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Breast implants – what are they for?

Breast implants in plastic surgery

Breast implants can be made of natural body tissue or synthetic (man-made) materials. About 80% of breast implants are for cosmetic reasons. The remaining 20% are breast reconstructions after surgery, often for breast cancer.

Natural tissue breast implants

Natural tissue implants are usually only attempted on women who are having breast reconstruction surgery. This will often be after all or part of the breast has been removed as a treatment for breast cancer. Natural tissue is rarely used for women deciding to have breast implants for cosmetic reasons, as the procedure is complicated, has an increased risk of side-effects, and may leave scarring on other parts of the body.

Tissue can be taken from either the back (latissimus dorsi reconstruction) or the stomach (rectus abdominus reconstruction). It is then implanted in the chest and molded to form a natural breast shape. The procedure uses the skin, fat and muscle of another part of the body to form the breast. It is not possible to create a new breast simply by injecting body fat into the chest. The surgeon must remove and redirect muscle and blood vessels to keep the implanted tissue alive and healthy.

Most women who have natural tissue implants are left with a neat scar running from hip to hip (rectus abdominus reconstruction) or in a horizontal line across the lower back (latissimus dorsi reconstruction). The scar is usually placed low enough to be concealed underneath underwear or a bikini.

Women who choose to have a natural tissue breast implant may also consider nipple reconstruction. If the existing nipple is unaffected by cancer and the implant surgery is performed immediately after a mastectomy (breast removal surgery), it may be possible to transfer the nipple to the reconstructed breast.

If this is not a possibility, a new nipple may be created from skin and tissue from another part of the body (often the upper thigh).

Some women may prefer to use a synthetic stick-on nipple or have a nipple tattooed onto the reconstructed breast.

Synthetic breast implants

There are two types of synthetic breast implants available in the UK; silicone gel and saline solution. Both are contained in a firm, silicone shell, which is made from a type of elastic called elastomer. Modern synthetic implants have a textured surface to reduce the risk of hardening and deforming (capsular contracture).

Silicone gel implants may be filled with a firm, jelly-like silicone or a softer, fluid silicone.

The firm silicone keeps its shape even if the implant ruptures (tears) inside the body. This reduces the risk of the silicone entering the bloodstream. Soft silicone is less likely to wrinkle, making it feel more like a natural breast.

Types of breast implants

Silicone implants have received a great deal of media attention in recent year, with some reports of unsafe or dangerous side effects. In the beginning of 21 century, the government commissioned an Independent Review Group (1) to look at the available evidence about the risks of silicone breast implants and publish a report based on its findings. The group found no evidence that silicone implants pose a risk to women.

Saline breast implants are filled with a sterile salt-water solution, which can be pre-filled or filled through a valve during implant surgery. As the solution is similar in consistency to natural body fluids, it can be absorbed safely into the body if the implant ruptures. Some women find that saline implants decrease in volume over time and are more likely to deflate. Saline implants are also more prone to wrinkling and can feel or appear less natural than silicone implants.

When breast augmentation should be done

Breast implants should only be considered by women who have taken medical advice from a qualified cosmetic surgeon. The operation is a surgical procedure performed using general anesthetic and carries the same risks as other surgical operations.

It is therefore important that women choosing implants are not being influenced by anyone else and have made an independent decision.

You may not be able to have breast implant surgery if:

  • you are under 18 years of age,
  •  you are pregnant,
  • you are breastfeeding,
  • you have malignant or pre-malignant breast cancer that has not been fully treated, or
  • you have an active infection anywhere in your body.

Breast augmentation

It is also worth considering that women rarely go through their entire lives with the same implants. Implant removal is often necessary at some point for various reasons, despite the fact that modern implants (those used in the USA since the early 1990’s) appear to have no risk of rupturing (tearing). If implant removal is necessary, the decision must be made whether to have further implant surgery or to treat the removal as permanent.

