Subglandular breast augmentation with cohesive gel implants
Breast augmentation / breast enlargement
Breast augmentation is a common consideration for women who have always had small breasts, or who have lost breast volume after breast feeding or weight loss.
Dr Davis is very experienced at breast augmentation surgery. He gives advice to help women decide if this is an appropriate procedure and will help guide them with many decisions including about volume and shape.
Frequently asked questions
Mr Davis does Breast augmentation for a fixed cost. For the current fixed cost please either email us or phone us on 0800 268 526.. Anatomic shaped implants cost more than round implants.
The quoted cost for surgery covers everything including anaesthetist fees, theatre fees, consumables, the implants, staying overnight in hospital after surgery, any additional consultations after the first consultation and all the follow up for dressings and checks in the first year after surgery. This cost includes GST.
Mr Davis only uses superior quality implants that are manufactured in the UK according to the ISO 13485 requirements necessary for Class III sterile breast implant medical devices. The implant is filled with a medical grade silicone gel. The gel is a semi-solid that is like the surface of a cut jellybean (Form stable – cohesive silicone gel). Older silicone implants contained a liquid that could leak out if the implant ruptured. Silicone particles can still “bleed” across the multilayered silicone outer shell. There is no known medical effect of this process.
Although modern breast implants are thought to be very safe, implant related complications can still occur and are discussed below. The implants used have a lifetime guarantee from the manufacturer for rupture and severe grades of capsular contracture.
After surgery patients are given warranty information, along with a sticker attached to the implant packaging confirming the lot number, style and size of the implants used.
There is no minimum age for surgery. You must be fully matured physically with no ongoing breast development occurring but more importantly, you need to be psychologically mature enough to make important decisions about your body. This age is different for everyone. Discussion with sensible family members and friends can help ensure the appropriateness of surgery.
I do all breast augmentation surgery under general anaesthetic. Although it is possible under local anaesthetic with deep sedation I do not do this, as there is more risk to the sterility of the operating site, including from the patients own breath. Contamination of the implants with a minor amount of microorganisms may increase the risk of capsular contracture (see below).
All implants will wear out at some point. Modern implants are referred to as 5th generation and do not need to be replaced every 10 years like older implants unless there is a problem with them. If there is no concern they could be potentially left alone for the lifetime of the patient. However all implants become more brittle with age and will deteriorate over time. Even if the implants never need replacing, the patient may choose to have a breast lift for gravitational droop one day, or downsize or remove the implants for personal reasons. The implants have a lifetime guarantee from the manufacturer for rupture and severe contracture.
There are several alternatives to breast implants:
1. Prosthesis or padded bra
A prosthesis may be placed inside the bra or a padded or push-up bra worn.
2. Brava system
Tissue expansion using the Brava system has some success. This is a suction cup system attached over the breasts. Over many months some minor increase in size is possible.
Also known as fat grafting. This is a technique I use a lot in the face for patients with reconstructive defects and is used in some cases of breast reconstruction after cancer surgery.
The advantages are that your own tissue is used and there are no concerns about implants. The disadvantages are the limited change in cup size, the extended time taken for surgery and therefore significantly increased costs, and the unpredictability of fat graft survival. The transplanted fat can also increase or decrease in size with future weight changes.
At the ISAPS meeting in Geneva in 2012, the world experts presenting this technique had an average volume change of just 140cc.
The potential cancer causing effects of transplanting fat into the breast gland are still not fully known.
4. Tissue reconstruction
Breast volume can be increased using flaps, including microvascular flaps and is one of the options following mastectomy.
5. Tissue engineering
I believe that in the future we will be inserting a biodegradable membrane that has the shape of the implant and it will fill with the patients own natural tissues.
Some New Zealand women choose to go overseas for their breast surgery.
The main advantages are the lower cost of surgery and the possibility of a “holiday” at the same time.
In many cases this surgery probably goes well. Unfortunately I see a steady stream of less than ideal outcomes.
As a surgeon the main concerns I have is the inadequate and rushed preoperative consultation many women describe, the use of inappropriately large implants with little patient choice in the process, the pressure to proceed with surgery even if there are doubts and the lack of back up after surgery if something goes wrong. Even the most experienced surgeon will have complications.
Cases I have been involved with have had inferior quality implants or no knowledge of the device used. I have seen cases of over oversized implants, stretch marks, infection requiring implant removal and I am aware of deaths due to a pneumothorax (punctured lung).
The New Zealand public hospital system will remove infected implants but will not replace them even if patient supplies the implants. This has caused considerable angst for some patients.
