The Breast Report

Breasts have been cultural, political and fashion icons, helped launch social movements and started showbiz careers. They come in all sorts of shapes and sizes, and thanks to the marvels of modern cosmetic surgery, breast implant surgery can give you the breasts Mother Nature did not.

Breast implants are available to suit the needs and preferences of just about every patient. Some women seek implant surgery to correct congenital or developmental anatomical abnormalities, while others are striving to repair the toll of age or breastfeeding by restoring their breasts to a more youthful and upright position. Other women simply want to have a larger size bust, which is more proportionate to their overall body size.

Implants may also be required to reconstruct a damaged or missing breast, which has sustained injury, illness or mastectomy. There are countless reasons women undergo breast augmentation and each one has unique importance to the individual.

Careful discussion of your expectations and concerns with your chosen surgeon, along with planning and assessment, can help to achieve a successful outcome and natural-looking results. You should thoroughly discuss your goals and motivations with a surgeon you trust and with whom you feel comfortable.

Listening to your surgeon’s feedback and advice will go a long way in ensuring expectations and motivations are realistic. Satisfaction with breast augmentation results ultimately depends on your understanding of the capabilities and limitations of the procedure.

WHAT MAKES A BEAUTIFUL BREAST?

The assessment of physical beauty varies enormously across both time and cultures. What one person considers sexy or beautiful might be far removed from what another perceives as attractive. However, there remain widely held standards of physical attractiveness, and achieving a positive aesthetic outcome is crucial to the success of cosmetic procedures.

When it comes to assessing the breasts, you may be forgiven for thinking it’s all about size. Indeed, breast augmentation involves adding volume to the bust, but a satisfactory augmentation is about a whole lot more than just adding volume.

‘There is no such thing as the ‘perfect’ breast,’ says British plastic surgeon Dr Paul Banwell. ‘However, there are four aesthetic guidelines that can help surgeons deliver a beautiful-looking breast.’

These guidelines, which refer to the proportions of the upper and lower breast, their slope as well as the position of the nipple were investigated by a group of London Plastic Surgeons at the University College and Royal Free Hospitals. In a study entitled ‘Concepts in Aesthetic Breast Dimensions: Analysis of the Ideal Breast’, Mallucci et al used computer measurements to examine the dimensions and proportions of 100 pairs of natural (non-enhanced) breasts deemed attractive, and identified four features common to all.

‘The study revealed that in all cases the level of the nipple lay at a point 20 degrees above the horizontal where, on average, the proportion of the breast below it represented 55 per cent of overall volume of the breast and above it 45 per cent,’ explains Dr Banwell.
‘In most cases, the upper pole was either concave or straight, and the lower pole of the breast was convex, creating a full curve.’

The UK group also analysed images of the breasts of ordinary women both before and after implant surgery to establish whether, if a breast deviates from these measurements, it becomes less attractive. The answer, they found, was that it does, regardless of size.
However, Dr Banwell is keen to reinforce the importance of tailoring breast shape and size to the individual proportions and circumstances of each patient.

‘A one-size-fits all approach is not appropriate,’ he says. ‘We have a way of assessing the aesthetics we’re trying to achieve with a breast augmentation, but it’s important to do that via a tailor-made approach.’

This involves detailed measurement, careful discussion with each patient and judicious selection of the optimal implant shape, texture and method of placement.

‘Every breast is different in terms of its shape and size and in terms of its characteristics,’ says Dr Banwell. ‘The surgeon has to assess that and then needs to make a judgement based upon the patient’s wishes in terms of what they want to achieve versus what can actually be achieved.’

With so many media influences, today it is even more important to marry your wishes,as the patient, with what is both realistic and achievable. ‘It’s all about having realistic expectations of improvement,’ he says. ‘Communication with the patient is therefore so important. The patient needs to fully understand what’s involved, and if there is any discrepancy between what they want and what can actually be achieved, it’s the responsibility of the surgeon to point that out.’

The education and knowledge of patients has changed in the past decade or so, and they are becoming increasingly discerning about the shape and type of implants they want. However, the most common request remains: for breasts to be ‘natural-looking’.
With an experienced and skilled surgeon and the right expectations, you can look forward to the most natural-looking, aesthetically pleasing breast augmentations for your individual requirements.

BREAST IMPLANT ESSENTIALS

1. Implant shape

Choosing the right implant is dependent on your existing breast size, shape, symmetry and projection, body type, and your personal preferences.

There is no one breast implant shape that is best for everyone. Your surgeon is the best resource for determining what breast implant is best for you and your body type.