Why breast augmentation can be necessary

Women decide to have breast implants for a number of reasons. Many are simply unhappy about the size or shape of one or both of their breasts, while others have implants to correct abnormalities that have been present since birth or to reconstruct the breasts after essential surgery.

While there is no specific medical advantage of breast implants, they can have great psychological benefits and help to improve self-esteem and confidence. Women who choose to have breast implants as part of breast reconstruction, may recover more quickly from the psychological effects of undergoing a full or partial mastectomy (surgical removal of a breast).

The majority of breast implants are performed to make the breasts larger. However, implants can also be used to make drooping breasts firmer and to even out unequal size or unevenly shaped breasts.

How breast augmentation is performed

Types of breast implants

The first step is to arrange an appointment with your GP. Your GP will be able to answer any initial questions you may have about what the operation involves and advise you on the best course of action taking into consideration your personal health and medical history.

Your GP will then refer you to a surgeon who will be able to answer your questions in more detail and provide you with all the information you need to make a final decision. It is a good idea to take notes or even record the conversation at this stage, and a good surgeon will not mind you doing this.

Your surgeon will then usually send the details of the intended operation to your GP and to the National Breast Implant Registry, who record information about breast implant surgery in the UK.

The operation will be carried out while you are under general anaesthetic. It may be performed as day surgery (you will be allowed to go home the same day), but usually you will need to stay in hospital overnight.

The following is a general guide to how the operation takes place, although individual surgical practice may vary.

During the surgery, an incision (a surgical cut) is made in or near the breast and the implant is inserted either between the breast and the chest muscle or behind the chest muscle.

Subglandular

Implant placement between the breast and the chest muscle is called a subglandular placement. The main benefits of this type of procedure are that the surgery and recovery are shorter and less painful, and further operations to remove or adjust the implant are easier. However, this type of placement carries more risk of the implant hardening and deforming (capsular contracture) and can cause difficulties with mammography imaging.

Submuscular

When the implant is placed behind the chest muscle, the procedure is called a submuscular placement. This type of surgery may be more uncomfortable and the recovery time may be longer. However, the breast appearance is often more natural and problems during mammography are less likely.

Types of incision

You may also choose, in consultation with your surgeon, what type of incision to have. This will depend on the shape of your body and where you would prefer the scars to be. The are three types of incisions commonly used to insert breast implants:

  • Periareolar.

This incision is made around the nipple and leaves minimal scarring. However, women who have periareolar incisions are more likely to experience difficulties breastfeeding at a later stage.

  • Inframammory.

The inframammory incision is used most often and involves making a small cut underneath each breast. While the scarring may be more obvious, the incisions are very small and should not appear unsightly. The inframammory incision should not cause any problems with breastfeeding.

  • Axillary.

An axillary incision is made in the armpit area, around the side of the breast. Axillary scars can be more visible than with alternative types of incisions, although they do not generally cause difficulties when breastfeeding.

Breast implant surgery for reconstructive purposes is slightly different than implant surgery for cosmetic reasons. For example, the surgeon may decide to use a tissue expander, a silicone outer shell that is inserted under the chest tissue and gradually inflated with injections of saline (sterile salt-water solution).

Once the expander has stretched the skin and muscle enough to create plenty of healthy new tissue, it is replaced with a permanent implant.

Shapes of breast implants

Women who have had a single (one breast) or double (both breasts) mastectomy may choose to have immediate or delayed reconstruction. Immediate reconstruction involves implant surgery at the same time as the mastectomy is performed.

Some women prefer this as it can help them to recover faster, psychologically.

However, there are often increased risks of infection and other complications such as deflation and the operation and recovery times may be considerably longer.

Delayed reconstruction is carried out some time after the mastectomy is performed. This often provides women with the opportunity to consider their options more carefully and can be advisable if your surgeon thinks that there may be complications with the initial surgery.

