Breast Augmentation:

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Frequently Asked Questions:
Who will benefit from breast augmentation surgery?

Naturally ladies desiring a bigger bust size will benefit from breast augmentation surgery, but in addition ladies very often request breast augmentation surgery after they have had children and they feel they lack volume and require a more 'pert' youthful appearance. Very often this latter type of patient will benefit from breast implants. However, depending on the anatomical shape of the breasts in the post-partum lady, they may also benefit more from a 'mastopexy' (or breast tightening procedure) and this may involve the use of implants as well as a breast tightening procedure i.e an 'augmentation mastopexy' (see Mastopexy section). By in large however many post partum ladies who require a modest rejuvenation of the breasts will benefit from breast augmentation alone.

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Is there a best type of implant to choose for breast augmentation?

In essence no one size fits all. There are a large number of choices e.g implant filler (silicone v saline), implant shape (teardrop v round) and of course, implant volume. This large number of choices allows a patient to get the best possible implant for her particular anatomy and to marry this up with her desires, both in terms of breast volume and shape. Only after a consultation and examination can a lady's desires be reconciled with her anatomy and then the best form of implant be chosen to give her the result that she desires.

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The next type of abdominoplasty (a modified or limited abdominoplasty) is designed for ladies with a lesser degree of skin laxity and this also leaves a scar in the pubic region. In order to remove the excessive amount of skin the scar is slightly longer than a caesarean section scar. Depending on the degree of skin excess however, scar length will vary i.e. the greater skin overhang then the longer the scar. Through this lower abdominal/pubic crease incision the muscles of the lower part of the abdomen can be tightened if there is a lower abdominal bulge. This type of abdominoplasty is also known as a mini abdominoplasty and with this technique liposuction can more safely be used in other parts of the abdomen. However the technique does not address any bulging of the abdomen above the belly button and this is more readily addressed with a full abdominoplasty.

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Breast augmentation Implant composition?

The vast majority of breast implants in the UK are made of silicone. Silicone was first introduced in 1962 and thus it has got a long track record and overall good safety profile. Silicone has a natural feel to it, like normal breast tissue, and the life expectancy of the implant is greater than that of saline (salty water) filled implants. Silicone implants are a form of gel made from silica (sand) and the gel has got various degrees of viscosity (runniness). Mr Fogarty uses the latest form of silicone gel implants that have a high viscosity and are thus called 'cohesive gel' implants. That is to say if one were to cut one of these implants in half the gel would not run out of it but it would appear like 'Turkish Delight'. This not only has a natural feel but enhances the safety profile in that these are felt to be less likely to rupture secondary to trauma and if there were to be a disruption in the shell around the implant the gel would not leak out. Saline implants are used in a minority of breast augmentation cases in the UK and this is because they are more prone to rupture. Furthermore, they have a shorter life expectancy compared to silicone implants and if a saline implant were to rupture the implant would fully deflate as all the saline is absorbed by the surrounding breast tissue. For further information about silicone the Department of Health Independent Review Group (IRG) have fully reviewed this topic and the publication may be found at the following website www.silicone-review.gov.uk

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What is the best shape of breast augmentation implant? Teardrop or Round?

Because more modern silicone gels are more viscous or cohesive they can be shaped into a teardrop shape that is known as an 'anatomical implant'. Anatomical breast implants have an upper sloping surface to them so they are larger at the bottom than at the top. This mirrors the shape of the natural breast and thus for the lady who has very little breast tissue, who wishes a more natural appearance, anatomical implants are best suited for these cases. For a lady however who has ample breast tissue and who wishes to restore a more youthful appearance to their breasts eg the lady after childbirth for example, then a round breast implant would ably meet their needs. In this type of case a round implant would have an advantage over a teardrop shaped implant because a teardrop implant may potentially rotate (albeit very rarely). This would result in a misshapen breast and hence there would be no need to take the potential risk in this situation. For the lady with very little breast tissue however it would be worthwhile by in large to take this risk, as the risk of an anatomic breast implant rotating is extremely small.