In New Zealand patients can check the training and qualifications of their surgeon and take their time selecting the appropriate person after seeing them for a consultation to ensure they can trust them. If something goes wrong, redress can occur through ACC, the NZ Medical Council, the Health & Disability Commissioner, disputes tribunal and court system. This cannot happen with overseas surgery.
PIP implants were manufactured in France and subsequently discovered to be filled with an industrial grade of silicone gel normally used for things like ball bearing lubrication and mattress foam.
These implants were used widely in Europe and the UK. About 20 were used in NZ.
I have not used PIP implants. I have removed several sets of PIP implants that were inserted overseas.
For frequently asked questions and further information about these implants, please see the NZ Medsafe and Australian TGA links below.
Polyurethane implants have been used for many years. They went out of favour for a time because one of the breakdown products, toluenediamine (TDA) was thought to cause breast cancer. More recent research suggests this is highly unlikely.
South American surgeons who have performed many thousands of implants have recently shown that they had a lower than expected capsular contracture rate.
Some surgeons suggest that as the polyurethane is broken down, the silicone shell is all that is left and this just delays the onset of capsular contracture.
Because my own capsular contracture rate is very low, I don’t see any advantage to changing the implants I currently use and would prefer to see longer follow up studies from other groups first to confirm their safety. I may consider their use in future if there is a demonstrated advantage over my current practice.
There is no perfect implant size for a person but rather a range of sizes that may be appropriate. Breast augmentation surgery is not just adding volume. Shape is equally important and this involves assessing the breast base and tissue type. I estimate the volume needed to be added by inserting trial implants within a surgical bra and wearing a tight top. The colour of the top can affect the apparent size of the implants and dark tops disguise the shape changes more than lighter colours.
It is important to assess overall physique including the hips, waist, shoulders and the projection of the buttocks and stomach. Some people have recommended using rice inside a bag as another method of assessing volume. For most people there will be a range of possible implant sizes that their tissue type will accept and the exact size can be a personal choice depending on the look wanted. Most of my patients trial the various implant ranges discussed again after the initial consultation to be sure about everything. They may have specific items in their wardrobe they want to check these with.
The smaller the implant, the more natural the look. At some point increasing the implant size will no longer look natural. Many people I see do not want other people to know that they have breast implants.
Large implants can give the optical illusion that the person is overweight, or may give a “matronly” look depending on their physique.
Large implants stretch the breast tissue and will accelerate the natural drop that occurs in all breasts with gravity. It is more difficult to do physical exercises.
Future corrective surgery is much more likely. If the implants are removed one day, the stretched breast envelope will be more droopy and may need lifting which creates new scars.
I place about 2/3rds of implants under the muscle layer. The main reasons for putting implants beneath the muscle are to disguise the upper medial pole of the implant and give better soft tissue coverage over the implant. If a soft semi-filled implant is used and there is adequate soft tissue coverage, placement under the muscle may not be necessary.
There is some evidence than under the muscle gives a lower capsular contracture rate and also makes future mammograms easier.
This decision is based on a careful assessment of the overlying soft tissue, the shape of the chest cage, dimensions of the implant, possible future weight changes and the person’s occupation.
Considerations for placement under the muscle are that the initial recovery could be more uncomfortable and when the muscle contracts the implant may move upwards and change shape. A very loose overlying skin envelope may not be filled if the implant is beneath a relatively tight muscle.
If a capsular contracture does occur, it is in a deeper plane and less visible.
Submuscular placement does not affect the rate of “drop” of the implant over time because the lower pole is not held up by muscle.
If you have “droopy” breasts, a breast lift (mastopexy) can be done at the same time if appropriate. Inserting a breast implant causes a degree of breast lifting in droopy breasts. With minor degrees of droop, implant insertion alone is all that is required. In severe cases an implant alone will not give sufficient lift.
There is a grey area in between where the decision to do a lift will depend on the nature of the breast tissues and the size of the implant inserted. On occasions a decision will be made to insert an implant and reassess the need for a lift six months later. Although a breast lift creates additional scars, for most people this is outweighed by the improvement in shape.
There is no evidence that medical grade silicone is harmful or that it causes breast cancer. Silicone gives a more natural “feel”. Saline implants are still covered with a silicone shell and they will deflate if ruptured. Their use is uncommon in New Zealand and Australia.
Although silicone implants were banned in the US by the FDA from 1992-2006, throughout this period surgeons in New Zealand, Australia and the UK continued to use silicone implants.