Round implants

Round implants are circular with an even projection of volume. They are a good choice for those who want more fullness in the upper part of the breast and tend to give greater cleavage. Many surgeons agree that round implants are typically the best choice for those patients with well-shaped natural breasts who desire a straightforward breast enhancement.

Teardrop implants

Teardrop, or anatomical, implants more closely resemble the natural shape of a breast, gradually sloping downwards to produce an attractive straight line from the collarbone to the nipple. Teardrop implants tend not to be as full as round implants but because they are fuller in the lower half they can also provide greater projection in proportion to the size of the base, making them particularly suitable for women with little natural breast tissue. Mild elevation of the breast and the nipple can also be achieved, making them particularly suitable for women who have mild droopy or tuberous breasts.

2. Implant size

Breast implant sizes are designated by their volume, typically ranging from 90 to 900 cubic centimetres (cc), or by their weight. One gram of silicone is equivalent to slightly less than 1ml (1cc). The higher the number, the larger the implant.

They are also made with different diameter bases to suit different widths of chest wall and with low to high profiles (amount of forward projection). For this reason, each manufacturer produces a number of ‘styles’.

It’s important to take your natural breast width into consideration. Your surgeon will measure the base diameter of your chest to determine the ideal width of implant. If the implant istoo wide for your chest, you may get ‘webbing’ between your breasts (symmastia) or too much ‘side boob’. If the implant is too narrow, it will not ll the chest appropriately and be dif cult to create a shapely cleavage.

The choice of implant projection is to a large extent a personal one. A woman with adequate breast tissue and a shape she is happy with may opt for a low- pro le implant that will simply increase the size of her breasts. Another patient seeking to create cleavage, or a patient with some degree of sag, may prefer a high-pro le implant that can help achieve these results.
Your surgeon will take into consideration the width of your chest and breast tissue and advise you on the most suitable implant size and style for your individual anatomy.

3. Implant material

This next crucial factor looks at the type of ll (saline or silicone) as well as the shell of the implant wall (smooth or textured).

Silicone vs saline

Saline and silicone breast implants both have an outer silicone shell; however they differ in material, consistency and techniques used for placement. Both types of implants have their own advantages and risks.

Silicone gel-filled implants are used more commonly in Australia. Silicone implants contain a cohesive gel, designed to mimic real breast tissue. It has a slightly firm, non-runny consistency, which can give a more natural feel. As the gel is not liquid, the risk of dispersal if the implant ruptures is minimised. It also typically maintains its shape better than a saline implant, especially in the upper part of the implant.

Saline-filled implants use a medical-grade saltwater solution, which makes the implant feel like a water-bed. This can be controlled to an extent by the volume of ll in the implant. If implant rupture occurs, the saline is absorbed by the body. However, saline implants feel rmer than silicone implants and have a higher risk of visible folds and ripples.

Unlike silicone gel implants, saline implants can be lled through a valve during surgery. Because of this, the insertion of the implants generally requires a smaller incision than that associated with silicone gel implants. The amount of ll can also be adjusted after
surgery, which is not possible with xed silicone gel implants.

Smooth vs textured

Implant shells can be smooth or textured. Smooth-shelled implants are easy to insert and may make the breast move and feel more natural than a textured shell in certain patients. However, they have increased risk of capsular contracture (hardening of the breast), which is a common reason for re-operation.

Textured implants have a thicker shell and the very nature of their surface means they can grab onto and adhere to the surrounding tissue, causing less friction between the implant and breast pocket and therefore helping to reduce the risk of capsular contracture. Many surgeons also believe it offers them greater control over the ultimate shape of the breast.

Round implants come in smooth and textured shells, but anatomical implants have textured surfaces only to allow for better integration with the surrounding breast tissue. The implant may still ip or move and distort the appearance of the breast, so the surgeon must be experienced with this type of implant.

The polyurethane foam coated implant provides a texture specifically designed to reduce rates of capsular contracture. The foam coating means the collagen bres around the implant do not line up, and are less likely to slide over each other and contract. Instead, the bres assemble in a circular pattern around the foam and are unable to form a hardened capsule. There are some differences in the surgical plan of foam-coated implants; for example the pocket size generally needs to be bigger than usual.

Regardless of the type of implant women choose, the shape, texture and size can be customised to re ect her individual body type and aesthetic goals.

4. Incision site

The three main incision options are the inframammary crease (under the breast where it meets the chest), periareolar (around the nipple) and transaxillary (inside the armpit).

Inframammary

The inframammary incision is by far the most common breast augmentation incision used today, made in the crease under the breast close to the inframammary fold. The surgeon creates a pocket for the breast implant, which is slid up through the incision, then positioned behind the nipple.

