’
Breast Droop:
The lower part of the breast will often drop after pregnancy and weight loss. An implant can fill out the volume but once all has settled the degree of droop will still be there.
 
 
If you want to address the droop then a ‘breast lift’ will be needed with or without implants. However you may not want scars. Occasionally we can compromise with a tall anatomical implant that fills out the the bottom of the breast as well as the empty upper breast, so avoiding the ‘tennis ball in a sock’ look that can happen if we use a round implant.
 
A round implant used in breast droop, sitting low on the chest wall. If used a tall anatomical implant would have filled in the upper chest hollow and given a nicer result.
The nipple position on the breast:
If your nipple is towards the bottom of the breast then it is not going to change without being surgically moved. However a compromise may be acceptable to you, rather than having the scars of a lift. Again, using an anatomical implant can help by ’kicking up the nipple’ a little.
 
 
Tall anatomical implant used to help ‘kick up’ the nipple
 
If the nipples are lying to the outside of the breast occasionally a shaped implant can be used to fill out the outside of the breast more. However if the nipples are pointing inwards or outwards there is a risk that this can be exaggerated if a large augmentation is chosen and it is often better to compromise on size.
The Cleavage area:
The cleavage is most often determined by the shape of the underlying chest wall and the attachment of the ribs to the breast bone, and how they slope away from the breast bone. If the natural cleavage is wide it is tempting to place the implants closer together but this means that the inner edge of the implants will only be covered by skin and become visible. If the natural cleavage is wide then high round implants will emphasize this giving a railroad look between the breasts. This effect can be softened by using anatomical implants. A narrow cleavage can become a cleft if higher profile round implants are used.
Narrow cleavage
 
Wide cleavage
Subpectoral:
The implant is placed under the pectoralis muscle which runs from the upper ribs and breast bone across the front of the shoulder joint to the upper arm. This muscle is strong and used in upper chest work such as in swimming, push ups etc. The benefit of going ‘under the muscle’ is that it can smooth over the upper edge of the implant avoiding the ‘speed hump’ effect which can be obvious in a high profile round implant, or if you are very thin. A guide is if you can pinch less than 1.5cm thickness of fat where the top of the implant will sit then you may need the implant to be placed under the muscle if a round implant is used.
A downside of placement under the pectoralis muscle is that the lower inner attachment of the muscle needs to be separated off the ribs and breast bone for the implant to lie in the correct position. This is more painful in recovery. If you do a lot of upper body exercise then there is a chance that the muscle activity will push the implant outwards, so widening the cleavage in time, and also the muscle activity might become visible through the skin creating a crease across the breast.
 
 
Round subpectoral mod profile
 
Round subpectoral high profile
 
Subpectoral anatomical
Subglandular:
The implant is put beneath the breast gland in front of the muscle. It has the advantage in that the lower breast can be reshaped with some spreading of the tissue to widen the base or lift the nipple a little. The recovery is quicker than if the implant is placed under the muscle.
 
 
Round subglandular implant
Subfascial:
This is technique which confers some of the benefits of ‘under the muscle’ without having to cut the muscle. The implant is placed under the fibrous outer layer of the muscle and so smooths over the top of the implant.
 
Round subfascial implants
 
Anatomical subfascial implants
 
Anatomical subfascial implants
 
Anatomical subfascial implants
Dual Plane:
This is combination of techniques in which the top of the implant is ‘under the muscle’ and the lower part is over the muscle. This technique is good in women who are relatively thin and have breast fed to help lift the nipple slightly.
 
Dual plane round implants
The surgical access can be from underneath the breast, the armpit or around the nipple. There are pros and cons to each and again the choice will be made together.
There are a huge range of implants available in different shapes and sizes. It used to be that you would choose a round implant of a certain size and that would make the breast that you have bigger, but not have much effect on shape. This is still an approach that is popular and you will see on the internet on many sites. Cohesive gels have meant that an implant can be selected to help influence shape change and so we can be a lot cleverer in getting a better outcome for you. Most patients are suitable for round implants, saline or gel, but there are occasions when an anatomical implant can be advantageous.
If you want a youthful round top this can be achieved with a high profile round implant under the muscle or the same effect can be achieved by using a thicker anatomical implant in front of the muscle.
  