This decision is based on the look that a patient desires. For small volume increases, a moderate profile round anatomic implant looks very natural but as the size increases it looks less natural especially from side on.
Anatomic implants have the advantage of looking fairly natural in the upper pole at large volumes and also creating more lift of the nipple and areola if there is any droop. In some cases they will avoid the need for a lift. The point of maximum implant projection is also lower on an anatomic implant so a lower nipple will llok more natural than if in the same position over a round implant.
Anatomic implants cost more than round implants (about $800 for a pair) and there is a theoretical risk of rotation. This has only occurred in one of my patients and followed a trauma 6 months after surgery.
There are a number of complications that can occur after surgery. These will be explained during the consultation and in written information given to you. Most are explained in more detail below.
Most potential complications or adverse outcomes can be improved by further surgery. In the case of breast augmentation this includes haematoma, ripples, poor position, implant rotation, implant rupture, capsular contracture and incorrect size. If the complication was caused by a technical error on my part I would fund the total cost of revision surgery. If this is not the case, for instance a capsular contracture, then I would not charge a surgical fee if the complication occurred within five years of surgery however the patient would have to fund the cost of the hospital and anaesthetic fees.
The implants I use have a guarantee from the manufacturer for rupture and severe (grade 3 and 4) capsular contracture. They would supply a new set of implants but not fund the revision surgery.
Patients stay the night after surgery and are checked by Mr Davis before discharge. They are given a detailed information sheet with his contact phone number. Appropriate pain relief is given to take home. Guidelines about lifting heavy weights, arm movements and driving will be given. Dressings are removed the following week, or detailed instructions given if these are to be done elsewhere.
You do not need to wear a bra immediately after surgery because of the way the breasts are taped, but you may do so if it is more comfortable. I recommend wearing a tight singlet, crop top or a very soft single piece fabric sports bra without lots of internal reinforcing. Lots of my patients have been wearing the Ahh-bra from the Warehouse and report that it is very comfortable. Similar bras are also available from Farmers and Postie Plus.
I recommend waiting at least 4-6 weeks before getting measured for a new bra. This allows time for any swelling to subside, the position to settle and the breast to soften.
I recommend avoiding chronic use of an under-wire bra after surgery unless it is well padded. The wire should not leave deep indentations on the skin after use. The implant compresses breast tissue against the wire may cause thinning of the intervening tissue over a long period and may make the implant more easily felt many years later.
Although some surgeons recommend massage of the implants after surgery I do not do this. I do not think it makes a difference to capsule development in most cases. I will often recommend pushing the implants from the outside towards the centre for 1 minute every day in the first week after surgery to maintain the medial cavity, which may otherwise close with scar tissue if you are lying on your back for extended periods.
It may be uncomfortable to lie on your side or front for a few weeks after surgery. In the long term there is no restriction in sleeping position and you may sleep on your front if you wish.
Most of my patients prefer a natural look. They prefer others not to be able to tell they have breast implants when undressed. Others prefer a fuller less natural look.
Most patients are between a C-D cup after surgery. Others prefer a larger cup size. Very athletic people may prefer a smaller size which looks more proportionate with their physique and the implant weight is less of a restriction during extreme competitions and when running.
The exact cup size is not absolutely critical. I believe the overall proportions are more important. Cup size can change over time especially if the patient loses or puts on weight.
The most important factors are the shape of the breast before surgery, the breast soft tissue characteristics and the type of implant used.
Examples of before and after pictures are shown on the website. Please carefully note the pre-existing breast shape in each case.
I usually place the incision in the fold beneath the breast (inframammary fold). This is relatively hidden and tends to leave a fine scar with time. This location is easier if the implants ever need adjustment in the future.
The scar is about 4cm long for implants up to 260 cc and 4.5-5cm long for implants over 320cc.
The periareolar incision (around the areola) may leave a more noticeable scar, will cut breast ducts and may affect breast feeding, is more likely to affect nipple sensation and may lead to a higher capsular contracture rate because of bacteria within the ducts.
The axillary (armpit) incision may be visible when wearing sleeveless dresses.
It is normal for an area of skin about the size of a 50 cent piece immediately above the incision to be very numb for a long time. Rarely there may be numbness of the nipple and areolar complex. Hypersensitivity is more common, about 1:10 cases. This can take many weeks to settle and slight hypersensitivity may be permanent in a small number of cases.
Smoking greatly increases the risk of surgery complications and has specific risks for breast implants. I want my patients to have the best possible result so please don’t smoke!
