Breast augmentation involves placing implants behind the breasts to increase the overall size This is a common plastic surgery procedure and patients who request them include patients who are underdeveloped, those who have lost volume after childbirth or weight loss, and those who simply desire more volume in their breasts. Though the majority of women have minor volume differences in their breasts, patients with significant differences may also request an augmentation of one or both breasts to enhance as well as symmetrise their breasts. Breast implants are also used for breast reconstruction after breast cancer and for congenital deformities such as tuberous breasts. All of these patients have different considerations and implications for achieving desired results. Ageing causes skin laxity and breast volume loss, both of which cause breast droop or sag. These changes are often worsened by childbirth and large weight changes. Effects of childbirth During pregnancy, the breasts enlarge and more so when the “milk comes in” for breastfeeding after birth. After birth and breastfeeding, they shrink back to the previous or even less volume. The skin often does not shrink back as much as hoped. The net effect is stretched skin with or without volume loss, both of which contribute to breast droop or sag. If breast droop is mild, it may be able to be treated with implants alone as a pendulum effect will lift the nipple. However, if breast droop is moderate or severe then a nipple or breast lift procedure may be required to reposition the nipple and tighten the skin brassiere despite increasing the volume of tissue behind it with an implant. Effects of weight change Large weight gain can enlarge the breasts significantly and cause the surrounding skin to stretch and thin. Subsequent weight loss will usually cause breast volume loss but leave stretched skin that is thin, with overall breast droop. This situation commonly requires both augmentation and breast lift procedures to restore breast shape. Patients with mild and moderate weight changes may be able to achieve good breast shape with breast implants alone. Weight loss after breast and other procedures can alter the results achieved. At your first consultation, Dr Raja will assess your needs and form a tailored approach to achieve your goals. Pre-operative decisions No procedure is booked through the Sculpted Clinic before a thorough assessment is made and pros and cons of all options are openly discussed with our patients. It is imperative to Dr Raja Sawhney that his patients feel well informed and have realistic expectations. Some of the pertinent decisions in breast augmentation that he will discuss at the first consultation are: Incisions / scars Before and after images Magnifying Glass Patient 1 Magnifying Glass Patient 2 Magnifying Glass Patient 3 Magnifying Glass Patient 4 Magnifying Glass Patient 5 Magnifying Glass Patient 6 Magnifying Glass Patient 7 Magnifying Glass Patient 8 Magnifying Glass Patient 9 Magnifying Glass Patient 10 Magnifying Glass Patient 11 Magnifying Glass Patient 12 Magnifying Glass Patient 13 Magnifying Glass Patient 14 Magnifying Glass Patient 15 Magnifying Glass Patient 17 Magnifying Glass Patient 18 Considerations Need for nipple lift or breast lift procedure; Ageing, childbirth, breastfeeding and weight loss can all lead to breast droop or sag by combinations of skin laxity or stretching and loss of breast volume. Consultation and procedure At your first consult, Dr Raja Sawhney will ask you what your desires from a breast sculpting are and assess your breast features including skin laxity, breast volume and shape. He will also assess your chest wall features which may have implications on your surgery and the results that can be achieved. He will then advise on your likely outcome from a breast augmentation and whether or not you may need any other procedure to achieve your desired result. Chest wall features Chest wall features can affect your results and in the inexperienced hands can lead to poor and difficult to fix outcomes. For instance, if you have a wide breast bone then it can be difficult to bring your implants close together to provide good cleavage. Dr Raja Sawhney will discuss all the above choices in breast augmentation and the pros and cons of each in depth with you. He will then go through all the well-known complications of the procedure before suggesting a plan that you and he feel is best for you. Feel free at any time to ask questions that come to mind so he can answer them. Dr Raja prefers to give information for you to think about in the first consultation without making decisions. This may bring up lots of further questions for Dr Raja to answer at your second consultation. It is now mandatory to have a second consultation prior to any cosmetic procedure so you have time to assimilate the information given and make a well informed and considered decision. You can also email us or contact any of our practice staff for information. You may get appropriate quotes at or after your first consultation. Dr Raja Sawhney would prefer a patient to change their mind multiple times and be sure than perform a procedure on a patient who is in any dilemma. FAQs Are there different types of implants? Shape – Tear drop (Anatomical, Natural) or Round Round implants are cheaper than naturally shaped ones but often not best suited for optimal results, especially if one is looking for a natural look. Simple physics dictates that round implants have the same width and height. Thus, if a patient has a similar breast width and height she may be a good candidate for a round implant. If however, breast width is wider than the height there are two alternatives – choose an implant with diameter to match the height or width. In matching the height, the implant might not be wide enough for good shape. If using the width, you