Low, moderate and high profile round implants
 
 
Different shaped anatomical implants with different thicknesses
An anatomical implant can lift the nipple if your breast is a little droopy after breast feeding. If your chest is long with your breasts sitting low this can be disguised with a tall anatomical implant. If your ribs slope down and out a wide U cleavage can be avoided with anatomical implants. They also work well in athletes with well developed pectoral muscles.
The outside coating of the implant is normally silicone and can be textured or smooth. There are also different texturings available too. Implants coated with polyurethane are also available. Implants are filled with either saline or a cohesive silicone gel. There are differences in the amount of fill and how cohesive the gel is. These choices are determined alot by the surgical approach chosen, the look you want and your tissues; also if you have had previous surgery. Ms Corduff will guide you through this at the consultation.
We work with you to try and achieve the result and look that you want using our expertise and experience with the different surgical techniques and wide array of implants available. We use a state of the art 3D imaging computer programme to help plan. As with all these technologies it has limitations in that it does not show how your tissues will redrape over an implant especially with time.
Breast surgery as with all other surgery has its risks and complications. We all need to be prepared for when things do not work out as you hoped and also to work together beforehand to minimise the risks. You need to be fully aware of these issues and know how we will address them so that ultimately you can achieve a good result. In making your decision to go ahead with surgery as well as being aware that your ideal may not be achievable and some compromises may need to be made you need to be able to accept the risks and understand the following issues:
Capsules
This refers to the scar tissue around an implant. Whenever anything foreign is placed in the body, it becomes encased in scar tissue. Breast implants are no exception. Scar tissue can vary, and in some people can thicken, harden and contract. This squeezes the implant so that it becomes more spherical and can ride up, giving rise to an unnatural round appearance. In a few people this can happen quite severely even within a matter of months. In others it can come on quite slowly over years and many patients will have no problem at all. Unfortunately we have no way of testing who is susceptible to this problem. Hardened, contracted capsules are one of the biggest problems associated with breast implants that we deal with.
There are a few factors that have been suggested to be linked with thicker capsular formation;
Collection of blood around the implant
Infection around the implant
Any radiotherapy to the breast
Factors that have been suggested to reduce the risk of capsular thickening;
When the implant is in front of the muscle texturing of the implant shell has been shown by some studies to reduce this risk
Placement of the implant behind the pectoralis muscle
Avoiding any bacterial contamination as the implant is placed in the wound and incision selection
Saline implants have a lower risk than gel implants
This capsule does in fact provide some protection. In women with the old type ‘runny’ silicone gel implants the shells were often thin and with time have ruptured. The gel is contained within this capsule and even though in some patients the implants may have ruptured some time ago the patient has been unaware of this fact as they have not caused any problems. Remember capsule is scar tissue, and is not harmful to your health. However because it looks unsightly and feels uncomfortable you may want it treated.
Mammography
The breast implant is placed behind the breast which spreads out over the surface of the implant. This makes standard mammography trickier to perform. In Australia augmented breasts undergo a displacement technique mammography examination sometimes followed by an ultrasound and a physical examination. Radiographers are specially trained to deal with breast implants so that the chances of missing an early cancer are minimal as are the chances of damaging an implant. One in 11 Australian women will develop breast cancer so regular mammograms are vital. Once you are over 40 you will need to make an appointment with breast screen telling them that you have breast implants so that they can arrange for you to have a proper assessment. Self examination is possibly easier with an implant as all the breast tissue is spread over the implant, so making it thinner and easier to feel any changes.
There are many studies which show that breast implants DO NOT increase the risk of developing breast cancer.
How long do implants last?
Nobody knows the answer to this question. Implants stay in until there is a problem. There is no set time span attached to them and to have them changed means further surgery and a general anaesthetic. The majority of patients with breast implants will need further surgery at some stage, either for correction of capsules or changes in breast shape. It is important to consider the future financial implications of this when deciding on having a breast augmentation. It is reasonable to expect that the shearing forces on an implant will cause the implant shell to weaken and eventually rupture. The only reliable test to look at the integrity of an implant is a MRI examination which is unfortunately not fully covered by Medicare so there will be an out of pocket component to pay. The US FDA is recommending a MRI at 5 years and every 2 years from then on. Again one must consider the long term cost implications of this when considering an augmentation.
