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Despite its apparent simplicity, correct decision-making in breast implant surgery takes years of experience and a thorough understanding of breasts anatomy, breast ageing and breast physiology. All breasts are different, and they all sit on different shaped chest walls, with differences in skin, support, nipple position and many more factors. Therefore, getting the best result takes meticulous planning, with excellent communication between surgeon and patient, to understand what outcome can be achieved. And importantly, one size does not fit all! I have had plenty of consultations with the sister of a previous breast augmentation patient of mine, to whom I have given completely different recommendations, as their bodies are different – often to their surprise having expected exactly the same as each other.
Naturally, size decisions feature high up on the list of priorities, but it is important to understand that an implant needs to fit your breast like a hand fits a glove to give the optimum possible outcome. Therefore a “biodimensional” planning approach (one in which the advice given is based on careful measurements of your breast and chest wall) is best. From this a choice of 2, 3 or 4 implant sizes may be ascertained, and then it can be up to you to decide which to pick. However, always bear in mind that the bigger the implant and the higher the profile (projection, or how far it sticks out), the less natural and more augmented the result will be. There is also evidence that larger heavier implants will have a long-term effect of gradual thinning of the breast tissue.
In addition to the above, a thorough understanding of the scientific evidence in the plastic surgery literature to support the advice given is needed by the surgeon. In this blog, I thought I’d provide a brief update on the latest evidence. As well as being interesting, it might help explain some of the advice I might give patients coming to see me about breast augmentation.
Implants come in a variety of shapes and their surfaces (shells) may vary too. Each has a role in the right situation. Regarding the implant surface this may be smooth shelled, textured silicone or polyurethane; the shape may be round, anatomical (tear drop) or even conical; and the implant may be silicone or saline (although silicone is far superior!).
Breast implant shape
So how does this affect decision-making? Regarding shape, studies have shown it is impossible to determine whether an implant is round or anatomical (shaped) when analysing breasts that have been augmented. The idea that shaped implants give a “more natural” appearance is now old hat and debunked. A predictable “natural” result is achieved by careful implant selection after thorough analysis of an individual’s breasts.
However, shaped implants are an excellent choice for certain breast shapes and dimensions, An anatomical implant, in my practice, is particularly used for breasts with low lying nipples, or those that may be of short height and broad width.
This is NOT true!! A round implant does not necessarily mean a less natural shape than when using an anatomical implant and vice versa
Breast implant surface
What about the implant surface? The latest FDA studies have shown some really interesting results, that have changed the way we view things from a long term safety perspective: if an implant is placed under the breast (on top of the muscle) it should be textured to minimise capsular contracture (the problematic long-term complication of hardening of the natural scar tissue around an implant). However, when the implant is placed under the muscle (or dual plane) smooth and textured implants have similar low rates of capsular contracture. However, the smooth implants confer the advantages of less rippling (as the implant does not adhere to the inside of the pocket) and more natural behaviour (as they move to the side when you lie down, like a normal breast, rather than sticking up). Therefore in my practice, smooth round implants in a dual plane (partially under the muscle) is my preferred option wherever possible.
Polyurethane coated implants have shown low long term rates of capsular contracture, but, in my opinion, the data is not significant enough for me to change to using them routinely, and they have other issues that deter me from adopting them into my practice.
Demonstration of a textured implant in the left hand and a smooth implant in the right
Regarding decision making about scar location, there are a variety of ways an implant can be inserted – through scars in the breast crease, around the areola or in the armpit. A breast crease incision has the lowest long-term incidence of capsular contracture (compared with armpit and nipple incisions) and it allows the best access and most accurate control during surgery, so this is my preferred choice. I will sometimes use a scar around the areola if I am performing surgery in that area anyway, but not often.
Fortunately, infection rates are extremely low in breast augmentation surgery. However, the main theory behind capsular contracture is that there is a very low grade “sub-clinical” infection that causes a scar tissue reaction. Therefore studies have shown that an antibiotic irrigation solution to wash the implants before they are inserted lowers the risk of capsular contracture in the long term. There is no need to be on a course of oral antibiotics after breast augmentation surgery – those given at the time of surgery are adequate. So all my patients have a combination of a powerful intravenous antibiotic as well as an antibiotic pocket and implant wash during surgery.
As mentioned at the beginning, one size does not fit all, so a bespoke plan must be made for anyone considering breast augmentation. I would highly recommend seeing a surgeon who regularly performs breast augmentation, and ensure you see examples of their work. Ideally, your surgeon should be performing at least 25 primary breast augmentations a year to ensure they have good experience. I hope these thoughts have been helpful in deepening your understanding about breast enlargement surgery. There are many other aspects to consider, and future blogs will cover other areas.
If you would like any further information on breast surgery or to see one of our Consultant Plastic Surgeons, please contact us on 01892 536960 or email us at firstname.lastname@example.org