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What is the best volume of breast implant for breast augmentation?

Again there is no ideal volume for every lady. Commonly patients ask me that my friend had a such and such volume implant and they look great. The volume of implant however is dictated by the shape of the ribcage which in turn is dictated by the height and general size of the patient. Thus a particular breast implant may look satisfactory in a patient who is 5 feet tall but completely unsatisfactory for a lady who is 6 foot tall. Furthermore, depending on the amount of breast tissue that a lady has to start with and the degree of laxity of the skin of the breast this will further influence what volume of implant can be placed. So not only will the volume of implant be dictated by the lady's anatomy but of course it will be determined by the patient's desires depending on what they wish to achieve, whether that be a small, modest or large breast augmentation. Because of the advent of the anatomic or teardrop shaped breast implants, surgeons now tend to talk much more about the dimensions of the implant in terms of centimetres as opposed to volume. The greatly enhanced choice of breast implants allow a surgeon to tailor the implant to that particular patient to achieve their goals and that is why the dialogue between the patient and the surgeon is extremely important so that patients can achieve their desires.

Ladies should be cautious about seeking too large a size relative to their breast tissue. Time has shown that ladies who have had 'very large' breast augmentation implants go on to develop a wasting of the natural breast tissue because of the pressure of the implant. This means that when the breast implant reaches the end of its life expectancy (approximately 15-20 years) replacement of the breast implant may not produce a cosmetically desirable result and further surgery in the form of an augmentation-mastopexy may be required and this entails additional external scarring. Thus implant volumes greater than 400 mls should only be considered in special circumstances.

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Where is the best place to put the breast implant?

Either underneath the muscle or underneath the breast/gland? All breast implants are behind the breast but those immediately under the breast(or gland) are said to be in a sub-glandular position. The implant may also be positioned at a deeper layer underneath the main muscle of the chest (the pectoralis muscle) hence this is called the sub-pectoral or submuscular position. Again there is no 'best place' for all ladies to place the implant. For some ladies it is best to put the breast implant underneath the muscle if they have got particularly thin skin as the edge of the implant may be visible in the upper chest. Thus placing the breast implant underneath the muscle in these cases helps disguise the upper part of the implant and maintain a natural appearance. Other ladies however, who have thicker skin or slightly more breast tissue, do not necessarily have to have the implant underneath the muscle as the implant is well disguised underneath their own breast tissue/skin. Furthermore in ladies with sagging breast tissue placement under the breast may be best to 'fill out' the sagging breast tissue

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What would I expect at the consultation?

All consultations are held with Mr Fogarty himself. During this he feels it is extremely important that there is very good dialogue between himself and the patient as this is the best way for the patient to achieve their desires. A full medical history is taken in case there are any medical factors that may require adjustment of surgical technique. A breast examination will allow assessment of breast tissue characteristics as well as the size and shape of the rib cage/thorax. Gathering all this information the patient may be presented with her choices as to what will optimally achieve her desires. Mr Fogarty feels that it is imperative that the patient is in the driving seat and they can go away armed with that information and if they decide they wish to proceed with surgery they may contact his secretary to arrange a date or if they so desire they may wish to come back for a second consultation for clarification prior to making any decision. Surgery can then be arranged at any of the clinics from which Mr Fogarty works so this fits in best with a patient's diary. Finally it may help to bring to the consultation a sports bra of the size you wish to be as well as a close fitting tee shirt. It is then possible to place implants of a variety of sizes into the bra and his can help the understanding of the size you wish to be in the discussions with Mr Fogarty. It must be stressed however that the breast implant volume that is placed in the bra does not necessarily equate to the implant volume that is required in the operation. Again this is because patients' chest wall size and skin qualities vary and an implant under a bra is an artificial situation.

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What is involved in breast augmentation surgery?

