Breast Augmentation is a very popular operation worldwide and, in recent years, the popular myth has grown up that it is a minor procedure without complications. In reality, it is a major operation and you must ask the right questions of your Plastic Surgeon, make the right decisions for you and ensure you have enough time to recover properly after surgery. Only if all these pieces of the puzzle fit together will you minimise the risk of complications and maximise your satisfaction with the procedure. This booklet will help you make the right choices and understand the procedure better. If you have any questions after reading the booklet, please ask your BAPRAS Surgeon, who will look after you to the best of their ability.

Introduction
Who is this information for?
This booklet is for women looking for more information about breast augmentation – or breast enlargement. It aims to give an overview of what is involved and the expected outcomes. It will also go through the possible problems associated with breast augmentation and breast implants.

What is breast augmentation?
Breast augmentation is enlargement of the breast. This is usually done by inserting an implant beneath the breast to make it look larger. It will enlarge breasts that have always been small, but can also be used to fill out breasts that used to be larger. An example would be breasts that have emptied out, perhaps following pregnancy. Breast augmentation will reshape breasts to some extent. Breast augmentation can also be used to correct breasts that are of unequal size. Patients who have breast augmentation tend to be very pleased with the results. However, it is essential that you understand what can and can’t be achieved, the limitations of surgery and the longterm consequences of having breast implants.

How will this booklet help me?
This booklet suggests how you should go about the process of consultation and getting advice about a possible operation. It discusses who might be suitable for surgery, and explains who might benefit most from it. It explains the surgery and what is involved including the various techniques that can be employed. It gives detailed information about breast implants and alternatives. It explains the recovery process and gives an idea of what to expect after the operation. It explains in detail the possible risks, difficulties and complications that can arise after breast augmentation surgery. It explains what you can expect in the long term if you go ahead with breast augmentation. Whilst this booklet is quite detailed it is intended to complement a consultation with a surgeon who can explain what is appropriate for you and what you might expect from surgery. Every patient is different and it is unwise to go into cosmetic surgery with a fixed view about what you want done and how it will turn out. Hopefully, following a consultation with the surgeon who will be doing your operation, and this booklet, you will have put yourself in a position to make an informed decision.

What is my next step?
It is recommended that you consult your GP if you are considering breast augmentation. Your GP will be able to refer you to a local plastic surgeon to discuss your options. You don’t need to travel far and wide to have this surgery. A local private hospital will have plastic surgeons who work there and possibly also in your local NHS hospital. Some patients will choose to approach a private hospital or clinic without seeing their GP. If you do this you should ensure that your initial consultation will be with the surgeon who will be doing the operation. Your surgeon will normally seek permission to write to your GP following your consultation. You should expect to pay a fee for your consultation.

At your first consultation you will be asked what is bothering you about your breasts and about your expectations from the surgery. You will be examined and some discussion will follow about implant shapes and possible sizes. If you are considered suitable you will be told about the operation, the expected outcome and possible risks and complications. You should be given a ‘cooling-off’ period of at least 2 weeks before having surgery, and you will usually be offered a second consultation.

How can I check my surgeon’s qualifications?
You can check in advance that the surgeon is on the specialist register of the General Medical Council (GMC) in plastic surgery. This is done on www.gmc-uk.org; click the link ‘Check a doctor’s registration status’, type in the surgeon’s name and/or GMC number and their details will appear. Under ‘Status’ they should be listed as “Registered with a licence to practise; this doctor is on the specialist register”. Under ‘More details’ ‘Specialist Register entry date’ you will see the specialty under which the surgeon is registered. You can also check on the BAPRAS website (www.bapras.org.uk) by clicking the link ‘Find a surgeon’ to see if the surgeon is a Full Member of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS). There are other membership categories of BAPRAS, but only Full Members are on the Specialist Register for Plastic Surgery. Many patients use internet search engines to look up doctors and services. You should bear in mind that information accessed in this fashion may be promotional in nature. Those listed may have paid for such a listing. A prominent listing is not a measure of service quality. Sometimes doctors other than plastic surgeons offer breast augmentation and other cosmetic surgery. It is entirely reasonable to ask your surgeon about their qualifications, experience and registered specialty.