A single cigarette will cause the small vessels in the skin to tighten (vasoconstriction) for about 50 minutes. This will affect wound healing. The chance of a hypertrophic scar, wound edge separation and infection is much more likely in active smokers.
Smoking decreases the elastin content of the skin. Over time it will have less elastic recoil. This is most noticeable in the face with visible wrinkles but also affects breast skin.
The risk of a capsular contracture distorting the breast implant is more likely in the presence of smoking.
Atelectasis, or collapse of the small air spaces in the lung, is much more common after an anesthetic in smokers.
Ideally smoking should stop a minimum of six weeks before surgery and needs to permanently stop to maintain the best results and tissue tone over time.
Complications after breast augmentation surgery include infection, bleeding, capsular contracture, changes to nipple sensation, implant ripples, implant rupture, implant rotation and movement, seromas, poor scars and other breast gland changes over time including cysts and calcium deposits.
I give my patients a copy of the Australian Society of Plastic Surgeons information sheet, which has more detailed information about these complications. If a patient of mine has a complication, I will do my best to sort it out. Below is a summary of what I consider to be the more important complications.
Infections are rare after breast augmentation surgery. In severe cases the implant would need to be removed and replaced at a later stage. I have not had this happen. Rarely there may be a minor skin infection for which I prescribe antibiotics as a precautionary measure for a few days.
The risk of haematoma, or bleeding in the surgery site is about 2% (1 in 50).
Haematomas typically occur between 8-12 hours after surgery. Initially the breasts are soft and symmetrical then one side will become very swollen. It may be quite uncomfortable as swelling progresses. If this happens you will need to be taken back to the operating theatre, the incision opened and the clot removed. Most people will still go home the next day as planned but this will depend on the timing of surgery. I have never had a patient develop a late haematoma after they have been discharged.
There is no long-term detrimental effect on the surgery. The cost of the further surgery is covered by ACC as a “Treatment Injury”. You do not have to pay additional costs.
Every foreign body inside the body (eg hip joint, heart valve, chemotherapy catheter, shrapnel, windscreen glass) is walled off by scar tissue.
In the case of a breast implant, this scar tissue is called a capsule. It is normal for every breast implant to be surrounded by a capsule.
In about 5% of cases, this capsule may tighten, a so-called capsular contracture. My own personal rate of capsular contracture is much lower, but because they may develop many years later, I do not yet know if my contracture rate may be as high as 5% a decade after surgery.
There are various grades of capsular contracture.
- Grade I. The implant feels firmer than the other side
- Grade II. The upper pole of the breast becomes more rounded
- Grade III. The implants are quite distorted and misshapen
- Grade IV. The implants are painful
I have several patients with Grades I and II contractures who have decided it is not worth intervening unless the contracture becomes worse. The implants I use have a guarantee from the manufacturer for Grades III and IV capsular contracture. They will supply a new set of implants.
It is thought that capsular contracture may be caused by a bacterial “slime” layer, a so-called “biofilm”. This is not an infection. Every time you brush your teeth, bacteria from the mouth can appear in the blood stream. This is called a bacteraemia. Bacteria from any source of infection or during major dental surgery could lodge on the implant capsule and cause a biofilm. It is recommended that a short course of antibiotics be taken if undergoing major dental surgery to decrease the risk of capsular contracture.
Modern implants are filled with highly cohesive memory gels that are more solid than liquid. Their consistency is a balance between maintaining shape and creating a “feel” similar to normal breast tissue. When the implants are upright, the gel will preferentially fill the lower pole of the implant giving a more anatomical shape. In under-filled implants this can cause a rippling of the overlying implant shell. I use nearly fully inflated implants to minimise this effect but it is still possible.
If the implants are overfilled, there will be an unnatural fullness of the upper pole of the breast in some cases.
Traction rippling is also possible and is more noticeable in very thin people with minimal fat overlying the implant. It may be able to be disguised by inserting fat grafts.
Rotation is not a concern with a round implant. It will not be detected if it occurs. Rotation of 20 degrees of an anatomical implant is noticeable but rotation is uncommon.
Minor asymmetry before surgery is common and normal. Asymmetry may occur if there is a pre-existing asymmetry of the breasts of the chest wall. It may become more pronounced as equal sized implants project forward. This would normally be detected during the examination and whilst trialing implant sizes. In significant cases of asymmetry, different sized implants may be used or a breast lift or breast reduction procedure performed on one side.