Round implants on average will last approx. 10 years, Anatomical implants average 15 years, High Cohesive Gel 100% fill round implant are thought to have a similar longevity to Anatomical implants.
Very rarely as implants wear out tiny amounts of silicone can be transported through the capsule and cause lumps in the breast or armpit. These are very easily distinguished from cancer on testing and do not make you ill. They are an indication that the implants are wearing out and new to be replaced.
Breast Feeding and Pregnancy
You can breast feed after breast implant surgery. Many studies have been done to look at breast feeding after breast augmentation, and all have failed to show any problems with feeding a baby, with gel or saline implants.
The effects of pregnancy and feeding on your breasts still occur. After children the breasts may shrink back to a softer version of what they were. Sometimes the breasts do not shrink back completely and you may consider a tightening of this loose skin or very occasionally replacement of your implants with bigger ones if the volume of your breasts has reduced..
Implant deflation
With time the breast implant shell weakens and in a saline implant this may lead to a deflation. The saline is harmless and rapidly absorbed. Obviously in this event another operation is required to replace the implant.
Feel and Visibility
Gel implants feel the softest and most natural. Anatomical implants are filled with a more solid gel to maintain the shape and so feel thicker. Saline implants can feel like a thick plastic bag filled with water when palpated through the skin. Occasionally patients have reported the sensation of sloshing of the saline. The folds in saline implants are much more of a problem than with gel implants, and these can be visible especially in thin patients. To reduce the visibility they need to be placed behind the pectoralis muscle, but this does not cover the lower outer part of the implant where ‘wrinkles’ may be seen.
The edges of the implant may also be palpable or visible. This is usually hidden under the breast fold, and so is not a big problem. However in thin patients even the upper edge can be visible, so in these patients it is often better to place the implant under the muscle. In thinner patients even with thick gel implants ripples can sometimes be seen.
Infection
This can be disastrous. Most infections occur secondary to bacteria passing in the circulation from another site such as a sore throat, a dental filling, and infected finger etc. Your implants, being foreign in the body, are a perfect environment for bacteria to multiply around especially in the first few weeks following surgery. If you do have a sore throat, dental problems or other infections then in the first 2-3 months I would recommend a course of antibiotics, even though you would not normally need them.
Depending on the severity of the infection intravenous antibiotics, ultrasound guided needling of the infection, surgical wash out, and ultimately removal of the implants with replacement 3 months later may all be required.
Bleeding
You may bleed after the operation, and if this occurs it will mean a return to theatre to stop the bleeding and wash out the implants.
Wound healing
Rarely the the wound comes undone and needs restitching. Sometimes a more extensive repair may be required. There is a high risk of infection in this situation. This is more likely to occur with larger implants and in smokers.
Scarring
Troublesome scars are rare in breast augmentation surgery but every scar has the potential to become thick and red. Nearly all scars will fade out given sufficient time (years) apart from a very few which are true keloids. You must bear this in mind when deciding on incision site placement.
Sensitivity and numbness
It is not unusual for an area of the skin near the incision to be numb after the operation and this nearly always recovers. The nipple sensation may also alter and the nipples may be numb. This nearly always recovers within a few months, but there is a small risk of permanent loss of sensation. Sometimes the nipples can become over sensitive, but with desensitisation will settle down.
Cosmetic Satisfaction
It is not always possible to achieve your desired cosmetic outcome and there is always the chance that you could be disappointed. Please talk about this, because I will endeavour to get as close as possible to the outcome you want even if this means a revision operation. To get your breasts perfectly even is virtually impossible. We all have some degree of asymmetry, and this can become more obvious after surgery. I will point this out to you preoperatively where I can. Very occasionally the implants can lie a little uneven as the swelling goes down and this can be revised if necessary.
Human Adjuvant Disease and other health scares
This is a name that was given to a collection of symptoms including weight loss, joint pains, and fevers in women that had silicone breast implants. No other cause was found for their problems. With this concern about a potential major health risk, silicone breast implants were withdrawn from use in breast augmentation until full scientific studies were completed. An editorial in the New England Journal of Medicine summarized the findings. This disease entity is as prevalent in women without breast implants as those with, and thus no causative link can be made. The TGA has now allowed silicone breast implants back on the market.
There are always going to be ongoing investigations as to possible health risks associated with implants and you will hear of them from time to time. It is important you keep your annual check ups so we can keep you updated on any relevant issues.