How much will it cost?
Before your consultation it should be possible to obtain an approximate cost for the surgery from your local private hospital or the surgeon’s secretary. After your consultation you will be sent a quote regarding the cost. You should receive this in writing. You should avoid any deal in which you are asked to pay any form of nonrefundable deposit. In addition, you should not be offered a financial inducement to proceed, and you should avoid any such offer or time-limited deal. Even an agreement to refund a consultation fee if you proceed with surgery is considered an inducement and against GMC guidance. It is appropriate to be offered a package price that covers the entire process and the cost of treating any complications arising in the initial weeks after the operation. Many hospitals will also offer a satisfaction backup, agreeing to manage dissatisfaction as well as complications for a specified period. You should establish exactly what your quoted package includes. As with most things in life you get what you pay for and the cheapest deal will rarely be the best. Cosmetic surgery involves a significant financial commitment and you should ensure you are getting what you need. We would advise against taking out loans to finance cosmetic surgery. You should only proceed when you have the financial means to do so. In fact wise counsel in respect of breast augmentation is to have the funds needed twice; one amount is used to pay for the operation and an equivalent amount is put away in savings so that it is available in the future should revision surgery be needed.

Is this surgery available on the NHS?
Cosmetic breast augmentation is generally not available on the NHS so you will have to consult a plastic surgeon as a private patient and pay for the operation yourself. There are some exceptions to this rule. In some parts of the country the local NHS rules will allow consultations and operations for patients with small breasts in certain circumstances. These exceptional circumstances vary from region to region. In general, patients with absent breast tissue, very little breast tissue or marked asymmetry might be considered exceptional. Your GP will be able to tell you about the local rules in your area.

 

Implant techniques
Why is there a ‘cooling-off’ period?
Breast augmentation is a lifetime commitment. It is essential that you are making the appropriate choice and understand all the implications of the surgery you are considering. You may need revision surgery as the years go by and you need to be prepared personally and financially for this. Nobody needs an urgent breast augmentation. If you are not offered a cooling-off period, or you are put under pressure to proceed, you should walk away and look elsewhere.

What surgery is available, and what techniques are involved?
Breast enlargement involves the placement of an implant under the patient’s breast tissue to enhance the size and shape of the breast. The implants are usually inserted using an incision placed under the breast at the crease, but can also be put in via an incision in the armpit or around the nipple. Implants can be placed either directly behind the breast (known as sub-glandular placement), or behind the breast and chest wall muscle (known as sub-muscular placement). Your surgeon will advise which is appropriate for you.

Behind the breast
The insertion of implants behind the breast is considered to be the simplest of the available enlargement procedures, and less likely to cause significant discomfort. This route is also effective for patients with slightly drooping breasts.

Behind the muscle
The insertion of implants behind the breast muscle provides more padding, which is a key consideration for slender patients and those with very little breast tissue where the edge of an implant may be detectable through the skin. The muscle provides extra cover and helps to hide the upper half of the implant, and so is often recommended for those who have very little breast tissue and whose ribs may be visible through the skin.

Dual plane augmentation
When slender women with slightly drooping breasts seek enlargement surgery, surgeons often combine these two routes, placing the implants partly behind the breast and partly behind the muscle. Through this combined approach surgeons try to give patients the benefits of both techniques. This is called a dual plane augmentation.

What type of implants should I have?
The outer layer, or shell, of all implants is made of silicone. Some implants have an additional polyurethane coating. The shell can be filled with either silicone gel or saline. Implants have been used for breast augmentation since the 1960’s and, when made to appropriate specifications, the evidence suggests they are safe to use. You should ask your surgeon exactly which type and manufacturer of implant will be used and why. In general, wise surgeons will use tried and tested implants made by reputable manufacturers. Most patients will be offered silicone gel filled implants. They tend to feel the most natural, can readily be made teardrop-shaped and are durable. Saline filled implants tend to feel less natural, folds and ripples may be more visible and they have a risk of deflation. All other filler materials have been withdrawn for use in the UK. The two most important decisions to make about your implants are their size and shape.