may need to lower the fold below the breast or the implant will sit too high. Lowering the fold is not straight forward and runs the risk of a double bubble deformity where the original fold forms a tight band over the lower part of the implant. If the fold is poorly defined lowering by 1-2cm is readily achievable without double bubble deformities. Similarly, if a patient has a long narrow chest then a round implant matched to the width will give poor upper breast fill and shape with less cleavage, whereas an implant matched to the height will protrude in front of the arms. Anatomical implants often give a more natural slope to the upper breast especially out of a bra. Push up bras can be used to create more cleavage as desired within a bra. Anatomical implants can however rotate whereas if a round implant rotates its shape does not differ (unless it flips back to front). Thus, pockets formed for anatomical implants need to be more precise to avoid rotation. Round implants give more upper pole/breast fullness, which may be desired. This works well in patients with good amount of breast tissue in the upper pole to start with. However, if the patient’s upper breast tissue is thin the upper edge of the implant can be quite obvious and “fake” looking. Suffice to say, if a patient has similar height and width of their breast and good thickness of breast tissue in the upper pole a round implant can give pleasing results and avoid the risk of rotation. The other exception is where previous round implants have been used or a mega-pocket technique utilised where replacement with anything, but round implants will lead to higher risk of rotation unless a new controlled pocket is formed. At Sculpted Clinic we use 3D imaging with Vectra to show patients a simulation of what they may look like with a breast augmentation. You can choose different styles and sizes to help decide with Dr Raja’s guidance what implant and look you prefer. Please note that Vectra creates simulations as a guide and is not a guarantee of an outcome. Textured or Smooth All implants have a silicone outer shell that may be textured or smooth. The texturing is done in an attempt to allow tissue attachment and ingrowth to hold position better. All tear drop/natural/anatomical implants are textured. There is good literature to show that texturing decreases rates of capsular contracture. This decrease is significant when implants are placed behind the breast and in front of the muscle. Behind the muscle, the effect of texturing in lowering capsular contracture rates is less obvious but present in the literature. Textured implants do require slightly longer incisions for placement, especially the more cohesive “form stable” implants. Brazilian implants have a special coating of polyurethane and have been shown in some studies to be associated with lower rates of capsular contracture. Some surgeons experience that they tend to adhere firmly to surrounding tissues and feel firmer than many other available implants. Dr Raja does not routinely use Brazilian implants but will consider using them for patients with recurrent capsular contracture or where tissue adherence is desirable e.g. revision surgery where implant position was lost or on patient request. An older technique of inserting implants was to make a large pocket and put round smooth implants in. The patient would then massage and move the implants around to stop adherence and decrease chances of capsular contracture by virtue of the fact that the capsule would have to constrict a lot before deforming the implant. In the appropriate setting and certainly in many revision cases this may prove a useful technique to revert to. One major problem with this technique is that when the patient lies down the implants drift into the armpits, lose projection and appear less perky. Dr Raja has revised patients with this problem to textured implants in new controlled pockets. Silicone or Saline Filled As mentioned above, all implants have a silicone shell. They may be filled with sterile saline (salt water) or silicone in a gel form. The advantage of using saline-filled implants is that if they rupture or leak the saline will be absorbed into the patient’s tissues without harm, leaving a deflated implant. Older silicone gel implants had runny thin gel in them with thin outer shells which allowed the gel to leak into breast tissue or move around other parts especially if the shell ruptured for any reason. Newer cohesive gel implants have gel that is firmer and even after breaking may stay together like a cut piece of Turkish delight. Thus, shape is not necessarily lost immediately on rupture, nor is leak and dissemination into breast tissue and elsewhere e.g. armpits. The most obvious advantage is that silicone implants feel softer and more breast tissue like than saline filled implants which tend to feel firmer and rigid. Secondly, especially if under-filled, the implant shell can indent and ripple leading to an uneven feel to touch and even visible rippling if covered with thin breast tissue. How are my Implants placed? Behind breast and in-front of muscle (submammary/Subglandular/ Prepectoral/Subfascial) Submammary and subglandular mean behind the breast gland. Prepectoral means in front of the muscle and is equivalent. Subfascial is a newer technique of placing implants behind the outer covering of the muscle. The advantages of placement behind only the breast is that muscle function is not altered, and the muscle cannot move the implant when it contracts. This is often desired by bodybuilders for instance. It can often give the breast and nipple a more effective lift if they are sagged. The major problem is that the upper part of the implant may be palpable or visible especially if the patient has little breast tissue of her own in the upper breast and more so with round rather than natural shaped (tear drop) implants. The other major problem is that this pocket has a higher rate of capsular contracture, especially with smooth implants. The capsular contracture risk is hypothesised to be related to organisms from breast ducts that may seat the implant and cause low grade infections or biofilm. The subfascial placement was created in hope that the fascia will protect the implant from organisms found in breast ducts by preserving this barrier between the breast tissue and implant. Indeed, there is good literature to show that this may be the case. It does not however significantly increase soft tissue cover of the implant edge in the upper breast area. Thus, it may be a great technique in certain circumstance, for example, when there is droop but good upper breast soft tissue and you are trying to get maximum lift from an implant to avoid a breast lift. Behind the muscle (Submuscular / Subpectoral) The most prominent advantage of placing an implant under the pectoralis major muscle is that it covers the upper edge of the implant and gives a more natural slope to the upper breast, desired by most. It is considered by most specialist plastic surgeons to be mandatory in patients with poor (< 2cm pinch thickness) breast tissue in the upper breast. This is best appreciated when not wearing a bra. One can achieve extra cleavage for that special dress with a push up bra. It also has a significantly lower capsular contracture risk associated with it which can be a troublesome complication. The one disadvantage of this placement is that the muscle can distort the implant and push it down and out if it is not detached from its inner lower attachments. However, by releasing this segment the muscle slides up on the implant like a visor decreasing potential for distortion on muscle activity. Even after releasing and refunctioning this portion, the muscle can decrease the effect of the projecting implant on lifting the nipple in droopy or sagged breasts. Dr Raja detaches the muscle from the overlying breast to varying degrees in this instance (as described by Dr Tebbett’s) to achieve better nipple lift without losing upper edge muscle cover to the implant. Nevertheless, with all subpectoral techniques animation i.e. movement of the implant when contracting the muscle e.g. pushing on your hips is possible. Dr Raja uses intra-operative techniques to minimise this particular potential. How do i prepare for a breast augmentation? When you book your procedure, our team will go through the date, time and place of your procedure. They will inform you that you need to not eat or drink anything for six hours before the procedure. It is necessary for you to have an empty stomach as you may vomit during the procedure in response to the anaesthetic or procedure, and foodstuff can be inhaled into your lungs and make you very sick. You should shower the night before and the morning of the procedure at home. Please arrange your transport so you are not driving yourself home as this would be unsafe and your insurance will not cover you after a procedure and anaesthetic. If you have concerns about this or any other arrangements, please let our practice staff know and we can arrange alternatives for you. Can Dr Raja Sawhney show me where the scars will be? Dr Raja Sawhney will discuss the where the scars can be put and what the pros of cons of each will be in you. He can also discuss the length of those scars as different implants need different length of scars for insertion and even the same implant may need different lengths of scars depending on where you want the scar placed. How close will the Vectra 3D simulated result be to the actual result? Actual results will be very similar to the simulations. Vectra simulations are based on the actual implants that your surgeon will use. The Vectra has some limitations though; for example, it cannot show the difference between implants placed behind and in front of the muscle. This is where Dr Raja will guide you to how your result may differ from the simulation by virtue of technique he may use, and ancillary procedures you have with your primary procedure to enhance your result. Will this software help my surgeon to see that my breasts are different sizes? Vectra software includes special tools to show the size and position of each breast. Breast “asymmetry” is very common, and Vectra analysis helps Dr Raja Sawhney develop a surgical plan which will compensate for it if necessary. How long do I need off work after a nipple lift procedure? Generally, after any breast procedure we recommend from two days, up to one week off work depending on your procedure and work. With a nipple lift alone you should be able to return to general office-based work within a couple of days. You should avoid lifting significant weight or manual work for two to three weeks while your wounds are healing. If you are having a combined breast augmentation with nipple lift, you need to follow recommendations and exercises for a breast augmentation with nipple lift. Dr Raja Sawhney will individualise your work plan to suit your procedure, your predicted response to that procedure, and your work commitments. Please note each patient responds differently to pain and surgery. We describe the usual or common response for each procedure. Your recovery may be slower or quicker and we will be there to help you through your experience. This may mean slowing you down if you are moving a little too fast, to protect you from undoing good work or causing injury that may later give you more than usual pain or other symptoms. On the other hand, if you experience pain more than predicted, we will review you and increase your pain relief if there seems to be no adverse cause for the excessive pain. How long does the procedure for breast implants take? If done in one sitting, your procedure will take two to three hours to