Breast Augmentation (Implants)

Breast enlargement with a prosthesis is a very popular, easy and uncomplicated operation, with patients delighted with the increased fullness and projection of their new breasts, a better balance in their figure, very confident with their self image in dress and beachwear.

Dr Harper performs all the techniques of a mammoplasty with no restrictions or limitations.

Firstly, please read about this procedure in detail as prepared by the Australian Society of Plastic Surgeons Website: www.plasticsurgery.org.au

For further information and costs, please ring the Manly rooms on (02) 99771275 to arrange a consultation.

For Total costs
Medical: Surgeon and anaesthetist fees.
Hospital.
Prosthesis - Round/Anatomical

• Consultation 'Getting the shape right'
• Prosthesis Choice
• Chest wall measurements
• Breast Tissue Over
• Incision
• The Rice test - a trial run
• Placement of prostheses - behind or in front of muscle
• Operation and Post operative care
• Results: Shape of prosthesis and projection
• Long Term results
• Further results for comparison

Consultation 'Getting the shape right'

The optimal shaped breasts can be obtained for each patient over 2 - 3 consultations with Dr Harper.

Types of prostheses, size, shape, placement behind or in front of muscle, incisional site will be discussed:

back to top

Prosthesis Choice

Dr Harper now uses the polyurethane foam cover gel silicone prosthesis from Brazil.

Both round and anatomical (tear drop) shaped prosthesis, with a variable projection forward are used to match each patients request in size and shape.

The benefits of the polyurethane foam coat is due to its ability to adhere to the surrounding tissues reducing to a very low occurrence of:

1. Capsular contracture (hardness and deformity of the breasts)
2. Displacement and rotation of implant (mishapen breasts)
3. Downward displacement of implant ("bottoming out")

The prosthesis is filled with a cohesive gel that is softer giving a more natural feel to the breasts. There have been no leakage, or rupture of the cohesive silicone. The ideal prosthesis.

back to top

Chest wall measurements

The patients width and height of her chest wall is measured.
How much cleavage (1-3cms) and lateral breast bulge the patient desires is discussed.

back to top

Breast Tissue Over

The thickness of breast tissue cover in the upper pole and medially is measured as a pinch test:

This thickness of cover decides placement of prosthesis behind or in front of muscle, the cut off part being 1½cms of tissue thickness (> in front of muscle). Placement will be discussed in detail.

back to top

Incision

Three incisional line sites, this will be discussed The approach in the inframammary incisional is the ideal, uncomplicated and well concealed.

back to top

The Rice test - a trial run

At this stage in the consultation Dr Harper will indicate 3 consecutive breast sizes (in grams), to give the optimum result. A trial run at home, during work, sport, gym, in different dresswear. Rice is boiled, placed in a plastic bag, cooled, then moulded to breast shape (like prostheses) then worn inside a bra deciding on breast size (in grams).

back to top

Placement of prostheses - behind or in front of muscle

• In front of chest muscle is the ideal, natural, comfortable, and easier.
• Behind muscle, requires dividing the muscle from ribs below, to allow placement of prostheses and prevent muscle distortion. It is more painful. Little difference in appearance between the two, however feel and movement of comfort is ideal in front of muscle.

back to top

Operation and Post operative care

Performed in private hospitals, under general anaesthetic, about 2-2½ hour procedure. Day only or stay overnight.

• Walking next day
• variable pain
• discomfort over 2-3 days

First 2-3 days with drains in place, bathing, walking. Drains removed 2-3 days in rooms when the drainage is under 20 mls per day. Shower/wash breasts 4th day. Into bra and tight elastic top.

2 Weeks all tape removed, incisional lines sunbaked, tight bra/elastic girdle 12 weeks night and day, walking driving, no running or horse-riding.

back to top

Results: Shape of prosthesis and projection

Round Prostheses: low priced, uncomplicated to use (does not rotate or have a palpable edge). Use in patients with 1) adequate breast shape already 2) when patient is requesting upper pole fullness with a normal size.

• 1. Low Profile - Round prosthesis.

• 2. High Profile - Round prosthesis
  the more curvaceous projected result
  the narrow chested patient
  loose skin present
  

Patient requested C+ upper pole fullness, extra projection and lateral fullness. In front of muscle placement.

Anatomical Prosthesis (Tear drop, breast shape) Price double that of round
More complications (palpable edge, rotation, seroma formation). Used specifically when inadequate shape or development in patients long and wide chest wall. Patients requesting the 'natural' look. Avoids fullness above nipple.

