Since the start of mankind’s history, the female breast has not only been the symbol of fertility but of femininity as well. It is not surprising that thousands of art pieces – paintings and sculptures – are dealing with this symbolic body part, recording the beauty ideal of each era.
The development of the 20th century plastic surgery allowed of the aesthetic reshape of the breasts, which aims to correct the congenital shape and size defects on one hand and to restore the consequences of modified forms and sizes caused by the natural processes of life, including breastfeeding, weight changes and ageing.
The size and form of the breasts can be modified by several types of surgery methods:
- Augmentation, the increasing of breast size means the implantation of implants of different forms and sizes
- Mastopexy or breast lift aims to modify the position and shape of the sagging breast
- Breast reduction reduces the size of oversized breasts, including a breast lift as well
In order to reach the aesthetic goals, we often need a combination of the above interventions: for example, the breast lift may also include the increase of breast size by using implants.
Silicone implants were first used to increase breast size in the United States in the mid-1960’s (1964). Since then, this surgery type has become one of the most frequent aesthetic plastic operations. During the last decades the shape and structure of the implants have changed and developed significantly, modifying the implantation technique as well.
Aims of the operation:
- Increase of hereditary, congenital small breasts
- After nursing, the replacement and augmentation of the decreased breast volume
- The correction of the position and shape of sagging breasts
- In case of significant sagging, together with a mastopexy, to modify the size and the form
- The correction of significant size difference (asymmetry) between the breasts
(Implants are also used to reconstruct breasts after mastectomy, in case of congenital or hereditary lack of breasts, or if breasts were lost in accident.)
Who is suitable for this operation?
WE RECOMMEND the operation to the following patients:
- Who have decided to visit a plastic surgeon as a result of their own psychic intentions, on the basis of realistic self-evaluation.
- Who have been considering this decision for a long time, and the decision is well thought over.
- Who have gained enough and controlled information, partly from acquaintances and friends already undergone similar operations and partly from thematic sites available online.
- Who have visited at least two or more plastic surgeons and have gained information on the conditions of the operation personally.
- Who intend to achieve psychic harmony instead of utmost bodily perfection.
WE DO NOT RECOMMEND the operation to the following patients:
- Who want to undergo this operation following somebody else’s recommendations
- Who have decided to undergo this operation as a result of a sudden idea
- Who think that breast augmentation is a fashion trend which should be followed
- Who request this operation as a result of rivalry with other women
- Who would like to follow or copy their favourite stars
- Who have psychic illnesses with body image distortion (e.g. anorexia nervosa)
- The operation shall be considered thoroughly in case of patients having other psychic illnesses
- Who have illnesses increasing the risks of the operation or anaesthesy significantly.
During the last four decades, the structure and form of the implants have changed significantly. The most up-to-date implants have the following characteristics:
- Have several layers, impermeable, cohesive silicone gel filled in a solid silicone shell. This means that if the shell is damaged (for example in case of an accident with rib fracture), the thick silicone filling remains at its original position, does not deflate, and does not leak into the neighbouring tissues.
- The implants keep their form, regardless of body position.
- Rugged, ”textured” surface, which, establishing adequate connection to the neighbouring tissues, decreases the risk of capsule thickening.
(The distribution of implants filled with soy oil which were introduced some years ago have been prohibited, the distribution permits of the implants filled with “hydrogel” and covered with “titan” film have been withdrawn by the relevant authorities. The implants containing physiologic saline solution are not used anymore due to their disadvantages.)
Modern implants include round ones (low, moderate and high profile), as well as “teardrop”-shaped or anatomic implants as well. The latter type also includes low, moderate and high profile ones.
When selecting the adequate implant, we shall consider the anatomic characteristics and the requirements, beauty ideals of the patient. This is true for both the shape and the size of the implant.
In most cases, all mammaplasty operations (excluding the small corrective interventions) are performed in general anaesthesia.
According to the professional rules, the anaesthesia shall be followed by a 24-hour monitoring in hospital.
(Some doctors perform the operations in local anaesthesia. I don’t find this a good practice to follow.)
During the operation, we insert the previously selected implant beneath the breast tissue (directly beneath the glandular tissue, beneath the membrane of the chest muscle, partially or completely beneath the chest muscle) with several different possible incisions.
Armpit or ”axillary” implantation:
The cut is positioned high in the armpit. The pocket receiving the implant can only be formed adequately with endoscope. The sizes and forms of the implants are limited. The axillary cut – if the arms are raised and the armpit is shaved – may be noticeable in case of inadequate scar healing. At the same time, this is the one and only operation method for patients who are prone to form keloid scars.
