Breast Augmentation (Overview)
Breast augmentation (breast enlargement), also termed a “boob job”, is a cosmetic surgical procedure to increase the size and fullness of the breasts. Also known as augmentation mammoplasty, breast implants are placed under the chest muscles or breast tissue by a plastic surgeon.
For many women breast enlargements are about the aesthetic look of the body and are a way to enhance self-image and self-confidence. This cosmetic procedure is also effective as a breast reconstruction for women who have had a mastectomy (surgical removal of all breast tissue from a breast or both breasts) as part of their treatment for breast cancer or other conditions affecting the breast.
Generally, this procedure will be performed once under general anaesthetic, ensuring that you are in a comfortable sleep state throughout. During the procedure, a plastic surgeon places an implant in the breast to increase the size and fullness of a woman’s breasts. Implants are available in options of a soft silicone shell filled with silicone gel or saline (salt water).
A surgeon will insert the implant by making an incision (a cut) in the bottom crease of the breast (underneath), in the armpit, or along the lower edge of the areola (coloured area surrounding the nipple). Once inserted, the surgeon will position the implant by carefully adjusting to get the correct shape (contour) and placement either under the chest muscle beneath the breast or breast tissue. The incision is then closed with stitches or surgical tape.
As it is a surgical procedure, breast augmentation is usually done in a hospital or surgery centre but does not typically require an overnight stay. If there are any complications during surgery, it may be required to stay in hospital for observation and medical care for a period of time.
Why is breast augmentation done?
Breast augmentation is about the aesthetic look of breasts on the body. The cosmetic procedure is primarily done to enhance both their size and shape. One may decide to get breast implants for the following reasons:
- If you are unhappy with the size of your breasts. You may feel that your breasts are too small or too large. (in this instance, you may consider having a breast reduction procedure) Size is relative to an individual’s personal opinion. An aesthetic change can help to improve self-image and self-confidence.
- To enhance the shape and size of the breasts after major body changes such as those experienced during pregnancy or after losing a significant amount of weight.
- To match breasts a little better. Many women have one breast that is slightly larger or that sits higher than the other.
- Reconstruction after having a condition or surgery that has affected the breasts.
During your initial consultation with a plastic surgeon, you will be able to discuss your goals and reasons for wanting this cosmetic procedure. Your plastic surgeon will then help develop a realistic expectation of what this type of surgical procedure can do for you, giving you the most desirable results that meet your goals.
Types of implants
The type of implant used comes down to preference, by both yourself and your plastic surgeon. There are pros and cons to each basic type of breast implant. You can either opt for a saline or silicone gel-filled implant:
- Saline breast implants: There is a growing trend of surgeons opting to use silicone implants instead of the saline variety. The preference comes after the FDA (The Food and Drug Administration in the USA) approved silicone implants in November 2006 and many surgeons began to recommend these as a result. The saline implants contain a silicone outer shell which is filled with a sterile saline. These types of implants may either be pre-filled prior to surgery or be filled during the procedure of implantation. They are available in different sizes and have either a smooth or textured shell surface. Saline implants can be placed with integrated remote-fill ports (such as a trans-umbilical incision) and can also be adjusted postoperatively (adjusting the saline volume in the implant). These implants can be less costly than the silicone-filled type but can rupture or cause visible rippling on the surface of the breast (especially if a woman has thin breast tissue). Any ruptures are easily detectable and the fluid is absorbed by the body with no real issue as it is purely salt water. The bag however, will have to be removed and/or replaced.
- Silicone gel-filled breast implants: These implants are generally safe to use in women aged 22 years and older (or younger if the breast has stopped growing) or for reconstructive purposes in women of any age. Breast augmentation may also be considered earlier for those with congenital conditions such as Poland's syndrome (a rare birth defect that is characterised by underdevelopment or the absence of chest muscle, known as the pectoralis, on one side of the body). In this instance, surgery may be considered around the age of 15 or 16 years. The implants have a silicone outer shell and are filled with a silicone gel. The gel is available in varying consistencies. The implants are available in different sizes and have a smooth or textured shell surface. The consistency of the silicone gel can help the implant to have a more natural feel than that of a saline-filled implant. The implant is best inserted via the inframammary incision (under the breast where the lower part of the breast meets the chest wall), but may also be done via periareolar (around the outside of the nipple) or transaxillary (through the armpit) incision methods.
A woman’s breasts will continue to develop well into her teens and early 20s. For this reason, saline-filled implants will only be considered once a woman is 18 or older, and at least 22 years of age to receive silicone-filled implants (unless a pre-existing medical condition exists as mentioned).