• Low Profile - Anatomical prosthesis.

• High Profile - Anatomical prosthesis. Larger size with increased projetion

back to top

Long Term results

95% patients are delighted with long term results, breasts retained good shape and size. Excess size (over 300gms) is associated with more problems. Patients regular examinations, mammograms for cancer detection, and remain in excellent health.

1-2 year follow up. Anatomical prostheses to C cup. The size, shape, softness of the breasts is the same. No further children after operation.

Removal of Prostheses
About 1 in 20 patients return 20-30 years later after a mammoplasty seeking removal of prostheses. Reasons, hardness and deformity in their breasts; worried about cancer detection; or increase in breast size especially after menopause now seeking a reduction.
Procedures are:

• Removal of prostheses returning to natural state
  GA / Day only, with covered by medicare and funds

 

• Removal of prostheses then redo BAM
  Deformity of hardness due to scar capsul. These patients do want to go back to their flat chests

 

• Removal of prestheses and capsul, then uplift to correct droop

 

Combined Procedures
Augmentation can be combined until other cosmetic procedures, liposuction, abdominoplasty.

back to top

'Ideal breast augmentation results' - Report

This report comes from the Australian Society of Aesthetic

Plastic Suegeons meeting at Lorne Vic November 2010 on Breast Augmentation

The results of 100 patients , consecutive were assessed and judged by 10 plastic surgeons and 10 non medical people. The results as follows

Size
• 20% patients wanted a larger size
• 10% patients wanted a smaller size
• 70% were happy

Prosthesis Round or anatomical
The round produced the better cosmetic result as it fills the upper pole. Has a more natural look.
However in patients with high positioned breasts, little development, no shape, tight skin, patient requesting a larger size with more projection. The anatomical is a better prothesis.
Patients with lower hung breast require a round prosthesis
Placement in front of muscle gives best cosmetic result.
Better cleavage
Feel and movement of breast, more natural
Prosthesis not displaced with muscles movement.
Satisfaction Round prosthesis in front of muscle most satisfied

Final conclusion: Patient hosts tell patient what she wants, what is her concept of natural beautiful result. Photographs of her desired look and rice test are vital.

Long Term Results.
The nipple and the interior breast fold descend with time, amount related to size of prosthesis, and skin quality. Don't use a prosthesis over 350cc

Further results

• Last 3 consecutive patients of Dr Harper
• All requested round prosthesis, small natural size no excessive projection.

1st Patient

2nd Patient

3rd Patient

back to top

Risks associated with any Surgery

• Wound infection — not common; treatment with antibiotics may be needed, or even removal of the implant.
• Bruising and swelling — usually subsides in one or two weeks but sometimes can take up to a month or more.
• Bleeding from the wound.
• Poor or slow healing of the skin and breast tissue, even possible wound breakdown.
• A chest infection may develop after a general anaesthetic.
• Heart and circulation problems — a blood clot (thrombosis), heart attack or stroke; a blood clot can move to the lung and cause a pulmonary embolism, which can be life threatening.
• Breathing difficulties — due to the general anaesthetic or the endotracheal tube, which can cause swelling. noisy breathing and discomfort.
• Abnormal scarring from the incision — if the scar is unattractive and too big, additional surgery may be needed to try to improve it, though no guarantees can be given.
• Keloid lumpy scar tissue which is pink, raised and irregularly shaped; it may be itchy and tender for many months but will usually fade and settle over the following 18 to 24 months.