All surgery is performed by Mr Fogarty himself and surgery may be carried out under either general anaesthetic or sedation with local anaesthetic (twilight sedation) depending on a patients preference and after discussion with the consultant anaesthetist. For the healthy patient (i.e. most patients requesting cosmetic surgery), modern anaesthetic techniques are very safe and in fact patients have more to worry about travelling on the road to hospital than in hospital ! The surgery itself will last approximately 60-90 minutes and during this a 5 to 6 cm incision is made beneath the breast and this allows access to the tissues behind the breast. A space or pocket is created behind the breast tissue itself or at a deeper level behind the main muscle of the chest (pectoralis major). Within this space the implant can be placed and then the incision is closed with dissolvable sutures. Drains are not usually required but occasionally a soft narrow drain may be placed if there is a potential risk of developing a blood clot (haematoma) within the breast. The incision is then covered with paper tapes and an adhesive bandage but strapping is not required. An overnight stay is usual and patients' value having the security that trained nursing staff are close at hand. Usually there are minimal problems with sickness after the surgery although some ladies who are prone to this can discuss this with the anaesthetist pre-operatively in case any alteration of medication is required. There is usually minimal pain after the surgery but of course everybody's pain threshold varies but by the next day ladies can expect to go home just taking painkilling tablets. Within 5-7 days most of the pain should have settled and ladies can expect to go back to driving at that stage and 7 days after the operation you will return to Mr Fogarty's clinic to have the wound inspected. Usually the wound will be well healed at that stage and you can recommence full body showering. Prior to this first review appointment it is wise just to shower the lower half of the body and use a facecloth for washing the upper half of the body. Bathing however, is not recommended due to the risk of cross infection to the breast incisions. After the wound check at one week one will be able to resume driving and light carrying eg 1- 2 shopping bags. Pain or discomfort will dictate subsequent activities but by in large vigorous exercise should be refrained from for the first 4 weeks after surgery. Most ladies in light jobs can return to work a week after the surgery. After discharge from the hospital you may be required to wear a sports bra 24 hours a day and thus one should bring a bra of the size you wish to be when having the procedure. It is not absolutely necessary to wear this but many patients find that it is helpful, and it will depend on the exact circumstances of the operation.

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What is the recovery after breast augmentation surgery?

After the operation patients are discharged the next day and a friend should drive them home from the hospital. Patients are asked to bring a sports bra of the size that they wish to be to the hospital for the procedure as they may find it more comfortable to wear this after the surgery. They can wear this bra for as long as they like but in some patients it may be necessary to wear it 24 hours a day but this will depend on your individual circumstances. By in large most patients do not have any bruising after the surgery although occasionally some patients do but if this is the case, it will be beneath the breasts and thus be hidden underneath clothing. There will be a small degree of swelling within the breasts because of the surgery and there should be slight reduction in the swelling with time although minimally so. For those ladies who have not had children before, very often the skin feels quite tight and again the tightness in the skin tends to relax in the first few weeks after surgery and the breasts then assume a more natural appearance. When going home the next day patients will usually just require painkilling tablets to take on a regular basis for the first 5 days but this should not be very sore. So patients may be able to resume driving around day 5, although most patients will wait until day 7 when they have had a wound check-up with Mr Fogarty's clinic. When at home for the first week normal daily activities will not be a problem but one should avoid lifting excessively heavy weights such as heavy shopping bags. Lifting young children however is not a problem. When at home patients can shower from the waist down and use a face cloth to clean above the belly button. There are waterproof bandages over the wounds which are splash proof but patients should refrain from having a bath for fear of cross infection into the wounds.