This incision offers the best exposure for visualisation and allows the implant to be placed over, partially under or completely under the chest wall muscle. The scar is hidden in the crease under the breast.

Periareolar

For the periareolar incision, an incision is made just beyond the areola, which is the darker area of skin surrounding the nipple. The incision should be made at the very edge of the areola where the dark tissue meets the lighter breast tissue, which makes the scar least visible.

Similar to the inframammary incision, the periareolar incision allows the surgeon to work close to the breast.

It is possible for the surgeon to easily and precisely place the breast implants in various positions in relation to the chest muscle. However, this is the only incision that involves cutting through breast tissue and ducts, and sensitivity in the nipple may be reduced.

Transaxillary

The transaxillary incision is made in the natural crease of the armpit and a channel is created down to the breast. This may be performed with an endoscope (a small tube with a surgical light and camera in the end) to provide visibility. The implant is inserted and moved through the channel into a prepared pocket.

The greatest advantage of an underarm breast augmentation incision is that no scar is left on the breasts. The scar is virtually invisible in the armpit fold and lack of tension generally makes for straightforward healing.

The transaxillary site is relatively far from the breast, where the surgeon needs to create a pocket for the implant, so visibility is limited. There is also a higher incidence of the implant being positioned too high and a greater risk of breast asymmetry after surgery.

5. Implant placement

The placement of breast implants has a signi cant impact on the nal outcome of breast augmentation and therefore it requires individual consideration.

Experienced surgeons base their implant placement decisions on factors such as the patient’s quantity of breast tissue, natural breast size and symmetry, dimension and shape of the chest wall, amount of subcutaneous fat and quality of breast skin.

Generally, there are three placement options: subglandular (in front of the muscle), submuscular (behind the muscle) and dual plane (partially under the muscle). There are pros and cons for each position.

Subglandular

The subglandular pocket is created between the breast tissue and the pectoral muscle. This position resembles the plane of normal breast tissue and the implant is placed in front of the muscle. Sometimes the implant is covered by a thin membrane, the fascia, which lies on top of the muscle. This is called subfascial placement.

This position is suited to patients who have sufficient breast tissue to cover the top of the implant. This procedure is typically faster and may be more comfortable for the patient than submuscular placement. There is generally less post-operative pain and a shorter recovery period because the chest muscles have not been disturbed during surgery. The implant also tends to move more naturally in this position.

However, subglandular breast implants may be more visible, especially if the patient has little breast tissue, little body fat and thin skin.

With subglandular implants, there tends to be more of a pronounced ‘roundness’ to the breasts, which may look less natural than those placed under the muscle, but this is a matter of personal preference.

Submuscular

The implant is placed under the pectoralis major muscle after some release of the inferior muscular attachments. Most of the implant is positioned under the muscle.

This position can create a natural-looking contour at the top of the breast in thin patients and those with very little breast tissue. The implant is fully covered, which helps to camou age the edges of the implant, as well as rippling. With this placement, data has shown there is less chance of capsular contracture occurring.

There may be more post-operative discomfort and a longer recovery period. The implants may appear high at rst and take longer to ‘drop’.

Dual plane

This is where the implant is placed partially beneath the pectoral muscle in the upper pole, where the implant edges tend to be most visible, while the lower half of the implant is in the subglandular plane. This placement is best suited to patients who have insuf cient tissue to cover the implant at the top of the breast but who need the bottom of the implant to fully expand the lower half of the breast due to sag or a tight crease under the breast.

This position minimises the rippling and edge effect in thin patients while avoiding abnormal contours in the lower half of the breast. Generally, this placement is able to achieve a more natural shape to the upper portion of the breast instead of the ‘upper roundness’ that can be more common with subglandular implants. However, it involves more complex surgery, which if not performed correctly may result in visible deformities when the pectoral muscles are contracted.

WHAT ARE THE RISKS?

While breast augmentation is typically a predictable procedure, all surgery carries some level of risk. Complications arising from breast augmentation can include the following.

CAPSULAR CONTRACTURE

Capsular contracture, or hardening of the breast, is thought to be the most common complication of breast implant surgery. It can occur at any time but more commonly in the months immediately after surgery.

During surgery, a pocket is made for the implant in the breast tissue. After the implant has been inserted, the body naturally forms a capsule of brous tissue around the implant. This lining, or capsule, is formed by the body’s living tissue, and is the body’s natural response. The capsule allows the implant to look and feel quite natural. In some cases, however, the capsule begins to tighten, causing a shrink-wrap effect and squeezing the implant that it surrounds. Depending on the severity, the breast can feel rm or hard, become distorted and cause pain.

