Breast augmentation

The breast is read as volume, position on the chest, and the relationship between the two sides. Underdevelopment leaves the upper pole and the outline of the breast short of the frame of the torso. After pregnancy and breastfeeding the skin envelope may still be there while the volume has gone, so the breast looks emptied rather than simply small.

Cup size is not a useful surgical unit on its own. It is a relative measurement between the chest wall and the projection of the breast. Two women with the same cup letter can have very different volumes, and the same implant will read differently on a narrow chest and a wide one. We start with volume and projection, then test how that volume sits on your chest, rather than starting from a cup letter.

Asymmetry is part of the same problem. When the difference is mostly volume, different implant sizes can narrow the gap. When the chest wall itself is different from side to side, the implant can improve the impression without making the two sides identical. Perfect symmetry is not a realistic aim.

The operation is a good match when the main problem is missing volume — either because the breast did not develop fully, or because volume has been lost after pregnancy and breastfeeding — and the skin and nipple position are still reasonable for the planned implant.

It is a weaker match when the breast has descended and the nipple sits low on the mound. Adding volume does not, on its own, put a descended breast back on the chest. That is a mastopexy problem, sometimes combined with an implant, and it should be planned as such. It is also a weaker match when the request is driven by a cup letter rather than by how the breast should sit on your frame.

Weight that is still moving, planned further pregnancy in the short term, and breasts that have not yet settled after breastfeeding all change the plan. In general we like the volume of the breast to have returned to a stable state before we operate; after breastfeeding that usually means waiting until feeding has stopped and the size has settled.

On its own, fat transfer to the breasts is a smaller-volume enhancement. The graft has to gain a blood supply where it is placed, so the amount that can be added in one sitting is limited, and some of what is placed will not stay. It is a better match when the aim is a modest change in outline rather than a clear jump in cup volume, and when there is a donor site that can spare the fat.

Used with an implant, fat transfer is not a second enlargement. It is a way to blend the device into the chest: a little more softness at the upper pole, a less abrupt edge on a thin chest wall, or a small extra on the smaller side when the implants are already as close in size as the pocket will reasonably take. It does not replace good pocket design, and it does not hide a device that is simply too large for the cover available.

Harvest is from areas that already have a useful surplus — commonly the tummy, the flanks, the inner thighs or the inner knee. The fat is separated from fluid and fibrous tissue, then placed in small parcels through fine, blunt cannulas. Access points are the size of a larger needle and do not leave a scar in the sense of a crease or nipple incision. When fat is used with an implant, it is usually placed in the same sitting, after the pocket and the device are in position, so that the extra volume can be put where the outline still needs it.

Longevity of transferred fat is variable. Smoking, a very low body-mass index and a very active lifestyle can all shorten how much of the graft remains. The same planning caveat applies as elsewhere in this practice: a 3D simulation can show a target volume; it is not a photograph of the settled result.

Breast implants have evolved considerably. They can be filled with cohesive silicone gel or with saline. In recent years, implants filled with cohesive silicone gel appear to have the closest correlation with the feel and texture of natural breast tissue, and they tend to be the most popular choice.

It is possible to use both smooth-surface and textured-surface implants, depending on the goal. The surface of the implant influences some of the risks related to breast augmentation. Smooth-surface implants are associated with the lowest risk of breast implant-related illness and of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Smooth-surface implants can only be round. Teardrop-shaped implants require a textured surface to stop them turning in the pocket. That is a genuine trade-off, not a preference of fashion: if a shaped implant rotates, the breast changes shape with it. If the priority is the risk profile of a smooth surface, the implant will be round, and the pocket and the cover of your own tissue become the way we control the upper-pole outline.

The decision about breast augmentation involves three connected choices:

• implant projection and volume

• placement of the scar

• placement of the implant pocket

Some of these choices constrain the others. The starting point is the implant volume.

Using implant sizers, and 3D computer simulation, it is possible to evaluate with each patient the implant volume that would correspond best to the desired outcome. Cup letters remain only an indication of the starting size and of the size being aimed at.

At home it is also possible to get a first sense of volume with a measured amount of rice placed in a stocking and fitted inside a larger-cup bra. That is a crude tool, but it is a useful one: it translates a number of millilitres into something you can see in clothes, rather than leaving the conversation only in cup letters.

3D imaging adds the chest wall and the existing breast shape to that conversation. It can show how a given volume sits from the front and from the three-quarter view, and how a difference between the two sides might be handled. As with facial planning in this practice, the simulation is not a promise of the postoperative photograph. Soft tissue settles. The implant sits in a pocket that your tissues then cover. Those things cannot be rendered exactly in advance.

For access to insert the implants, it is possible to use:

• an incision in the crease under the breast

• an incision on the edge of the nipple

• an incision in the armpit

The incision in the crease under the breast is generally considered more favourable to minimal biofilm around the implant, and it is considered to have advantages for the overall safety and longevity of the augmentation. Biofilm on the implant surface is one of the mechanisms linked to later problems around the device, so the access that keeps that risk lower is not only a scar conversation.