The incision is made on the areola, in the transition area between the dark and the lighter skin in a semicircular shape (if the operation includes a breast lift as well, in a circular shape). In some cases, the pocket is formed by an incision through the breast tissue. This technique may only be used if the areola is wide enough. Implanting through the glandular tissue has a higher risk of infections.
This method is mainly recommended if the breast augmentation is performed together with a breast lift.
The most frequent intervention. The incision is made at the edge of the breast tissue, in the natural crease. In case of a good recovery process, the scar is hardly noticeable and hidden. The pocket receiving the implant is well observable and can be formed easily. Better symmetry may be achieved. The risk of infections is the lowest compared to other similar operations.
(At some places, the operation is performed through an incision crossing the areola, bypassing or dividing the nipples. In both cases the implantation is done through the glandular tissue, increasing the risk of infections, and affecting the future operation of the glands inadequately. Its only advantage is the unnoticeable scar.)
Inserting the implant
Direct subglandular implantation:
The implant is inserted beneath the breast tissue, above the chest muscle and its membrane.
Its advantage is that the implant is moving together with the breast tissue, following the position and sagging of the breast. The disadvantage is, however, that in case of a thin breast tissue, the implant may become palpable or noticeable. Rippling is more frequent.
This method is suitable for patients having adequately thick, compact and flexible breast tissue before the operation.
The whole implant or the upper half- one third is placed beneath the chest muscle.
This method is recommended to patients with less own breast tissue. As the breasts are sagging, the inserted implant may form a noticeable contour on the chest, which might be an aesthetical problem. The implantation results in a longer recovery time and more pain.
The advantage is that the implant is inserted in a hidden place, the contours cannot be seen, rippling is very rare.
This technique has been spreading for the last years. The implant is inserted beneath the membrane of the chest muscle (fascia), deeper than beneath the glandular tissue but the chest muscle remains intact.
This method combines the advantages of the previous two techniques. However, rippling may occur more frequently, less often than beneath the glandular tissue but more often than beneath the chest muscle.
In my operation practice, I am using textured surface modern implants filled with cohesive gel. In two-thirds of the cases the implant used is anatomy (teardrop)-shaped. The incision is most often located in the crease, I only use the areola cuts if the operation includes a breast lift as well. Most frequently, the implant is inserted in the subfascial layer.
Similarly to other surgery interventions, plastic operations also might have some complications!
Some of the complications are general operation complications, while some of them are specifically related to the insertion of the implant.
In other words, there are some complications arising directly during or after the operation, while other inconveniences or complications are observed later.
The rate of the complications related to the general anaesthesia is low, given the fact that mainly healthy people plan to have aesthetic operations. The congenital or other illnesses may increase the risk of complications. This shall be revealed by the thorough examination performed before the operation. If the risks are too high, the anaesthesiologist may not recommend the intervention.
The rate of infection risk is lower than 1%.
Harmful bacteria might reach the surgical site in two ways: during the operation, which might be caused by the non-observance of hygienic rules, or by using tools or materials without perfect sterilisation (this should not happen theoretically). During the post-operation days through the inadequately handled drains, through the bandage if it is not kept adequately clean, through the incision or through the bloodstream, originating from an inflammation inside the body.
The latter one shall be revealed by a thorough examination performed before the operation.
If the infection happens during the operation, the inflammation symptoms can be noticed 4-6 days after the operation, while in other cases the symptoms are developing in 2-3 weeks. Later no bacteria might reach the surgical site from the outside.
In case of infection, the inserted implant shall be removed!
Despite adequate astringent procedure it might happen that blood starts to escape from the smaller vessels during the post-surgery hours and the blood becomes trapped around the implant. If the inserted drains are not able to remove the pooling of blood and the bleeding cannot be stopped by medications, a new operation shall be done. During this, the haematoma shall be removed and the bleeding shall be stopped.
Seroma (fluid accumulation):
Serous fluid may accumulate around the implant during the post-surgery days, weeks or even years later.
This may happen after smaller haematomas as a result of the gore becoming fluid, or as a consequence of the so-called sterile inflammation if the bacteria present on the surface of the skin enter and proliferate in the surgical site. This does not present any of the symptoms of the clinical infection. The latter is considered to cause capsular contracture.
Bigger seromas shall be removed, and if the seroma was caused by bacteria, the implant may also be removed temporarily.