Implant Shapes and Textures
Breast implant shapes
Your cosmetic surgeon will likely offer you two options when it comes to the shape of your implant: round or teardrop.
- Round breast implants: This traditional implant shape remains a highly popular one and is still regarded the shape that provides the most desirable / attractive result. Round implants create a soft, well-proportioned breast. Round implants tend to provide more upper pole fullness (upper portion of the breast), yet feel softer than teardrop shape implants. This implant shape comes in a range of different diameters and degrees of projection, giving your surgeon flexibility when fitting it to any woman’s breast and body shape. Both saline and silicone-filled implants are available in round shapes.
- Teardrop breast implants: This shape is available as a silicone gel implant and implants are made to maintain their shape. They are often known as ‘form-stable’ and in some circles, particularly in the United States of America, were widely termed ‘gummy-bear’ implants because the gel is thicker than that of the traditional round variation. As with round shapes, teardrops are available in a wide variety or dimensions and shapes, these include tall, short and wide varieties. The cohesive silicone used is firmer (due to its thickness) than the traditional round silicone implants and can be more easily felt in thinner patients, in comparison to a round silicone gel implant. Anatomical implants may provide a more natural look with less upper fullness compared to round implants. There is a tendency for these implants to look more natural, but they may 'feel' more unnatural because of the firmness of the implant.
Breast implant textures
Breast implants are available as either smooth-surfaced or in varying degrees of texturisation.
- Smooth: These feel softer, like the sleek surface of a blown-up balloon, and are only available in a round shape. These implants have the lowest risk of 'breast implant associated anaplastic large cell lymphoma' (ALCL) and also don’t require a large incision for implantation. Smooth implants are becoming increasingly popular as capsular contracture rates are not as high as previously thought to be. There is no difference with capsular contracture rates when placing a smooth or a textured implant underneath the muscle. Smooth implants move freely within the breast and they feel soft and natural. They also have the lowest risk of producing seromas and breast implant associated anaplastic large cell lymphoma (ALCL - a type of cancer).
- Textured: Textured implants have tiny grains in varying sizes on the surface of the implant shell. The texture can be felt when touched and resembles that of a very fine piece of sandpaper. These implants are available in both anatomical and round shapes with a firmer silicone-filled gel. Some surgeons feel that this improves shape for the long-term with a lower risk of moving around once implanted, however this is not entirely true. Studies have shown that there is a decreased risk of capsular contracture when placing textured implants above the muscle. There is, however, no difference when placing the implant below the muscle. Breast implant associated anaplastic large cell lymphoma has been reported as a rare complication following textured implants. It appears that this complication is not seen with smooth and nano-textured surfaces. To date, there have been just under 400 cases reported worldwide.
- Nano-textured: The newest of the texture options available are nano-textured implants. These implants offer an enhanced shell surface for silicone implants which may lower the risk of potential complications, including capsular contracture. The texture is designed to mimic the body’s own cell surfaces (the basal layer of the skin), making it easier for breast tissue cells to ‘grow on’ the surface of the implant (foreign object in the body) and not react negatively (such as adverse inflammation). Fewer foreign materials such as sugar or salt (as is used in textured implants) are used in this variety and this promotes better biocompatibility and a more natural interaction between the body’s tissues and the implant. These implants are favoured for a more natural look and feel (mimicking a woman’s anatomical shape with little risk of movement or rotation).
Which shape and texture should you choose?
A selection process should be one where a woman is well informed by her surgeon about the implant type (saline, silicone and the variations in shells) and size, and discussed in detail in relation to her desired expectations and the findings of her physical exam. The option is almost entirely yours as a breast augmentation candidate, as most surgeons are experienced in using either shape and all textures (although nano-textured implants are considered "next-generation" are often recommended by surgeons these days).
A selection of the type, shape and texture of implants is a critical step in your breast augmentation process and can be the lengthiest part of your consultation. Take your time, and ask as many questions as comes to mind. Your surgeon will be able to assist with any and every concern you may have, as well as give you all the information necessary, and pros and cons of each available variation, to help you make the most informed choice and achieve the results you’re after.
How is the procedure done?