perform. If done separately, each procedure will usually take one to two hours. Im taking supplements, will i need to stop? It is imperative that you discuss any medications and supplements, vitamins, herbal remedies you are taking with Dr Raja at your first consultation. Many of these will interfere with anaesthetic drugs, healing or cause bleeding tendencies. He will advise on manipulating any prescribed medications around your surgery. Any blood thinning medications will usually need to be stopped such as: Fish oils Ginseng Gingko Biloba Glucosamine Garlic Ginger St John’s Wart It is best to stop all these at least two weeks prior to and after surgery. Red wine should also be avoided for two weeks before and after as it is a blood thinner (white wine doesn’t have this effect). Please advise Dr Raja if you smoke as the risks of infection and wound breakdown with even intermittent social smoking are far higher in most, and especially this procedure. It is best to be off smoking for six weeks prior to and after this procedure. How much will be breast augmentation surgery cost? That will depend on the type of procedure and implant you choose, where it is performed and other factors. You can get a quote at the end of your initial consultation with Dr Raja Sawhney. Will I be able to see what different implants are best for me? Yes. You will be able to see how you would look with different size and types of implants. You will also be able to see the possible benefits of a breast lift in conjunction with the augmentation. What anaesthetic/pain relief is required for breast implants? You will require a general anaesthetic to be administered in a single sitting. If you and Dr Raja decide that you are best to have this procedure in two stages, you will need a general anaesthetic for each procedure. You must have an empty stomach before any general anaesthetic can be given and this requires not drinking or eating anything for six hours prior to your procedure. If you have foodstuff in your stomach and you vomit in reaction to the anaesthetic or procedure, you can inhale this vomit into your lungs and become very ill, even requiring admission to ICU. Your anaesthetist will clarify that you have fasted appropriately prior to your procedure. After any general anaesthetic, you will need to stay in recovery for two hours before going home or to the ward if you are staying overnight. You need to be accompanied by a mature adult when leaving the hospital, especially if you are having day surgery. An adult should be with you after any significant procedure for the first 24 hours. You may have effects from the anaesthetic or the procedure that may mean you need adult help. The local anaesthetic will keep you comfortable until that evening or the next morning depending on what time of day your procedure is done. We recommend you take some basic pain relief before going to bed for a better chance of a good night’s sleep. You will be given painkillers to take for the subsequent few days and by a week you should usually only need intermittent, basic over the counter painkillers. Where will my skin incision or scar be? Under breast (Inframammary fold, IMF) This incision allows the most precise control of pocket dissection and implant position. It also gives definitive control of the fold itself especially when it needs to be lowered or raised. It is also the preferred incision by most specialist plastic surgeons for specific types of revision breast surgery. Furthermore, it has the lowest rate of capsular contracture, thought to be due to keeping away from organisms found in breast ducts and armpit skin. Dr Raja routinely covers the nipple and areolas with sealed dressings to avoid this contamination by organisms. The scar tends to heal well and is well hidden in the fold below the breast. In the instance of a bad scar, it is easily revised without significant deformity to breast tissue. The incision is typically 4-6cm, depending on size and type of implant. Textured and more cohesive “form stable” gel implants require slightly longer incisions. Under nipple/Areolar (Peri-areolar) This incision is possible in patients who have a significant width to their areolas and are having small to moderate implant sizes. Larger and especially textured implants are difficult to place through these incisions and impossible if the areolas are small. Also, this technique has a slightly higher capsular contracture risk thought to be related to contamination of the pocket and implant by organisms in breast ducts encountered during placement. The scar tends to heal extremely well and camouflage better than all approaches. However, if a tethered or complicated scar occurs it tends to tether through the breast tissue causing noticeable deformity which can be troublesome to improve and difficult to fix. Armpit (Transaxillary/Axillary) This incision gives the least direct control of placement but with the assistance of an endoscope can allow reasonably precise placement in the appropriate patient. Larger patients with long narrow or concave (pectus excavatum) chests can be more difficult. There is a higher infection and capsular contracture risk. As the implant is being placed from a distance the incision may need to be slightly longer especially for textured cohesive gel or “form stable” implants which some surgeons would avoid using through this approach. The scar is meant to hide in hairy skin of the armpit but most patients requesting this incision to avoid a scar in the fold below the breast or around the areola do not have lengthy hair growth in the armpit to camouflage the scar. It is a useable incision for the right patient and can give good results. If you’re ready to come in and see Dr Raja Sawhney, book in your comprehensive and confidential appointment today. Don’t forget to share this via Twitter, Google+, Pinterest and LinkedIn.