back to top

Specific risks of augmentation mammoplasty

• Capsular contracture ~ the body always forms a capsule of scar tissue around the implant, which can thicken and make the breast round, unpleasantly firm and, in some cases, painful. This condition can occur within months of the surgery, or years later. If capsular contracture is severe, the implant may have to be replaced or removed. The need for reoperation due to capsular contracture occurs in about 5 women of every 100 (5%). Some surgeons have reported that reoperation is needed in 20%, but newer implants seem to have reduced this problem.
• Calcium deposits — these can form in scar tissue around the implant and may be confused with calcium deposits seen in breast cancer. Surgery may be needed to remove these deposits and examine them.
• Fluid accumulation — body fluid (serum) and blood can accumulate around the implant after surgery, injury or very vigorous exercise. Treatment may be needed to drain the fluid. Surgical drainage causes scarring, which is usually minor.
• Changes in feeling around the nipple. areola and skin of the breast — changes in sensation are common after any surgery but normal sensation usually returns within several weeks or months. Permanent loss or alteration of sensation is not common. Changes in nipple sensation may affect sexual response and breastfeeding.
• Clotted veins — small veins in the breast can become clogged with blood clots and look like thin cords. They normally heal and go away without treatment.
• Lumps or cysts can form (as with an unoperated breast) and require excision or needle biopsy for diagnosis.
• Leakage or breakage of implants — this can occur due to injury, during mammography, or for no known reason. If an implant leaks or breaks, it cannot be repaired and should be removed. If a saline-filled implant leaks, the saline will be absorbed by the body. Sometimes small pieces of the silicone outer shell break away from the implant but appear to cause no harm.
• Granuloma -— small lumps called granulomas may form in response to silicone gel which gets into breast tissue. They are not cancerous in themselves but may cause concern, and must be checked by your doctor.
• Implant movement — an implant may move from its original position, causing discomfort and a distortion in breast shape.
• Implant extrusion — the implant may push out or "extrude" through the wound or the skin and become exposed. This is more likely after severe infection or after radiotherapy for breast cancer.
• Skin wrinkles and ripples — while most implants normally develop some wrinkles, larger wrinkles in the implant can lead to wrinkles and ripples appearing on the skin near the implant.
• Deformity of the chest wall — breast implants and the procedure of tissue expansion can cause minor chest-wall deformity. The effects on health, if any, are not known.
• Allergic reaction — some women may have allergic reactions to suture materials, tape adhesive or other medical materials or lotions. These reactions are not common and are unrelated to the implants.
• Connective-tissue and autoimmune disorders — there have been allegations that implants are linked to the development of connective-tissue diseases such as rheumatoid arthritis, lupus erythematosis, scleroderma and similar autoimmune conditions. Although many medical studies have not shown that the implants increase the risk of these problems, some research has suggested small increased risks. Although women with implants have developed these diseases, it has not been proven that the diseases were caused by the implants, since a proportion of all women in the community will develop these diseases. The possibility of the development of connective-tissue and autoimmune diseases, even if remote, should be considered.
• Rarely, some women with implants have reported general symptoms, including joint pain, general aching, swollen lymph glands, unusual tiredness, greater frequency of colds and ’flu, hair loss, rash, headaches, poor memory, nausea, muscle weakness, irritable bowel syndrome and fever. The relationship of these symptoms to autoimmune disorders has been suggested but not been proven.
• Gel diffusion — in gel-filled implants, microscopic amounts of gel can diffuse or "bleed" through the silicone shell; this does not appear to cause any problems for the implant, the breast or the woman‘s general health. The body treats this silicone like other silicone present from many other sources such as food, medicines, and so on.
• Breast size and shape — While the surgeon makes every effort to make the breasts look the same, differences in size, shape and symmetry may remain.

back to top

Additional information

Mammography: Implants may interfere with the detection of breast cancer using mammography, a type of X-ray examination. If you have had breast cancer, a family history of breast cancer. or may have other risk factors for breast cancer, tell your surgeon. As implants can rupture from squeezing of the breast during mammography, always tell the radiography technician that you have implants.
To achieve a better examination of breast tissue, some women may need to have additional tests such as specialised mammography, ultrasound or MRI (magnetic resonance imaging). Specialised mammography will require more exposure to X-rays, but the benefits in better cancer screening are greater than the risks of the extra X-rays.
There is no evidence that breast implants increase the risk of breast cancer, although the question has been considered. lt is important that women learn how to perform breast selfexamination. They should examine themselves monthly for lumps, in addition to having any regular tests as recommended by their doctor.
Your surgeon may suggest a regular follow-up appointment for an examination of the breasts for lumps and to assess the implants.

Breastfeeding: Intact implants do not normally interfere with lactation, Many women with implants have successfully breastfed their babies. Not all women can breastfeed successfully, including those who have not had breast-enlargement surgery.
If complications occur, lactation and breastfeeding may be adversely affected.
Questions have been raised about Whether the health of babies of breastfeeding women could be affected in some way. Indeed, many children’s medicines contain silicone, as do many other foods and drinks. No evidence has been produced to show that babies develop or are vulnerable to any illness because their mothers have breast implants. Women with implants who want to breastfeed should ask their surgeon for the most up-to-date knowledge and research about this issue.

Outcome in the long term: Breast size and shape will change due to pregnancy, weight loss and weight gain, and as a normal process of ageing. Breast implants will not stop the effects on breast size and shape caused by these situations.