There are 4 typical approaches (incisions) to placing breast implants. These are:
- Inframammary (in the crease under the breast)
- Periareolar (the dark skin that encircles the nipple)
- Transaxillary (under the arm or in the armpit)
Before a breast augmentation procedure, your plastic surgeon will conduct a medical evaluation and discuss in detail, your expectations and reasons for opting to have the surgery. He or she will help to advise on the size and implant type which will give you the most desired aesthetic result. Together you will go through the different types and settle on the specifics – smooth or textured implant shells, round or shaped like a teardrop, saline or silicone etc.
The implant procedure will be discussed with you (method by which the implants will be inserted) as well and any questions you may have will be addressed. All risk and potential complications will be discussed with you too.
Where the incision is made will depend on the type of implant, how much enlargement is being done and other factors of the body. Incisions will be made under the breasts, under the arms or around the nipples.
If you are taking medication, you may be asked to discontinue any (where safe to do so) that may place you at higher risk during surgery in the days or weeks before the procedure. Aspirin and other medications can cause unnecessary bleeding during surgical procedures. If you are a smoker, you will be asked to stop for a period of time before your procedure as this can also cause complications during surgery.
Breast augmentation is an outpatient procedure, but an overnight stay may be required if any complications occur during the surgery. All in all, the surgery can take between 1 and 2 hours. During this time, you will be placed under general anaesthesia and be ‘asleep’ during the entire surgery. This way you will not experience any pain or discomfort associated with the surgical process or have any recollection of the operation. In select cases, a local anaesthesia may be preferred where you will be awake during the procedure, but the breast area will be numbed.
Depending on the manner in which your plastic surgeon has decided to perform the surgery. This may be done in one of two ways:
- Placing the breast implant under the muscle: To do this, your surgeon will separate the breast tissue from the muscles and connective tissue of the chest, creating a pocket either behind or in front of the pectoral muscle. Most surgeons opt for a dual plane implant process where the superior portion of the implant is covered by the muscle and the inferior, beneath the gland.
- Placing the breast implant over the muscle: With this method, the implant will be placed between the chest muscle and breast tissue. This is known as a sub-glandular placement as opposed to the sub-muscular placement described above.
Once in place and the surgeon is satisfied with the position and shape, he or she will close the incisions with stitches (sutures) or surgical tape.
What to consider before deciding to have breast augmentation done
Some important things to note about breast augmentation and that should be taken into consideration before having the procedure done are:
- Breast implants will not prevent breasts from sagging. Sagging can still occur as you age or go through body changes due to pregnancy, but can be corrected with a breast lift procedure. A breast lift can be done at a later stage or at the same time as a breast augmentation procedure.
- Breast implants are not guaranteed to last a lifetime. Breasts will continue to age after augmentation. Other factors such as weight gain or loss can also change the way breasts look. The implant can rupture at any time too, causing internal complications. Any of these issues can be corrected with additional surgery. For many women, at least one more related breast surgery will be needed in their lifetime (breast lift, second breast augmentation or breast implant removal).
- Your body may ‘reject’ the implants. This is highly irregular and rare, with many believing that it is almost entirely a misconception. There is a greater chance of capsular contraction (internal scar tissue forming a tight or constricting capsule around a breast implant. This reaction by the body’s immune system forms a membrane that contracts until the implant becomes misshapen and hard) or infection. These conditions are easily misinterpreted as a rejection, but are merely the body’s way of showing ‘mild irritation’ to the foreign object and not necessarily medically considered as such. Either complication should be treated swiftly by your surgeon. He or she will examine the issue and determine if further procedures are necessary. Any strange sensations should be checked as soon as possible, such as pain, hotness or unexpected / unexplained swelling.
- Mammograms may require additional or more specialised tests. It may be more complicated to detect any problems such as abnormal breast tissue or breast cancer during a routine mammogram. Cancerous tissue can also resemble scarring and calcium deposits around the implant, making it more difficult to interpret the results of a mammogram. During a mammogram, the breast needs to be tightly squeezed to get detailed images. It is rare, but it can happen that an implant ruptures or leaks during this process. For any and every mammogram, a woman with breast implants should inform the technician. He or she will also need to know what type of implants were used and where they have been place (behind or in front of the chest muscle). A technician may take more views than is normal and may even recommend an MRI scan, in some cases, to get a clearer and more accurate image in addition to the mammogram.
- MRI scans may be recommended for women with silicone breast implants every 2 years, at least 3 years after the augmentation procedure. The MRI is done to check that the implants are still intact and that the breast tissue is still healthy. An MRI for these purposes may not be covered by your medical health insurance, so it is best to check this before deciding to have the procedure and whether it is affordable for you if it becomes necessary.