It is not actually the implant that has hardened – the shrinking of the capsule compresses the implant and causes it to feel hard, but if the implant is removed it is still in its original soft state.

Though the exact causes of capsular contracture are unknown, there are factors that may lead to this complication, including seroma (the development of extra uid around the implant), haematoma, infection and smoking. Another contributing factor is the placement of the implant above the chest muscle. When the implant is placed below the muscle, capsular contracture is said to be typically less likely to occur.

To treat capsular contracture, there are both surgical and non-surgical options, although generally most cases of capsular contracture will require secondary surgery to remove the implant. If the implants are replaced, to prevent reoccurrence a new pocket should be made as fresh tissue needs to be in contact with the implant.

FURTHER SURGERY

It’s important to understand that breast implants have a limited life span and, before going ahead with breast augmentation, patients must accept that more surgery may be required initially or in the future to address complications, remove or replace the implants.
Additionally, the size of the original implants may become less suited to a woman’s body over time, due to hormones, pregnancies, weight gain and menopause.

INFECTION

Infection is a serious risk of any surgery and occurs when wounds become contaminated with microorganisms, such as bacteria or fungi. When infection occurs, it generally appears within six weeks of the procedure. Most infections can be treated with antibiotics, but in the worst cases the implant may need to be removed and the infection eliminated before the implant is replaced.

It’s important to keep an eye out for signs of infection, which may include redness at the site, fatigue and fever. Increased pain and swelling are also typical signs of infection but, because these symptoms are typical of all breast surgeries, they can be difficult to detect.

RIPPLING

Rippling occurs when the lling inside the breast implant moves, creating a winkle or fold on the outer shell of the implant which then
can be felt by the patient, or which becomes outwardly visible. Rippling can also occur when adhesion to the envelope restricts its movement.

Various factors govern the likelihood of rippling, including the implant type, texture and position. It occurs less with silicone gel-filled implants, smooth-surfaced implants and those that are positioned under the chest muscle.

If it occurs, the appearance of rippling is dependent on the patient – their physique and the thickness and quality of their skin. If there is little muscle or fatty tissue to cover the implant, any rippling that results will be more noticeable. Rippling generally appears on the outer and bottom sides of the breast and in the cleavage.

IMPLANT DISPLACEMENT

Displacement refers to the implants moving out of their desired position, and is more prone in women who have teardrop-shaped or very high-pro le implants. Displacement may occur due to the implant being misplaced in the tissue pocket, or from excessively stretched tissue, or trauma. Displacement can occur at any time after the procedure, and will generally need to be surgically corrected.

INTERFERENCE WITH MAMMOGRAPHY

Depending on where the implant is placed, breast augmentation may interfere with the ability of an x-ray to ‘see’ all the breast tissue, and therefore can hinder the success of a mammogram. Women with breast implants should therefore choose a facility that has technicians experienced in obtaining reliable mammograms from those who have had breast augmentation.

Repeated studies have shown there is no delay in the diagnosis of breast cancer in women with breast implants compared to women without implants.

Women should inform technicians of the age of their implants before mammography, as the age of the implant increases the risk of rupture during mammography.

Recently, there have been media reports about a rare type of cancer linked to breast implants: anaplastic large cell carcinoma (ALCL).
Breast-implant associated ALCL is not the same as breast cancer; it is a rare type of lymphoma that develops in the uid surrounding breast implants, not in the breast tissue itself.

Current expert opinion is that the risk of contracting breast-implant associated ALCL is about one in 5,000 women with implants. By comparison, the risk of breast cancer is one in eight.

The majority of cases are cured with the removal of implants and the brous capsule around them from both breasts.

If there are changes in your breasts associated with breast implants, and especially if there is general swelling or a lump, contact your specialist for further investigation.

IS BREAST IMPLANT SURGERY RIGHT FOR YOU?

The psychology behind the decision to have breast implants is one of the most important aspects of the procedure. A good candidate for breast augmentation is mentally and physically stable and understands the reality of what this surgery can achieve.

Often women seek cosmetic surgery as a means of fulfilling emotional needs or resolving problematic body image issues. Any cosmetic procedure affects the patient on a psychological level just as much as on a physical one and it is important to remember that if a woman with low self-esteem elects to undergo surgery in the hope she will feel better about herself, she is likely to feel disappointed with her surgery. While breast augmentation can help boost a woman’s con dence, she will not bene t from surgery if she thinks it is the cure-all for every aspect of her life.

Many women view their breasts as a vital component of their gender identity, as the female breast is one of the prime symbols of femininity, motherhood and sensuality. However, women are notoriously critical of their bodies and some may be especially so of their breasts. When contemplating breast augmentation, ensure it’s for the right reasons. CBM

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