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Summary of recovery after breast augmentation surgery Day 1-5 Normal daily activities around the house but no heavy lifting (nothing heavier than a toddler!) Painkilling tablets can be taken either on a regular basis or as required depending on the level of discomfort and a sports bra may be worn to reduce any discomfort. Because there are splash proof dressings, only showering of the lower body is acceptable but bathing is not allowed. Day 5-7 Usually pain is diminished significantly to allow driving but only short journeys at the start and it is very much up to the patient's discretion as to whether they feel safe to carry out 'an emergency stop' and safely wear a seatbelt without causing any discomfort. Day 7 Usually review for wound check at Mr Fogarty's Clinic, no sutures to be removed as sutures are dissolvable. Can resume work depending on degree of upper body activity involved in work at this stage. If wound is satisfactory one can resume full body showering. Week 2 Usually can resume bathing at this stage. Still niggly aches and pains and often one breast may feel slightly different discomfort relative to the other breast. Usually there is minimal bruising after the operation but if there is any this should have resolved by this stage. Week 4 If asked to wear a sports bra '24/7' this can be a discarded and a normal bra adopted. Week 6 Final review appointment with Mr Fogarty's Clinic. Majority of swelling/tenderness within the breasts should have subsided by this stage. If the breast augmentation is large or the skin was quite tight this will have subsided by this stage. Top


What are the scars like after breast augmentation surgery?

The vast majority of breast augmentation procedures utilize an incision beneath the breast in the fold of skin just where the breasts meets the chest/abdomen (inframammary fold). This scar is usually no greater than 5 cm in length and lies to the outer side of the breast so that one can still wear a low cut dress if desired. The scar essentially lies along the same line that the under wiring of a bra would rest on. This incision allows the implant to be placed in the best possible position with the least amount of complications. Other potential access incisions are rarely used in the United Kingdom. An incision can be made around the nipple but this carries with it an increased risk of contamination of the implant with bacteria and possibly increase risk of nipple numbness. Sometimes an incision may be made in the armpit (or axilla) and this is often utilized by surgeons who place saline implants. Also there is a greater risk of implant mal-position with this technique. Finally an incision may be placed in the belly button and again allow saline inflatable implants to be placed underneath the breasts. This latter technique is rarely used as one can only place saline implants and again there is greater risk of implant mal-position.

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What are the risks of breast augmentation surgery?

There are risks associated with every medical procedure and indeed risks associated with everything that we do in life in general. We are aware of what the risks are involved in surgical procedures and thus can do everything possible to minimise the risks involved but unfortunately not eliminate the risks involved in surgery. In chronological order the type of things that can go wrong after breast augmentation surgery can include the following:-

Bleeding and haematoma; because ones blood pressure can rise after surgery blood vessels can open up and start bleeding in the first 6-8 hours after surgery. For this reason we like to keep patients overnight to observe for any signs of a haematoma. The risk of this happening is quite small, approximately 0.5-1% of patients develop this. If a haematoma develops then the patient must be returned to theatre that day and the haematoma or blood clot removed. This bleeding or haematoma would not require blood transfusion or be a threat to ones life but would be a nuisance and should not affect the cosmetic outcome.

Infection; many precautions are taken to reduce the risk of infection (changing gloves, antibiotics, washouts) despite this there is a very small risk of wound infection (0.5%) and if this occurs this is readily treated with antibiotics. If however infection were to occur around the implant itself then antibiotics cannot treat this unless the implant is removed. Once the implant is removed the body can fight off the infection and then after approximately 3 months, when everything has settled, the implant can be replaced. The risk of this happening is very rare approximately 1 in 1000 cases.

Adverse scarring/keloid; normally scars are red for the first few months and become pale white but will always remain permanent. Occasionally people who are pre-disposed to forming lumpy scars can get a lumpy scar called a keloid. This occurs in less than 1 in 300 patients and if it were to happen it would mean that the lumpy scar would get lumpier and larger with the passage of time. To treat the keloid one would have a number of steroid injections injected into the scar in the Outpatient Clinic. This course of injections will usually flatten the scar.