- Breast implants can hamper breastfeeding for some women. Depending on the manner in which the breast augmentation was performed, many women can breastfeed normally. For others, breastfeeding successfully may be a challenge.
- Medical health insurance may not cover breast augmentation. As the procedure is cosmetic, most medical health insurers will not cover the cost of the surgery. If the procedure is medically necessary, such as a reconstruction after a mastectomy, some medical health insurance companies will cover the costs. You must ensure that you are prepared to cover all expenses of the procedure, as well as any potentially related surgeries or imaging tests not covered by your medical health insurance.
- Additional surgery may be needed after breast implant removal. A breast lift or corrective surgery may be needed after implants are surgically removed to help maintain an aesthetically pleasing appearance. Natural breasts may become wrinkly or develop dimples once implants are removed.
- It is important to have realistic expectations. Breast augmentation will change the size and shape of your breasts, but the results may not improve your self-esteem or body image as you may have hoped or expected.
- It is also important to be 100% comfortable with your plastic surgeon. Breast augmentation is a very personal cosmetic procedure. It is invasive (surgical) and will have a permanent effect, which you will ultimately have to live with. It’s important that you feel comfortable with the surgeon you have chosen and that you are confident they can give you the desired results. You shouldn’t feel shy to request before and after visuals of their previous work.
Other things to be mindful of include reviewing all documentation carefully (and keep copies of pertinent information for your records), and arranging for someone to safely drive you home and stay with you for at least the first night following surgery.
Risk factors and complications
As with any surgical procedure, breast augmentation can have some risks and potential complications. If you opt for more than one surgery at a time, such as a breast augmentation and breast lift, the level of risk increases.
Possible risks and complications include:
- Breast pain, shortness of breath or a warm sensation in the breast area. If any pain or discomfort is accompanied by a fever, you may have an infection which will need medical treatment as soon as possible.
- Sensation changes in the breast and / or nipple (hypersensitivity or hyposensitivity). This can often happen after having implants, but typically doesn’t last for very long. In some cases, the change in sensation is more permanent.
- Capsular contracture - The formation of scar tissue and or / hardening in the area around the implant. The hardened scar tissue begins to squeeze the implant. Surgery would be required to clear away the scar tissue or replace the implant.
- Bleeding (haematoma – a collection of blood within the breast under the skin, causing swelling and pain)
- Abnormal scarring
- Seroma – A thin fluid collection around the implant.
- Problems with the size and shape of the implants (after surgery). The results may not meet the expectations originally agreed on.
- Implant rupture and leaks - Saline ruptures or leaks are usually safely absorbed by the body. The shell will typically begin to deflate. A silicone leak may remain inside or spill outside of the shell, and may not cause any obvious symptoms. The capsule of fibrous tissue that forms around the implant once it is fitted holds any leaked material when rupture occurs. This is often referred to as a silent rupture. A rupture can cause breast pain or changes in the contour or shape of the implant if the fibrous tissue becomes inflamed (and may even form additional scar tissue). A surgeon will be able to determine a rupture with an imaging test (such as an MRI). The course of action will be determined by both you and your surgeon. You may both opt to replace the ruptured implant even if you aren’t experiencing symptoms of discomfort. If you are experiencing symptoms, your surgeon will recommend removing or replacing the implant. In some cases, your surgeon may recommend a breast lift or corrective surgery as well.
- Changes in the implant – It can happen that, over time, the implant may harden, develop ripples or change in shape or shift position. Surgery may be required to remove or replace the implant.
- Difficulties in detecting breast cancer – It may be difficult to detect breast cancer in some women with implants and other screening or testing processes may be required.
Recovery and maintenance
Once the implant procedure is done, your plastic surgeon will place gauze over the stitched-up incisions (these may be removed in 7 to 10 days if not dissolvable). The newly implanted breasts will be carefully wrapped in an elastic compression bandage or soft, wireless surgical bra. Some plastic surgeons may insert drainage tubes following a breast augmentation procedure, others will not do so.
If drains are inserted, these will need to be removed by your surgeon at a follow-up appointment.
Post-op, you will experience some bruising and swelling, as well as some tenderness (soreness) in the breasts for a few days. Some women experience a burning sensation in their nipples shortly after surgery. Bruising and swelling may last for a few weeks following surgery.
You will be required to wear a surgical bra (support) 24 hours a day as this will alleviate swelling during the healing process. You may also be prescribed pain medication and antibiotics to help alleviate discomfort and prevent infection.