Recommended further reading
The Therapeutic Goods Administration of the Commonwealth Department of Health and Family Services in Canberra has published a pamphlet entitled Breast Implant Information Booklet, which is recommended. It is available from Commonwealth Government bookstores or may be viewed and downloaded from the Internet on www.health.gov.au. if you order the booklet, be certain to get the most recent edition.

back to top

Questions asked by the patient Mrs Jenny G.

This patient requested augmentation mammoplasty. She had three consultations, performed the rice test, and externsively research the exact look and size she wanted. Also below are all the questions she wanted the answers to. Her results are shown at the end, and she is available to answer any questions.

Q: I read a PDF document on the web by the Therapeutic Devices Evaluation Comittee (TDEC) quoting that with all implants completed 40% experience local complications with 4% requiring surgery. What ar the local complications they are reffering to?
A: These are Dr Harpers local complications (5%) in last 100 brests. No patients had additional surgery.

• Pain discomfort till drains removed
• Bruising / swelling - settled in one week
• Clotted veins in the breast skin producing thin, hard cords
• Fluid accumulation within the breast after the drains have been removed, necessitating reinsertion of drains. Cause; excessive exercising.
• Allergic reaction to medical drugs & materials
• Temporary charge in nipple sensation

Q: It was also quoted in various documents, and in the 4^th edition Breast Implant document produced by the TGA, that 5 to 6% of women will suffer from capsular contracture - or at least 1 in 20. As this is quite high can you please tell me what appears to be the main factors associated with CC.
I.e. Age of patient, amount of existing breast tissue and upper chest tissue (skinny women), type of implant (smooth or rough, round or tear drop), positioning of implant - either sub glandular or under muscle. I have read in other documents on plastic surgery sites that placing the implant sub glandular does increase the risk of CC. Is this correct?
A: Capsular Contracture. In Dr Harpers patient 1%, much lower than in many other plastic surgeons due to

• Drains - not removed till drainage is below 20mls per day per breast. Usually removed 3^rd day (95%)some up to 5-6 days.
• If seroma (fluid collection) around prothesis are drains removed Dr Harper will put drains back
• Tight elastic garments around breasts are worn night/day for 8 weeks
• No jolting exercises as for 8 weeks
• No movement of prosthesis

All these precautions are to help the surrounding breast tissue to become attached to the rough coat around the prothesiss. No ingrowth of tissue = capsular contracture
Main reason plastic surgeons put prosthesis under muscle so that this capsular contracture can be detected or seen

Q: With respect to these statistics, and the fact that the most recent TGA document is dated 2001, can you please tell me what the percentage would be currently and what percentage you would see with your patients. How many would you see return for corrective surgery?
A: In last 100 patients none have returned for additional surgery either a complication are change in size of prosthesis

Q: Is the implant you are considering for me less likely to have complications? Is it a smooth or rough implant? And why was this implant chosen for me?
A: I only used jel silicons rough coated prosthesis 80% round 20% anatomical

Q: Which implants have the most success - smooth or rough? One site quoted that rough implants tend to have less incidence of CC. The same site also quoted that if the implant is placed in front of the muscle the short term benefits are good however the long term benefits are poor. What would it have meant by that quote?
In this same site it stated that there is less chance of CC with silicone implants when positioned behind the muscle but more chance of moving out of Place.
A: That plastic surgeons site, he is saying that so he can put them all under the muscle. This is a very painful procedure under the muscle the prosthesis sits on the ribs, always uncomfortable, does not feel or look right. This surgeon is pulling them under the muscle so that he when a patient gets captular contractiem it is less obvious to look, but very obvious the feel - like a rock. In front of muscle, when capsular contrature ocours it is more obvious and the same feel (rock) Patrients are more likely to come back complain and have it corrected. If a prosthesis ruptures under the muscle, it is a real problem, with gel silicon into lungs and axilla

Q: I have also read that massaging the breasts post op may reduce the likely hood of CC. Is this correct?
A: Wrong, no massaging, no movement. Must have tissue ingrowth into prothesis.