Capsular contracture; any foreign object, whether it be a hip replacement or a breast implant, gets walled off by the body by a layer of scar tissue. In the case of breast implant this is called a capsule. In the vast majority of breast augmentation patients this capsule is invisible and one cannot feel it. However, if the capsule starts to contract this "capsular contracture" then becomes visible as an asymmetry between the breasts. Very occasionally this capsular contracture can be painful. The risk of this happening is relatively low approximately 3% of cases over the lifetime of the implant. A large number of things that we do and the implants that we use will help to minimise this risk, but it cannot eliminate the risk. If a capsular contracture develops then the lady can either opt to have both the implants removed or she can have the implants removed and replaced with new implants. This is usually the preferred option for most ladies.

Breast cancer and screening; there is no association between breast implants and breast cancer, in fact ladies who have breast implants have a slightly reduced risk of breast cancer compared to the normal population. When a lady gets to an age whereby she would be enrolled in a breast screening programme or if she were to be concerned about any breast lumps and request a mammogram (x-ray of the breast) then breast implants do not interfere with the ability to detect breast cancers.

Connective tissue diseases; a group of diseases such as rheumatoid arthritis and lupus are known as connective tissue diseases. There is no association between these diseases and breast implants. Further information about this can be obtained from the Department of Health's Independent Review Group at www.silicone-review.gov.uk

Deep venous thrombosis; any operation carries with it a small risk of developing a blood clot in the lower legs that is known as a deep venous thrombosis (DVT). If a DVT were to develop then this can travel to the heart and be potentially fatal. The risk of a DVT after this type of surgery is extremely small, less than 1 in 10,000 risk. Patients on the oral contraceptive pill would be at a slightly increased risk because the pill can increase the clotting of the blood. Although the risk is reduced by stopping the pill, overall the risk of a DVT is still very small, and thus it is not absolutely essential to stop the pill and indeed if ladies were to stop the pill they may be at risk of pregnancy, which in itself carries with it a high risk of developing a DVT !

Revisions/cost; early revision surgery is very unlikely after this operation. In the event of an early complication i.e. within six months of surgery, this would all be covered by the Fixed Price Scheme that each individual clinic would run and thus no extra charge would have to be incurred by the patient. Revision surgery after the six month period is generally rare but risk accumulates with time. One of the few complications to occur after this stage is capsular contracture which occurs in approximately less than 10% of patients over the lifetime of the implants. With later complications ie after 6 months post op, a fee would be applied

Lifetime upkeep: like any major purchase one should consider breast augmentation surgery potentially needing further surgery at some stage in the future eg the longer one has implants the more it is likely that you may need some form of implant replacement because of either capsular contracture , implant rupture or drooping of the breast tissues. Thus it would be sensible to budget for the worst case scenario if that is required.

Rippling; is essentially the visible edge of the breast implant being apparent at the top or side of the chest. This is more apparent as the lady leans over and there is tethering on the overlying skin. Incidence of rippling is very rare after silicone breast implants but is more common after saline breast implants (3% for saline implants). Rippling is a manifestation of a degree of capsule contracture around an implant that is transmitted to overlying thin skin. Ladies with thin skin or little breast tissue may thus be best served by having their implants placed at a deeper level underneath the pectoralis muscle and being conservative in the size of implant desired.

Nipple numbness; after breast augmentation the breast implant presses on the nerves that supply sensation to the nipple. This may result in a temporary reduction in sensation to the nipples for the first 7-14 days. Occasionally some ladies may notice an increased sensitivity to touch within the nipple area. The vast majority of ladies recover full and normal sensation of the nipples, however in 10-15% of patients may have disturbed sensation of a permanent nature. The risk of this happening are increased with the larger sized breast implants.

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How long do the results of breast augmentation last?