 

About the implant
Implant size
Implants are supplied by volume in millilitres or weight in grams. It is not possible to just pick a cup size and ask your surgeon to supply that. At your preoperative consultation your surgeon will assess your chest wall, your existing volume of breast tissue and how much skin is available to accommodate the implant. Your surgeon will be able to give you an idea of what implant size is appropriate for you. Your own view is also important since in most patients a range of possible implant sizes could be used and it is helpful if the surgeon knows if you would tend towards the larger or smaller end of that range. Your surgeon will not be able to guarantee you a cup size. In general the larger the implants that are used and the slimmer you are the less natural-looking your breast augmentation will be. The implant will be less obvious if it is not oversized and if you have a reasonable amount of your own tissue to cover the implant.

Implant shape
Implants can either be round or teardropshaped (otherwise known as anatomical). Round implants provide a bigger volume at the top of the breast, and by design are the same width as they are tall. With teardropshaped implants, it is possible for the surgeon to choose the width and height separately thus enabling more control of the eventual shape. With either of these options, there are varying degrees of projection, depending on whether the desired effect is to look subtle or more noticeably pert. In general your surgeon will advise the best shape option to fit your frame and your desired outcome.

Are silicone implants safe?
Breast implants are made from medical grade silicone. This is a polymer that has been tried and tested and is used in a number of other medical devices. Silicone is also used in frequently occurring household items such as shoe polish, hair conditioner, and kitchen implements. As far as we can tell this material is safe. All of us already will have small quantities in our bodies, apparently without affecting us. If you have breast implants, small quantities of silicone come off the surface of your implants and will be taken up in the lymph glands in your armpit and will end up in your liver. Silicone is inert in the body, you cannot react to it or reject it. There is no association between breast augmentation and breast cancer or cancer of any other part of the body. Neither is there any proven association with any other illness. There have been recent reports of an illness called anaplastic large cell lymphoma (ALCL) in association with breast implants, but it is sporadic and extremely rare, it does not seem to be as serious as ALCL occurring elsewhere. Over time the implant shell may fail and the silicone gel may leak out. Whilst this may cause symptoms and will result in re-operation to remove and replace the implants there is no evidence that a ruptured breast implant causes ill health.

What does the operation involve?
Breast enlargement surgery takes about one-and-a-half hours, and is usually done under general anaesthetic. The operation itself involves accessing and creating the pocket into which the implant will be placed, using one of the insertion routes mentioned above: breast-crease, armpit or nipple. Once the pocket has been created, the surgeon may insert a trial implant to check that the size chosen is appropriate. The trial implant is removed, the definitive implant inserted and the incision wounds are stitched. You may be able to go home the same day, but many patients will spend one night in hospital. Postoperative pain in these procedures is easily controlled. Your chest will feel tight. Your breasts and ribs below your breasts will be tender. Patients will be mobile from day one and should be back to full exercise within six weeks. Patients are recommended to take around one to two weeks off work immediately after the operation in order to ensure you recuperate fully. At first your breasts may look too high and the skin appear tight. This tends to settle down over the first six weeks or so after the operation as a more natural shape emerges. Most patients are delighted with the change that has been achieved, but some find their new shape is difficult to get used to. You should be prepared for this possibility. The nature of the scars will depend on the technique that has been used. Scars tend to be quite red in the first six weeks, changing to purple over next three months and then fading to white. Most patients will form good quality scars over time. Abnormal scarring is rare in breast augmentation surgery.

 

What complications can occur?
All operations are associated with risks. Fortunately, serious complications are rare with this operation. However, sometimes unavoidable complications will occur.

Bleeding
Some patients will bleed into the space around the implant. This usually happens immediately after the operation, but occasionally occurs up to two weeks later. If it happens the breast becomes very swollen and tight. You need to go back to the operating room and have the blood removed and the bleeding stopped. The implant can be retained. You are likely to spend an extra night in hospital and will be rather more bruised than expected, but things should settle down in time and it is unlikely to adversely affect your outcome from surgery. The risk of bleeding is less than 1%.