Potential Link with Lymphoma
There have been a few notifications of a rare type of blood cancer starting in the breast of women with breast implants and this is under world wide investigation as to whether there is a true link or if this is a coincidental link.
This is the statement put out by the TGA in Australia on their website:
Report of lymphoma associated with breast implants
27 January 2011
On 26 January 2011, the US Food and Drug Administration (FDA) announced a safety communication to warn about an association between breast implants and anaplastic large cell lymphoma. The risk of a patient developing this type of lymphoma is very low.
The Therapeutic Goods Administration (TGA) has been monitoring the situation and has been in communication with the FDA and specialist groups over the past year on the issue. The Australian Society of Plastic Surgeons posted guidance for patients on this issue in March 2010.
Women with breast implants should continue to routinely monitor their breast implants and consult their implanting surgeon if they have any concerns.
At this time, TGA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.
Additional information
- Anaplastic large cell lymphoma (ALCL) is a rare cancer of the immune system that can occur anywhere in the body. According to the Surveillance, Epidemiology, and End Results Program of the U.S. National Cancer Institute, an estimated 1 in 500,000 women per year in the United States is diagnosed with ALCL.
- ALCL in the breast is even more rare; approximately 3 in 100 million women per year in the United States are diagnosed with ALCL in the breast.
- Although there are no equivalent data for Australia, the rate of ALCL is likely to be the same in Australia as in the US.
- An FDA review of the scientific literature published from 1997 through May 2010 identified 34 unique cases of ALCL in women with breast implants throughout the world. Four of these cases are from Australia.
- The 34 cases of ALCL in women with breast implants identified by the FDA is extremely small compared to the estimated 5 to 10 million women who have received breast implants worldwide.
- Nevertheless, based on these data, it is possible that women with breast implants may have a very small but increased risk of ALCL.
- Because the risk of ALCL appears very small, TGA believes that the totality of the evidence presently available continues to support a reasonable assurance that approved breast implants are safe and effective when used as labelled.
- In total, FDA is aware of approximately 60 case reports of ALCL in women with breast implants worldwide. This number is difficult to verify because not all cases were published in the scientific literature and duplications may exist in the reporting.
- Patients with breast implants should continue to routinely monitor their implants in accordance with advice given to them by their implanting surgeon. If they notice any changes, they should contact their implanting surgeon to discuss their concerns.
- The FDA and the TGA will continue to evaluate the available information to understand the nature and possible factors contributing to ALCL in women with breast implants.
Anaesthetic Complications
Untoward anaesthetic events occur very rarely. They include allergies and anaphylaxis, deep vein thromboses, heart attacks, breathing problems, awareness during the operation. This is why you have your operation in hospital with a qualified anaesthetist and full back up facilities.
 On your first appointment you will need to allow about one to one and a half hours. You will be photographed by our practice nurse and these photographs put in a secure computer imaging programme. Then you will be examined by Ms Corduff and she will discuss with you the different surgical techniques and implants. Together you will work out what may and may not be achievable for you and she will give you her recommendations.
It is helpful if you can bring along photographs of what you like as well as what you don’t like to the consultation so that she can have some understanding if your desires and can work out with you what is practically achievable.
Ms Corduff will also explain what complications are associated with breast augmentation and how we would deal with such an eventuality. The potential long term problems of this surgery are also gone into. This helps you to make a fully informed decision. Any decision to undertake such a surgical procedure should not be taken lightly.
It is important that the implant selected is appropriate not only in shape and size but is a correct fit for your chest and tissues. Precise measurements of your chest wall and tissue thicknesses are taken. Using these measurements and understanding the desired shape and size of your outcome the implant selection can be made. These measurements are entered into the computer programme and a rough guide using 3D Estetix imaging can show you how you might look post-operatively. It is very important that you understand that everyone is different in their tissues and the way they will lie over an implant but this imaging is helpful in giving you an idea of how you will look. It is very helpful in demonstrating any chest wall variations that may influence your outcome. We also use ‘sizers’ and place them in a surgical bra to help you judge how you look. You can then discuss whether you would like to be bigger / smaller etc. Using these tools we can then together work out the right implant size and shape for you.
![labels_breasts[2].png](procedures_implants_pics/procedures_implants_clip_image117.gif)
 