Every woman handles pain or discomfort differently. Some may get through the recovery period fairly easily, while others find that they heal a little more slowly and find some basic movements a little difficult, especially during the first few days. Some may require assistance from a loved one due to reduced upper body strength during recovery (needing assistance with sitting upright from a lying down position or help with carrying objects such as a handbag). Most women should be able to return to most of their normal daily activity within a few days. Any strenuous exercise and heavy lifting should be avoided for up to 6 weeks after the procedure or until your surgeon gives the all clear. While healing, your breasts will be sensitive to jarring movements or physical contact.
The surgery will leave scars on the body that won’t disappear completely. Your surgeon will have discussed this with you before the procedure and given you a clear indication as to where an incision will be made on your body to insert the implant. Incisions are usually made in areas not easily seen, such as in the armpit or in the crease under the breast. Incision scars begin to fade within a few months. Bigger incisions will have been made if you had a breast lift at the same time. These incisions will leave a larger scar that can be more visible.
For most women, the overall result of increased size (volume) by at least one or more cup sizes, and or improved symmetry is a satisfactory one. If you were more realistic to begin with, the results are more likely to be pleasing following the surgery, once the swelling has gone down (remember that your breasts will always looker bigger than you thought they would for a few weeks and take a few months to settle).
Most who are happy with the results experience enhanced self-image and self-confidence, feeling more feminine in their clothing and overall physical appearance.
Do birth control pills affect your breast size?
Oral contraceptives or birth control pills can affect your breast size, however, they cannot influence any changes permanently. You may note changes to the overall fullness of your breasts when you first begin using birth control pills, but only a breast augmentation procedure can effectively change their size permanently.
The change in breast size (volume and fullness) is largely due to fluid retention or temporary weight gain caused by the increase in hormones in the body. Changes in size are often noted when taking the active pills (containing hormones) in the pill pack. Size may return to normal when taking the inactive (or placebo pills). Changes tend to subside after a period of time and the breast size typically returns to normal.
What is the ’24-hour’ boob job?
This procedure is also referred to as the ‘lunchtime breast lift’. For those wanting to look a little ‘fuller’ for a special occasion can opt for a temporary breast enhancement called ‘Instabreast’ without going under the knife (non-invasive).
A saline solution is injected into the breasts while under local anaesthetic and can be done in about 20 minutes. A woman’s natural size can be increased by a cup to a cup and half. The injected saline (salt water) is temporary and is absorbed back into the bloodstream within a 24-hour period. Breasts deflate and return to their normal size and shape once the saline solution is absorbed.
This procedure can provide women with a temporary, but instant confidence boost. It is also a great way for others to gauge if they would like to permanently enhance the size and shape of their breasts. The procedure is painless and a woman can go straight back to normal life and activity following the procedure.
Downsides are that the procedure doesn’t come cheap so you can expect a hefty bill each time it is done. There are also some minor side effects which can include a little bruising, potential for infection (at the site of injection where a needle has been used), nerve damage or haematoma.
If the procedure is done several times, a woman does run some degree of risk for stretching the skin (taking away some of the intrinsic support in the breast) and changing the natural architecture of her breast (shape and size).
Is there a link between silicone gel implants and connective tissue disease?
Scientific experts are looking into a possible link, but have so far been unable to find a direct link to an implant being the cause of a connective tissue disease.
Some women with silicone-filled (gel) implants have been diagnosed with anaplastic large cell lymphoma (ALCL) that is traced in the breast tissue near the implant shell. ALCL is a very rare type of lymphoma (cancer) involving the cells of the immune system. ALCL is usually contained within the fibrous capsule that forms around the implant shell and should not be confused with breast cancer.
Most women with implants were diagnosed with ALCL after seeking medical treatment for implant-related symptoms (such as pain, lumps and swelling, or asymmetry). In most cases, surgery was effective in treating ALCL by removing the implant and surrounding scar tissue. In some cases, additional treatment from radiation therapy, chemotherapy, or both helped to treat the condition.
The risk of ALCL is extremely low in women with breast implants and only occurs with textured options.
Can you breastfeed a new-born baby if you have breast implants?
Implants placed under the chest muscle can help prevent damage to the milk ducts and nerves, thus enabling a new mother with implants to successfully breastfeed her baby. Any breast augmentation procedure can result in increased (or decreased) sensitivity in the nipple which can have some impact on a woman’s ability to successfully breastfeed. Incisions made under the crease of the breast or through the armpit shouldn't lead to any cause for concern. An incision around the areola can, however, increase your risk of experiencing problems with breastfeeding.