Infection
This is the most problematic complication of breast augmentation. Again it is rare, occurring in less than 1% of cases. It will usually become apparent over the first two or three weeks after the operation that things are not settling down as expected. The breast will be swollen and tender, it may look red, there may be wound discharge, and you may feel unwell with a raised temperature. If this occurs you need to contact your hospital or surgeon who should see you again. Sometimes a mild infection will settle down with antibiotics, but usually this will not be enough. Most patients with an established infection around the implant will need to have the implant removed. A new implant cannot be inserted immediately. It is important to wait between three to six months for the effects of the infection to resolve before a new implant is inserted. The package price you pay for your breast augmentation should cover the cost of dealing with bleeding or infection.

Adverse capsular contracture
In every patient the body forms a scar or capsule around the implant that fixes it in place. In most people this is not obvious and the breast feels soft and looks natural. In a proportion of patients (for reasons that are not fully understood) this scar contracts around the implant and makes it feel firmer than a normal breast. In most patients they are not too troubled by this as the breast still looks satisfactory. However, in some patients the breast becomes unacceptably firm and may take on a spherical shape. It may also become tender. If this happens you should see your surgeon again to discuss the situation. Sometimes if the contracture is not too bad then you may decide to stay as you are. It is certainly safe to do this. Some patients will elect to have the implant removed and the capsule released/removed. This is called a capsulotomy or a capsulectomy. A new implant can then be inserted. Hopefully this will improve matters. The risk of noticeable firmness is up to 10% of all breast augmentations, but most of these patients will not need revision surgery. The chance of having a re-operation for any reason is about 1% a year. So, after 10 years about 10% of women will have had a re-operation. Adverse capsular contracture is the most common reason for re-operation. In addition, once capsular contracture has happened once it is more likely to happen after the revision operation. Changes to the feeling of the breasts Most patients will get some alteration in the sensation in their breasts after breast augmentation surgery, the most usual symptoms being some numbness near the scar, and oversensitivity of the nipples. This oversensitivity gradually settles down, but usually takes several months to do so. A few patients will get numbness of the nipples. If numbness persists for more than six weeks after the surgery it is likely to be permanent. Being able to feel or see the implants under the skin In particularly slim patients it is to be expected that you will be able to feel the edges of the implants. This is an inevitable consequence of the operation and will not improve with time. It is much less likely in patients who start off with a reasonable amount of their own tissue covering the implant. As time goes by some people will be able to see or feel ripples or folds in their implants perhaps when leaning forwards. For most patients it is best to simply accept that this has occurred and is a limitation of the surgery. It can be difficult to correct with another operation. In some patients the situation can be improved by injecting small amounts of your own fat under the skin. This is called lipomodelling or lipofilling. Occasionally a more marked crease can be felt. This can be a sign of adverse capsular contracture.

Implant failure
Implants are made to be very tough, but the shell can eventually fail and a leak can occur. This is not usually a serious event, in many cases the leak is contained within the capsule and the patient does not notice a problem. Patients may, therefore, have an implant that has failed and be unaware of it. This does not appear to be harmful. Some patients will notice a change in the size, shape or consistency of the implant. A lump might appear and the breast look swollen. If these things happen you should seek advice. A scan will usually be carried out and if this suggests the implant has ruptured, removal and exchange of the implant will be advised. There is no universally agreed replacement schedule for breast implants, and it is unusual for there to be a need to exchange breast implants before ten years. If you have not noticed any change in relation to your implants then you do not need regular follow up or regular scans. However, you may develop one of the problems described above and may need or choose to have revision surgery at some time in the future. For this reason anyone having breast enlargement should be prepared both personally and financially to have surgery again at some time in the future.

Other reasons for reoperation
Most patients are delighted with their breast augmentation, but a few decide as time goes by that they want to be bigger so will choose to have reaugmentation with larger implants. • With time augmented breasts, just like natural breasts, will change shape. In the case of most women this will not trouble them, but sometimes the shape is not as good as it was and further surgery might be considered. • Very occasionally teardrop-shaped implants can rotate behind the breast. The patient will notice a marked shape change, usually evident on waking in the morning. The implant will usually rotate back to its correct position by itself or can be gently pushed back in to position. This may happen only once, but if it becomes a repeated problem re-operation will be needed. Rotation is more likely in patients who have quite large implants inserted to correct markedly droopy breasts. • Some patients get intermittent swelling around their breast implants. This can be associated with fluid around the implant. If it occurs scans will usually be recommended to ensure the implants are intact and to see if there is a fluid collection. Further tests or implant replacement may be recommended if the problem persists.