Following your consultation you will be given a written summary of what has been discussed. You will be provided with relevant pamphlets and a written estimate of costs. We encourage you to take this home and study it and write down any questions you may have.
If you decide you would like to proceed with surgery then you will be asked to come back for a second appointment. You will see Ms Corduff again and also spend time with a practice nurse who will be able to answer any further questions, and measure you for surgical bras and do the paperwork. It is at this second visit that we make the final decision with you on implant selection. We relook at the imaging and try on sizers. We suggest that you wear a close fitting top so that you can see how you look in clothes. We emphasize that this is only a guide. Unfortunately there is no accurate way of showing you how you will look with the breast implants in place in your body. We encourage you to ask anything that you are unsure about, no matter how trivial it may seem. You are very welcome to come back just for another chat to further discuss the surgery. This does not mean that you have to go through with it!
The surgery takes place in hospital. It is our belief that your safety is paramount both for surgery and anaesthesia. The safest place for you is in a proper hospital that has full monitoring and back up. The surgery will be either in Cotham Private Hospital, Kew, or St John of God Hospital, Geelong. The surgery is performed under general anaesthesia with a specialist anaesthetist giving the anaesthetic and you will be able to go home later that day. The operation takes about an hour and at the end of the procedure local anaesthetic is used to minimize pain. If the implant is placed under the muscle we often use a pain buster. This is a pump that infuses local anaesthetic alongside the cut muscle in the breast wound for 2 to 3 days. It is designed for you to take home and gives great pain relief in what otherwise can be a painful technique. You can expect to go home on the evening of the operation.
If the implants are in front of the muscle recovery is normally within a week, however if the implant needs to be behind the muscle then you will be sore for a little longer, and can take up to 2 weeks to recover. Most patients can expect to be back at work within a week or two. We discuss with you the practical issues such as time off work, managing family etc. Due to techniques used, pain relief needed is basically paracetamol and anti-inflammatories. You are given these on discharge from the hospital plus some stronger tablets ‘just in case’ but these are rarely needed.
The wounds are closed with absorbable stitches and paper tape. If you have anatomical implants your breasts will be taped up for 10 days to prevent rotation. You can shower and dry the tapes with a hair dryer. If you have a pin buster this will be removed 2 or 3 days post-operatively. You will be seen again 10 days to 2 weeks post-operatively and then as often as need be. You will be in a surgical bra for 4 weeks day and night, and then 4 weeks day only. Any concerns, please call the rooms. Ms Corduff is on call day and night for any urgent concerns. We encourage you to come in and see us if you are worried about anything. Usually we would see you at 12 weeks, 6 months and 12 months post-operatively. You will then require an annual check up.
You can go back t o low impact such as walking, bike riding, etc, but all high impact and ‘bouncing’ including running should be avoided for 3 months to allow scar tissue to form to support the implant and minimise the risk of it dropping. If your implant is under the muscle you should avoid heavy chest exercises.
Breast implants do not last forever, they eventually wear out. Your body also changes with time and you may develop encapsulation (a build up of scar tissue around the implant.) You will need further surgery at some stage to change the implants or address changes in your breast tissue. It is important that you understand that you need long term maintanence. We offer an annual check up of your breasts. Once you are over 45 years it is important that you attend breast screen every 2 years for screening mammograms. There is no increase in the risk of breast cancer with breast implants but 1 in 10 women get this disease and so screening for early detection is essential (see below ) Once gel implants have been in for 5 years or more we offer an MRI scan every 2 years to look at the implant itself and check its integrity. The costs of ongoing maintanence of your implants is something that you need to consider carefully as part of your initial decision whether to undergo the surgery.
With respect to costs we provide a package which covers you for all your out of pocket costs for 12 months. That includes post operative care, bras, dressings and any unexpected return to theatre to revise scars etc. Insurance companies do not usually give you any cover for this type of surgery but it would be worth checking with your health fund as they do occasionally contribute towards the hospital costs. Depending on your level of insurance the secretary will be able to estimate the cost of such a package for yourself and provide you with this in writing.
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