Q: It was noted that a woman who is given an implant after a mastectomy may experience a higher incidence of complications which would be put down to the age of the patient and to the fact that there is little pre-existing breast tissue. Therefore there is little tissue between the actual implant and the skin. Can the same be said of thin patients?
A: No - In thin patients, less than 1½cms pinch test must go under muscle

Q: Will the implant change position during and/or after menopause as I have not been through that as yet. How does the look of the implant change over these years - does it mimic normal aging breast and begin to droop slightly or does the implant basically remain in the same position.
A: No I have many patients in this situation. No problems occured

Q: Exactly why does double bubble occur with implant surgery?
A: Can be related to poor surgical technique. Tight IMF crease, which may be in a an unfavourable position, has not been an adequate release of deep criss-cross scarring of deep breast surface and a new IMF fomed correctly

Q: With respect to nipple sensitivity most women seem to quote their nipples are very sensitive immediately after surgery. They remain that way for a while (many cover them with bandaids or protect them under the shower) however some have lost all feeling altogether.
Is it more likely that the feeling will be lost with too large an implant size or can this happen with smaller implants? Is it more common aigain in thin women? What factors seem to be present in that?
A: Very uncommen, < 1% mild reduction Nerve to the nipple - lateral 4th intercostal space - all surgeons look for it and protect it. Only in very excessively large implants, dissecting laterally may be nerve be parmanently damaged.

Q: What does a 260 gram implant look like? What can I expect it to look like on me?
A: A round implant, with right size base enlarges your existing breast in the same shape (if there is a breast present). Round implant produces a definite shape and does the anatomical. Projection froward (size) is choosen by patient through photographs provided by patient.

Q: How long can I expect the type of implant you are thinking of using with me last before it would need to be replaced? (Taking into account yearly mammograms and general wear). The TGA quotes 8 to 10 years. Is this figure still current? Do the implants you use last on average longer than this?
Are there other factors I should be aware of that will reduce the life of an implant?
A: New implants last much longer than 10 years if no inquiries occur. No factors reduce the life of an implant

Q: How will the implant feel in my chest to my husband? Will there be a noticeable 'unnatural feel'? Many of the forums have quotes by males complaining of the hardness or unnatural feel of implants. Will it be more noticeable as I am thin?
A: Implants feels, looks, moves like a normal breast, as long at capsular contracture does not develop.

Q: It was also noted the implant feels 'cold' for the woman as it does not always remain at a constant body temperature and will cool down (or warm up) with outside air temp and can take quite some time to warm up, leaving the woman feeling cold (or warm). Is this correct?
A: Implants feel some normal temperature not cold

Q: With respect to the evidence that demonstrates that implants do NOT increase the risk of cancer or autoimmune disease, I do carry the ANA for SLE (lupus) already - however lupus has been tested for numerous times and ruled out by my rheumatoid specialist. I do not have the three factors that must be present to have a definite diagnosis.
The TDEC quotes conflicting evidence with respect to implants on patients that are known to carry anti nuclear antibodies. Do you know if there is any evidence that shows I should be concerned as I carry those antibodies or if there is any documentation on what they are referring to?
A: No evidence auto immune disease occurs due to the prosthesis

Q: Can your body 'reject' the implants? Being silicone does this stop rejection.
A: There is no rejection of the prothessis. Immunity does not does develop against the prosthesis

Q: I currently have a small cyst on my left breast which has been there for a number of years. Would this be an issue?
A:

Q: If the implant 'fails' what is the manufacturer liable for? Do they cover the cost of corrective surgery, replacement etc?
A: If the implant fails to production failure, then the prosthesis and reoperation is covered for by the manufacturer.

Q: Does Medicare and private health cover the cost of any medical reason for having follow-up surgery? Say to correct CC or because the implant has degraded over time.
A: Redo surgery is under medicare and funds. There is little out of pocket expenses in hospital, Dr Harper does not charge, prosthesis frequently provided by funds only minimal out of pocket expenses until anaesthetist

Q: Presently I take the following tablets dailiy:

• Oroxine Thyroid tablets
• Glucosamine joint forumula
• High potency Vitamin C
• Multi vitamins
• Calcium

I know that two weeks prior to the operation I should cease taking the Glucosamine and Multivitamines (together with red wine or any anti inflammatories) but are the others acceptable or should i cease those also (excluding the oroxine).
A: Yes - as mentioned above Tablets not to take are given to you on the operational sheet.

Results of the patient

back to top

Contact Peninsula Plastic Surgery for a cosmetic breast surgery consultation. We offer breast augmentation, lift, reduction, and supplementary procedures to give you beautiful, natural looking breasts.

* indicates a required field



Message

Peninsula Plastic Surgery
7 West Promenade
Manly NSW, Australia 2095

Phone: (02)9977 1275
Fax: (02)9976 2802

infowharper@
ppsurgery.com.au

+