Many of these more long-term problems will not be covered by any package that you buy at the time of your breast augmentation. Neither should you expect the NHS to provide your future treatment. You must be prepared to pay for consultations, scans and further surgery if needed.

What are the long-term consequences of breast augmentation?
If you have a breast augmentation as a young woman you must accept that you are likely to have implants for many years. You may well have further surgery for any of the reasons outlined above. An operation that gives you more youthful looking breasts may seem quite appealing at the time, but will this be something that suits you when you are older? Breast implants push your natural breasts forward and so do not make it any more difficult to examine your breasts for lumps. They do, however, interfere with mammography. A mammogram is an X-ray of the breast looking for signs of a breast cancer that you cannot feel. It is used as a screening test in the UK from the age of 50 years. The X-rays cannot pass through the implant so some of the breast tissue is obscured. If you are called for a screening mammogram you need to tell the mammography service you have breast implants. They may scan you at a different centre and take special views. Submammary implants are more of a problem than sub-muscular implants. The more of your total breast volume that consists of implant the greater the problem with mammography. If you have a breast augmentation you will have to accept that this will reduce the sensitivity of a future mammogram. Several myths have arisen about implants such as it being unsafe to sunbathe, or unsafe to fly in an aeroplane. Neither of these two activities present a problem. There is no need to massage your breast implants. Indeed this is not recommended with modern textured surfaced implants. Routine implant replacement after a specified time is not recommended. Replacement is only advised if you are unhappy with the appearance or have developed a problem.

Are there any alternatives to breast augmentation?
The only alternative surgical technique to enlarge the breast is lipofilling. This is a relatively new technique where fat is removed by liposuction from another area of the body such as the hips or thighs and injected into the breast area. Only a relatively small amount of fat can be injected so patients will require multiple episodes to bring about a worthwhile effect. Some of the fat is absorbed in the initial weeks after the operation, but fat that lasts beyond this time will bring about a permanent enlargement. This is a much more gradual approach compared with implant based breast augmentation, but does avoid a breast implant. Since it is a relatively new technique we cannot be entirely sure how effective it will be in any given patient. Your own fat is the only substance that can be safely injected into the breast. Other materials have been tried, and then withdrawn from use. Do not allow anyone to inject anything other than your own fat into your breasts.

Do I need a breast uplift operation?
Some patients are bothered by droopiness of the breasts. If you are bothered by droopiness and are happy with the size of your breasts then you do not need a breast augmentation, but may be offered a breast uplift operation called a mastopexy. This is a quite different operation that involves lifting the position of the nipple and breast tissue and tightening the skin of the breasts. There will be an incision around the areola and possibly incisions passing vertically downwards and underneath the breasts. So, the scarring is more obvious than simple breast augmentation, but no implant is used. All breast uplift operations will tend to droop again as a consequence of time and gravity. Mild degrees of droopiness can be improved by a breast augmentation alone. Sometimes your situation falls between these two options and your surgeon feels that you may need a breast augmentation and mastopexy. In most instances it is best to do one or the other first and then see what result can be achieved with the proviso that the other operation can be done at a second stage if needed. However, in some patients it is clear from the outset that both operations will be needed and your surgeon will agree to do both at the same time. This requires careful preoperative planning and counselling. This is difficult surgery. The results are not always entirely predictable in terms of size and breast shape.

 

Further information

BAPRAS’ cosmetic surgery checklist

Visit the patient information section of the BAPRAS website
Department of Health – Cosmetic surgery
BAAPS – British Association of Aesthetic Plastic Surgeons
GMC plastic surgery specialist register

A downloadable copy of this page is available here.

Authors
Joe O’Donoghue (Editor) – Consultant Plastic Surgeon, Newcastle Upon Tyne
David Coleman – Consultant Plastic Surgeon, Oxford
Anita Hazari – Consultant Plastic Surgeon, East Grinstead
Andy Malyon – Consultant Plastic Surgeon, Glasgow
John Scott – Consultant Plastic Surgeon, Glasgow