In 1992 the US FDA banned the use of silicone breast implants until their safety could be verified because of a possible link to various medical conditions including connective tissue disorders. Subsequently it has been conclusively shown that the use of medical grade silicone is safe, and it is used in many types of medical devices. The FDA reapproved the use of silicone in breast implants in 2006. Throughout the period silicone implants were banned in the US, they continued to be used in Australia, UK and New Zealand.
Muzzafar A. The Silicone gel-filled breast implant controversy: An update. Plast. Reconstr. Surg. 742: 109, 2012
There is no evidence that breast implants cause breast cancer. The rate of breast cancer may be slightly lower in women who have breast implants but this is probably because they tend to have less breast tissue than the general population.
Over 3000 women in LA were studied over 10 years. The rate of breast cancer in women with implants was slightly lower than expected.
Deapen D. Augmentation mammaplasty and breast cancer: A 5 year update of the Los Angeles study. J. Clinical Epidemiology 48:551, 1995.
In the largest study to date, about 11,000 women from Canada were followed. The incidence of breast cancer in women with breast implants was the same as the general population.
Bryant H. Breast implants and breast cancer: Reanalysis of a linkage study. New England Journal Medicine 332:1535, 1995.
Breast implants have been associated ALCL which is discussed below.
This is a rare form of lymphoma, a cancer of lymphocytes in the blood. It can involve the capsule (scar layer) surrounding a breast implant. The risk of developing ALCL (Anaplastic Large Cell Lymphoma) if you have breast implants is thought to be 1:100,000.
On average, BIA-ALCL occurs about eight years following surgery. There are an estimated 11 million women worldwide with breast implants. By March 2015, 176 cases of ALCL had been reported. There are less than ten patients throughout the world diagnosed per year with this disease. The most common sign is a fluid swelling (seromas) more than one year after surgery.
Common causes of a delayed seroma are infection or trauma, however suspicious swellings should receive a fine needle aspiration test. Lymphadenopathy (swollen armpit lymph nodes) are a less common sign. The disease course is usually indolent and the majority of patients are completely treated with total capsule and implant removal. Even if appropriately treated however, aggressive variants have been reported which include lymph node metastases and death; although this is very uncommon.
The FDA website summarises available data as it comes to hand.
I am not aware of a patient of mine who has had breast feeding issues as a consequence of having breast implants. Breast ducts are not cut with the inframammary crease incision I use.
Using a periareolar incision cuts some breast ducts, has more of an effect on nipple sensation and increases the risk of capsular contracture.
When breast feeding, the breast gland can increase in size significantly. When it subsequently decreases in size, the breast may have a different shape and in some cases it may droop over the implant. In severe cases the patient may request a breast lift. This can be done without disturbing the implant although some people also request a size change at this time.
Breast screening is recommended every two years for women once they reach age 45. Women who have a strong positive family history of breast cancer will start breast screening at an earlier age. Approximately one in every seven New Zealand women will develop breast cancer during their lifetime.
When performing mammography in women with implants, a displacement technique is used, the Eklund technique. In reviewing the safety of silicone implants the FDA has reported “the effectiveness of mammography to screen women with breast implants for cancer is generally similar to that of women without implants”
Mammograms image the breast tissue better than other types of x-rays in most cases. Some women with very dense breast tissue may have ultrasound scans or MRI scans recommended by their breast surgeon.
A mammogram normally images about 93% of the breast gland. After breast augmentation this drops off to about 87% of the breast gland. Some breast cancers are felt more easily in the presence of breast implants. Studies show that breast cancer is diagnosed at a similar stage in women both with and without breast implants and the prognosis is comparable.
Handel N. Breast Cancer diagnosis and prognosis in augmented women. Plastic & Reconstruction Surgery: 118; 587-93, 2006.
With older generation implants, it was recommended that patients see their surgeon every year for an implant check. Because modern generation implants have a much lower capsular contracture and rupture rate, this is not thought to be necessary.
It is recommended that a course of antibiotics be taken if undergoing major dental surgery. The bacteraemia associated with this surgery may theoretically increase the risk of a capsular contracture. In the same way patients with a prosthetic heart valve have antibiotics if undergoing similar dental work.
With any patient I have operated on, I have an open door policy if any problem arises in the future related to that surgery. Consultations in the first year after surgery are not charged for.
Implants can be removed at any time if desired. In many cases this can done under a local anaesthetic. If the implants are removed in the future and not replaced, there is likely to be more tissue stretch and drooping than if implants had never been placed. Whether or not a breast lift (mastopexy) will be needed will depend on the size of the implants, the amount of breast tissue present and quality of the breast tissues.