Please also see the frequently asked questions about breast augmentation or implants to the right.
The General Information page also contains useful discussion for patients considering breast augmentation.
Scarring – access incision
Every time the skin is cut, a scar will be created.
There are several possible incisions for inserting breast implants. I almost always use a scar in the fold beneath the breast (inframammary fold). This incision is relatively hidden and tends to leave a fine scar with time. However a poor scar is always potentially possible and more likely in certain skin types.
The inframammary scar gives the best access to view the implant cavity and 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 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 can only be used for implants being placed beneath the pectoralis muscle. The visualization of the lower part of the pocket is more difficult and muscle fibre release and control of bleeding can be more difficult with this approach. The scar may be visible when wearing sleeveless dresses.
Under or over the muscle
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 patients occupation.
The main reasons for putting implants beneath the muscle are too disguise the upper medial pole of the implant and give a particular shape to the upper pole. Submuscular placement will usually give a more natural appearing result however if there is adequate soft tissue coverage, this may not be necessary.
There is some evidence that Submuscular placement decreases the rate of capsular contracture. If contracture does occur it is in a slightly deeper plane.
Breast Cancer and Breast implants
There is no evidence that breast 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.
Complications after surgery
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. In about 1:30 cases 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 ptosis. They will supply a new set of implants.
It is thought that capsular contracture may be cause 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.
It is normal for an area of skin about the size of a 50 cent piece immediately about the incision to be very numb for along time. Rarely there may be numbness of the nipple and areolar complex. Hypersensitivity is more common, about 1:10 cases. This can take many months to settle and slight hypersensitivity may be permanent is a small number of cases.
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 minimize 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 although in my experinec this is very uncommon. To date I have had a single case and this was caused by serious trauma several months after surgery.
If implants are placed above the pectoralis muscle, I have no concerns about them moving. About one third of the implants I place are above the muscle. Implant below the muscle may both move upwards and be flattened or otherwise distorted during pectoralis muscle contraction. I will only place implants below the muscle if I think the extra padding is necessary and this is discussed in more detail above.
To date I have never created stretch marks by placing breast implants. I am aware of New Zealand cases where this has happened. It is more likely if oversized implants are used in immature breasts.
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.
Breast implant surgery overseas
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. I unfortunately see a steady stream of less than ideal outcomes.
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 over oversized implants, stretch marks, infection requiring implant removal and am aware of a death in an airhostess 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.
The bitterness of poor quality lingers long after the sweetness of low price is forgotten. John Ruskin
Follow up and long term care
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.
Information booklets from the manufacturer and the US FDA complication booklet are all downloadable from the Resource page
Breast Augmentation Gallery
Click below for Breast Augmentation examples performed by Mr C Davis.