When breast implants are placed into the body, the body forms a thin lining around it which aims to separate the foreign material from other tissues of the body. This is a normal procedure.
If the connective tissue around the capsule thickens, we can talk about capsular contracture. This might include several steps. In the first phase the breasts feel firm, but no complaints or changes in form are caused. If the problem is more serious, the change of the form can be noticed from the outside, the breast may feel painful.
The rate of the capsular contracture is no more than 3-4% of all breast augmentations. This may happen some months postoperatively or even years later. The risk is decreasing as the time passes by after the implantation.
The capsular contracture may be caused by several known and unknown factors. The known factors may be avoided by adequate surgical technique, by selecting high quality implants, but the risk cannot be decreased to zero.
If the capsule is causing problems (both aesthetical and physical), a new surgery might be needed. During this, the capsule is removed, the implant is changed and inserted into a different layer.
Sometimes rippling may occur in certain body positions several years after the implantation, even permanently, including wrinkles running towards the sides of the breasts. The risk is higher for thin patients with loose and thin breast tissue, mainly if the implant was placed beneath the glandular tissue.
No surgery is needed if the problem is only present sometimes causing minor aesthetical deviations. If the complication is constant and causes problems, a new surgery might be needed, including the replacement and relocation of the implant.
Change of form:
The form might change even without a capsular contracture if the inserted implant turns around its axis. This problem mainly happens with teardrop-shaped implants. The reason: the pocket receiving the implant is oversized compared to the loose environment.
A new surgery may provide a good solution including the potential replacement and relocation of the implant, as well as the narrowing of the pocket.
Injury of the implant:
The modern implants wear well and keep their intact structures for a long period of time. However, they are sensitive to bigger interventions of sharp objects. The implant might be deflated by an injury caused incautiously during surgery or later as a consequence of serious impacts reaching the body. The implant might be deflated during an accident by a broken rib if the patient suffers rib fracture.
If the implant is filled with cohesive silicone, the filling does not leak in this case. However, the damaged implant needs to be replaced.
(Formerly, the implants filled with saline solution deflated without any external impact due to the failure of the filling valve. This is why such implants are not used anymore.)
The following inconveniences are not surgery complications but might accompany the operation.
The pain sensation is subjective, the same impact has different effects in two people. Generally, we can say that the breast surgery does not result in severe pain but sensitive people shall expect some days of inconveniences.
Changes in skin sensation:
Similarly to other surgeries breaking the connections between the tissues, the surgery site may experience temporary or permanent sensational disorders or lack of sensation. This is true for all breast surgeries. Over-sensitiveness (pain when touched) or numbness can both occur. After some months, the thin nerves grow back to the surgery site and normal sensation returns. Sometimes the sensation disorder may remain permanent.
The healing of the cut and the scar are basically congenital characteristics. Even if we perform the same surgery technique and incision, in one case an unnoticeable, thin and white line represents the incision some weeks after the surgery, whole in other cases 1-2 years can pass by having a purple-red, thicker scar line. These both are natural processes. Besides these, we can talk about abnormal scars – keloids – as well. This is not only an aesthetic problem but pain is also present. If the history of the patient shows this kind of complication, the operation shall be considered. New surgeries may increase the growth of the keloid (scar tumour), thus we should avoid it. The scar tumour might be decreased with medicines, shrinking back to the skin level and causing no pain but the aesthetic result is still questionable.
Sagging of the breasts:
After the insertion of average sized implants, if the skin and the connective tissues are flexible enough, we do not have to consider the possibility of sagging (ptosis). Oversized implants may cause ptosis due to the excess weight.
There are two types of warranties. One of them is provided by the producer of the implant, while the other covers the surgery ad the results.
The manufacturers guarantee that the implant produced by them is distributed in undamaged ad sterile packaging and is suitable for implantation. Several companies offer replacement warranties if the implant needs to be replaced due to capsular contracture or for other reasons.
Generally we can say that the surgery fee includes the costs of new operations needed right after the original surgery. These include: new surgery due to haematomas, costs of other interventions needed to avoid general complications and the fees of corrective surgeries (e.g. replacement of implants removed due to infections).
Warranty does NOT include the cost of the following surgeries:
- scar correction surgeries
- replacement of the implant due to capsular contracture (in certain cases the manufacturer provides the implant, only the direct costs of the surgery shall be paid)
- surgery and replacement of implant due to rippling and wrinkling
- future breast correction due to sagging
- replacement due to false selection of size