The crease scar sits in a natural shadow once the breast has volume again. The nipple-edge scar can be useful in selected cases but places the access through the breast tissue itself. The armpit avoids a scar on the breast, at the cost of a less direct path to the pocket and less straightforward control if the implant later needs to be changed. Those trade-offs belong in the consultation rather than in a single preferred slogan for every chest.

For the implant pocket, the options are:

• placement under the breast tissue and above the pectoral muscle

• placement fully under the pectoral muscle (subpectoral augmentation)

• the dual-plane technique, which is partly under the muscle and partly under the breast tissue

• more recently, intra-pectoral or intramuscular augmentation, where the pectoral muscle is split in its thickness to create the space for the implant

When the implants are placed fully subpectoral, the augmentation is less compatible with weight training at the gym, and for that reason it has become a less popular choice.

Placement above the pectoral muscle, under the breast tissue, is generally more suitable when there is already a moderate amount of breast tissue and enough natural cover to give a balanced appearance in the upper pole.

The dual-plane technique is probably the most commonly used approach for breast augmentation. In our practice we have also found that intra-pectoral or intramuscular augmentation can produce very nice outcomes. The muscle is not simply lifted off the chest wall as a single sheet; it is split in its thickness so that the implant sits within the muscle rather than entirely under it or entirely over it.

Pocket choice is not independent of volume, of how much cover you already have, or of how you use the chest. A plan that ignores the gym, or ignores a thin upper pole, tends to show itself later.

Our preferred technique for creating the implant pocket uses the ultrasonic scalpel. It is associated with excellent control of bleeding. As a result, the tendency to swelling after the augmentation is controlled to a very high level.

The procedure generally takes 1 to 1.5 hours. It is carried out under a general anaesthetic, although in select cases it can also be carried out under local anaesthetic with intravenous sedation. It is typically a day-case intervention.

After the surgery it is important to wear a supporting bra for the first 6 weeks, to help while the breast shape is settling.

Medical history and current medicines matter. Blood-thinning medicines raise the risk of bleeding into the pocket. Raised blood pressure does the same. Both need specific management before we operate; they are not items to discover on the morning of surgery. Please bring a current list of medicines and previous procedures to the consultation.

Implants are devices that stay in the body. They need a frank discussion of risk and of long-term monitoring, not only a discussion of cup size. The list below is not comprehensive. It is the part of the conversation that belongs on this page because it is specific to breast implants.

Breast implant-associated anaplastic large cell lymphoma is a rare lymphoma that can develop in the capsule around a breast implant. It is not a cancer of the breast tissue itself. The risk is associated particularly with textured-surface implants. Smooth-surface implants are associated with the lowest risk. Any later swelling, a mass, or a fluid collection around an implant should be assessed rather than waited out.

Some women with implants describe a cluster of systemic symptoms — often grouped under the term breast implant-related illness — that they attribute to the devices. The picture is not a single, tightly defined disease, and it is not predicted reliably by one test. Smooth-surface implants are associated with the lowest risk in the current discussion of this problem. The possibility still belongs in the consent conversation, including the fact that some women later choose to have implants removed because of how they feel, not only because of a local complication.

More recently the FDA has issued a notification regarding squamous cell carcinoma in the capsule around breast implants (BIA-SCC). It is a separate entity from BIA-ALCL and from ordinary cancer of the breast tissue. The reported cases are rare. For BIA-SCC, there is no information provided on whether there is any difference between women with breast implants and women without them. That uncertainty is part of what we tell patients: the notification exists, the condition is uncommon, and the data do not currently let us say that the implant is what makes the difference.

As with any operation, there is a risk of bleeding, infection, delayed healing, altered sensation in the skin or nipple, and a scar that is more visible than hoped. Specific to implants are capsular contracture, visible rippling where the cover is thin, implant malposition, and the fact that implants are not lifetime devices. Further surgery — to change, reposition or remove an implant — is a known part of the pathway for a proportion of women, not a sign that the original plan failed in every case.

Asymmetry that was present beforehand is reduced rather than erased. Chest-wall differences remain chest-wall differences, with an implant sitting on them.

This is typically day-case surgery. The early swelling is limited by the way the pocket is made, but the breasts still feel tight and unfamiliar at first. A supporting bra is worn for the first 6 weeks while the shape settles.

Time off work and the point at which exercise, including training that uses the pectoral muscles, can restart are discussed against the pocket that was used and against how you actually use your upper body. Fully subpectoral placement is the least comfortable companion to weight training; that is one of the reasons it is used less often.

Follow-up is part of having an implant, not an optional extra after the first dressing.

Breast augmentation adds volume. It does not lift a significantly descended breast back onto the chest, and it does not correct a wide difference in chest-wall shape. It is not a treatment for stretch-marked, emptied skin that needs a new envelope — that conversation sits with mastopexy, with or without an implant.

Fat transfer is part of the same conversation, not a rival operation. On its own it is a smaller-volume tool. With an implant it can make the outline more natural. It still does not create the same immediate, reliable volume as an implant when that is what the frame needs, and it does not lift a descended breast.

Fees are given after consultation, once the implant volume, the pocket and any additional work — a lift, a change of implant, work on only one side — have been defined. A figure quoted without that plan is not a useful figure.