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| Under investigation: Breast augmentation |
14-Apr-2005 |
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By Dr Marcela Cox
1. What issues should be
discussed with women
before referring them for
breast augmentation?
nIt is useful to establish why the woman wants the procedure, how long she has been thinking about it and whether she knows anyone who has had it done.
nThe breasts should be examined prior to referral to ensure there is no obvious pathology and to help with discussion about the options.
nThe size of the implants. Most surgeons help patients decide what size implant is most appropriate for them in relation to their height and body habitus. The usual size increase is two bra sizes, for example, from cup size A to C, or B to D. The greater the size increase, the higher the risk of long-term complications, such as capsule formation around the implant and contraction.
nPerimenopausal women who have a significant amount of ptosis of their breasts need to understand they will probably need additional mastopexy (breast lift) surgery to achieve a satisfactory result.
nPregnancy and breastfeeding can alter breast size and shape, so women who have started, but not yet completed, having their families should be advised that it is better to wait until childbearing is over before having breast implants.
2. What options are there
for breast augmentation?
There are three standard issues that surgeons discuss with women in the preoperative counselling consultation:
nWhere the implant will sit —either submammary or subpectoral. This decision depends on the size and shape of the existing breast, the desired increase in size and the amount of soft tissue on the chest wall. The subpectoral approach is a bigger procedure for the patient, but is often necessary for thin women in whom the contour of a submammary implant would be visible.
nWhat type of implant is to be used. In Australia all implants consist of a silicone bag containing either cohesive silicone gel or saline. Silicone gel implants are more widely used because they have a superior natural look and feel. Implants may be round or teardrop in shape, depending on where they are to be positioned.
nWhat type of incision will be used. A submammary incision is most common. Alternatives are a transaxillary or a periareolar approach.
3. What happens on the day
of surgery and immediately
afterwards?
nMost women have breast augmentation as a day-stay procedure.
nThe surgery takes about two hours, and patients wake wearing a support bra that they must wear for six weeks. Regular pain relief will be needed for the first few days.
nFor the first postoperative week patients should avoid strenuous activity and lifting their arms above their head.
nThey can return to sedentary occupations after one week but it is recommended they have three weeks off work. Patients with jobs involving heavy lifting should not return to work for 4-6 weeks.
nMost of the swelling and bruising will have subsided two weeks after surgery. Residual swelling continues to reduce for six weeks but can sometimes take up to six months. Bra fitting should be delayed until six weeks postoperatively.
4. What are the possible
complications?
Short-term complications include:
nBleeding and infection. These are both uncommon developments, but must be referred back to the plastic surgeon if they occur. Infection may require the removal of the implant.
nHaematoma. This is identified by unilateral swelling and tenderness, and occurs within the first week after surgery. It may require surgical drainage.
nDissatisfaction with the aesthetic outcome. If by six weeks the patient remains unhappy with the appearance of their breasts (eg, due to asymmetry of the implant position) they should be reviewed by their surgeon to discuss a possible implant exchange.
The most significant longer-term problems are:
nKeloid scarring.
nFibrosis and capsular contracture. A capsule of scar tissue always forms around the implant. In 3-5% of cases this may thicken and contract over the years causing progressive hardening around the implant and pain. If severe, the implant needs to be removed.
nRupture or leakage of the implant. A reasonable amount of trauma is generally needed to rupture implants. If the cohesive silicone gel implants rupture, the extruded gel is walled off by fibrosis and forms a mass adjacent to the implant. Saline implants may develop a slow leak that results in loss of volume.
5. Other general advice for
patients:
nThere is no evidence that breast augmentation increases the risk of breast cancer.
nPatients should advise the radiographer of their implants when having a mammogram so that special views can be taken.
nBreast implants do not interfere with future breastfeeding.
nImplants are foreign material so patients should receive the same antibiotic prophylaxis given to patients with prosthetic heart valves or joints when undergoing invasive procedures. This may reduce the risk of capsular contracture by preventing infection around the implant.
nThe total cost of a breast augmentation is $10,000-$12,000.
nThe web site of the Australian Society of Plastic Surgeons has useful information for patients. Visit www.plasticsurgery.org.aul
Thanks to Dr Anand Deva,
plastic and reconstructive
surgeon from Miranda in
Sydney, for his help preparing
this article.
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