Silicone breast implants on average last approximately 15 years but like anything 'man made' it may be less or more than this figure. We would like to think however that modern technologies that are involved in making implants today will allow today's breast implants to last longer than this as the implants that are lasting 15 years at present were obviously made some time ago. In fact there are some ladies in Cronin Gerow's original series of breast augmentation patients in the 1960's who still have their breast implants ! After 15 or 20 years if there are no symptoms from a breast implant then ladies may not be concerned at all. If however, ladies feel discomfort or notice any asymmetries or firmness of the breasts then this may be an indication in that a breast implant is degrading and further consultation should be sought at that stage. If there were a degree of capsule around the implant (see below) then removal of the capsule with or without replacement of the implant would be an option at that stage. Top


Is it alright for me to fly after breast augmentation surgery?

It is a common misconception that breast implants can rupture in an aeroplane. Breast implants are perfectly safe in this situation, however long haul flights ie. greater than 5 hours would not be a good idea in the first week after surgery, purely to minimise the risk of deep venous thrombosis in the legs (see above).

Breast Augmentation Summary Points:

     Type of anaesthesia          General

     Duration of surgery           60-90 minutes

     Hospital stay                      Overnight

     Return to work/driving      7 days

     Recovery                           Minimal pain by 10-14 days

     Back to light
     sports activities                4 weeks

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Summary points for patients undergoing Breast Augmentation Surgery

Mr Fogarty will have discussed with you at the consultation the nature of surgery, its implications and its potential complications. If there is any doubt or you have further questions, Mr Fogarty is always happy to see you again prior to surgery, at no extra charge, so as to ensure that you are clear in your own mind about the procedure. Out patient consultation Take a sports bra of the cup size you wish to be and a close fitting tee shirt. 6 weeks pre-operatively If you are going to stop the oral contraceptive pill prior to surgery, do so by this stage, taking alternative precautions against pregnancy. If you have not stopped the contraceptive pill prior to surgery the technique can be altered to minimise your risk of blood clot in the legs (DVT) 2 weeks pre-operatively Stop taking any aspirin or aspirin containing products as these may increase the risk of bleeding. Also any non steroidal anti inflammatory drugs (NSAIDs) such as Brufen or Volterol such should be stopped, as should any Vitamin E tablets or multi vitamins containing vitamin E. 1 week pre-operatively It is advisable to take 1 gm vitamin C twice a day to improve wound healing. Some patients also find homeopathic remedies such as Arnica may reduce bruising. One should also purchase a good sports bra of the size that you desire so this can be worn after the surgery. Night before surgery/
morning of surgery
If your surgery is planned for the morning it is wise to have a shower the night before using a medicated shower gel/body scrub (e.g. hibiscrub or hydrex) and wash ones hair. Nail polish should be removed prior to surgery for the anaesthetic equipment requirement. The day of surgery Dress in loose clothing with a shirt and zip-up top and/or cardigan (as opposed to a pullover) as lifting ones arms may be sore initially after surgery. Also pack the sports bra to wear after surgery along with usual toiletries for overnight stay. Day 1 after surgery You will be going home today and will have been given some tablets to take home, (antibiotics and painkilling tablets). NB if you have any allergies, especially Penicillin, please let Mr Fogarty's secretary know in advance. You may wish to wear your sports bra going home for support. A friend should drive you home. Day 2 post-operatively It is OK to shower today but just showering the lower half of ones body and using a face cloth to clean the upper half of the body, avoiding getting the bandages over the wounds wet.. 1 week post-operatively You should be reviewed today for a wound check at Mr Fogarty's clinic. The bandaging will be removed but there are no sutures to be removed but you may have the wounds re-taped for extra support and improved scarring at this stage. You may resume driving at this stage and can return to work. 4 weeks post-operatively If you have been advised to wear a sports bra continuously this can be dispensed with at this stage and just worn as required. An underwired bra can be used now at this stage but they are best avoided prior to the 4 week stage as they can exert some pressure on the incision line. 6 weeks post-operatively You will have a routine review again at Mr Fogarty's Outpatient Clinic and the vast majority of any swelling and skin tightness will have settled by this stage. Most patients do not need to be seen again after this stage.

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POST OPERATIVE ADVICE SHEET - BILATERAL BREAST AUGMENTATION SURGERY

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