You may be advised to consider delayed reconstruction if you are still undergoing other treatment such as chemotherapy or radiotherapy.

It may be possible for women who have had a mastectomy to have reconstructive surgery without the use of implants. This type of reconstruction is called tissue transfer surgery and involves using tissue, skin and muscle from another part of the body to mold a new breast.

Results of breast augmentation

It is important that you discuss your expectations with your surgeon before you make your final decision to have breast implants. Some women may have unrealistic expectations about what the surgery will achieve and may be disappointed with the results.

The results will depend on your shape to begin with, what kind of effect you want to achieve and what size and type of implants are used.

Make sure that you have discussed the following questions with your surgeon before having the operation:

  • What scarring will I be left with?
  • What size will my breasts be after the operation?
  • What kind of implant will be used?
  • What type of incision will be made?
  • Will the implant be placed under or above the muscle?
  • How much bruising and swelling can I expect after the operation, and how long will it last?
  • Will I be able to have the implants removed if I am not satisfied with the results?
  • What will the consequences of having my implants removed be?

In most cases, the scars left by breast implant surgery are very small and fade over time to become almost invisible. However, up to one in 20 women are left with red, thick or painful scars that can takes years to improve in appearance.

Recovery after surgical breast augmentation

You will almost certainly have some swelling and bruising immediately after the operation and will need to take some time off work to rest and recover. Your breasts may feel hard to the touch and you may experience some painful twinges or general discomfort. It is not unusual for these symptoms to last for a few weeks.

You may be worried that the implants look unnatural but is usual for the breasts to appear quite taut or rigid immediately after surgery.

They will start to appear more natural in a few months, as the breast tissue, muscle and skin stretches to accommodate the new implants.

You may also experience changes in feeling in your breasts, with different areas becoming more or less sensitive than they used to be. Although most of these sensation changes are temporary, some may be permanent and this is not unusual.

Any severe pain or symptoms that you did not expect should be reported to your surgeon. These include:

  • Unusual, unexpected or excessive swelling,
  • Deflated breast/s,
  • Smelly or badly colored discharge from the wounds,
  • Severe pain in the breast/s, and
  • Feeling of intense heat in the breast/s

Risks of a surgical breast augmentation

Breast implant surgery is carried out under general anesthetic and carries the same risks as other invasive surgical procedures.

There may also be a risk of:

Capsular contracture

This is when the scar tissue that naturally forms around the breast implant begins to shrink, causing the implant to harden and, in some cases, begin to deform. This is estimated to occur in around 1 in 10 women who have had breast implant surgery and requires further surgery to remove and replace the implant.

Rupture

This is when the implant splits or tears and was much more common before, when improved breast implants were introduced. The danger from ruptured implants is that the contents of the implant will escape from the shell into the breast, causing small lumps called siliconomas. Siliconomas can cause tenderness or pain in the breast and the implant may need to be removed. Very occasionally, silicone has been found in tissue around the breast, muscle or arm.

Firm, silicone gel implants are less likely to cause these complications as they are designed to keep their shape even if the implant shell ruptures.

Infection

Any kind of surgical procedure carries a small risk of infection. Antibiotics are used to treat infection. However, if the infection cannot be successfully treated with antibiotics, the implant may need to be removed and replaced.

The risk of infection is higher if a large hematoma (collection of blood) or seroma (collection of watery fluid) is present immediately after surgery. The body is able to absorb small hematomas or seromas but may need the help of a surgical drain to remove larger ones. Surgical draining can also increase the risk of deflation or rupturing.

Deflation

This means that the implant has deflated and reduced in size. It can occur as a result of complications after surgery such as capsular contracture and rupturing.

Mammography interference

Subglandular placement (when the implant is placed between the chest and breast muscle) may cause difficulties with mammography as it can cause an obstruction.

Occasionally, implant surgery can cause small amounts of calcium to form around the implant, which may be confused as tumors on a mammography.




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