Breast Augmentation Surgery - Breast enlargement

Breast augmentation is the operation where artificial means are used to increase the size and/ or improve the shape of the breasts. Estimates suggest that over 5 million women world-wide have had breast implants in the last 40 years, and each year tens of thousands of women continue to have breast augmentation surgery. Many women consider having breast augmentation to improve their size or shape because they think the breasts are too small, uneven in size or shape, or unattractive. Some women have breasts that do not fully develop or have significantly changed in size or shape after pregnancy, weight change or ageing.
Breast Augmentation Surgery, Breast Reduction Surgery After Breast Augmentation Surgery
The decision to undergo breast augmentation should be a personal one and not to please someone else. As with any cosmetic procedure, breast augmentation will not resolve any of life’s major problems, but may help to boost a patient's own body image and self-esteem. All the potential benefits will be discussed and assessed at the time of your consultation.

These days the woman wishing to have a breast augmentation has a number of options and choices open to her. These should allow her to achieve the appearance and result that she wants. Some of these choices and options are: implant type, size, placement as well as incision. Obviously there are pros and cons to each choice and option, however providing a woman has been informed accordingly, then ultimately she can decide which is best for her.

Mr Karidis uses Natrelle implants, for further information on please visit www.natrelle.co.uk


Breast Augmentation FAQs

Am I a suitable candidate?

Only a consultation can determine this. During your consultation Mr. Karidis will ask you about your general medical history including details about any previous breast surgery, family history of breast disease, childbirth and lactation.  The best candidates for a breast augmentation are healthy, emotionally stable women who are realistic about what surgery can achieve. While women of all ages can benefit, it's usually never performed before the breasts are fully developed. If you are a smoker you will be asked to stop smoking well in advance of surgery. Smoking seriously constricts blood vessels and therefore decreases blood flow to a given area resulting in poor healing. Aspirin and certain anti-inflammatory drugs and other medications (discussed in DO'& DON'TS section) can cause increased bleeding, so you must avoid these.

As every patient and surgeon has a different view of what is a desirable size, for breasts, it is important that you discuss your expectations frankly at the time of the consultation. Following this you will be examined and your breasts will be measured with a tape measure in order to obtain an idea of the dimensions of your breast. A discussion will take place, in which Mr. Karidis will try to encompass all the variables present- such as your age, the size and shape of your breast, body proportions and the condition of your skin. Please remember to ask any questions you may have, especially those regarding your expectations and concerns about the results.

Basic Facts and History on Breast Implants

The first silicone breast implant was devised by Thomas Cronin, and Frank Gerow in Texas in 1961 and inserted in 1962.  It is important to understand that the outer shell or envelope of all breast implants has mainly been  made of silicone. However, the actual filling substance has differed through the years, giving rise to various types of implants including saline (salt water), sugar & salt gel (Hydrogel) pure silicone gel which is divided into simple or cohesive gel (i.e. McGhan) and Soya oil (Trilucent).

Silicone gel implants are currently the most common type used in Europe. Currently in America Saline breast implants are the most common, however following the decision of the FDA in November 2006 this is anticipated to change in favour of Silicone gel implants in the very near future. In Europe current sales figures show a distribution of 85% silicone, 15% saline. As modern silicone gel implants have been available since 1962, surgeons therefore have over 45 years of experience with these types of implants. This is more than any other type in use. Evolution has brought changes and improvements over the years with the introduction of textured surface envelopes made of newer formulations designed to minimise the “bleed” or diffusion of what is usually tiny amounts of the silicone oil fraction of the gel contents. Importantly the standard silicone gel by most accounts, arguably "feels" the most natural of all breast implants. This is probably as a result of the inherent smoothness of the silicone gel content.

What about all the horror stories I have been hearing about silicone?

Many ladies considering this type of surgery will no doubt have heard of frightening stories about silicone toxicity or autoimmune/connective tissue disease, due to gel “bleed” or migration. As a result, breast augmentation has, in the last 10 years, received much unfavourable publicity mainly through the irresponsible actions of the media whereby, regardless of the facts, claims have been made with respect to silicone safety. Undoubtedly, most of these stories began to attract attention after the American Food and Drug Administration (FDA) in January 1992 imposed a ban on the use of silicone gel breast implants. The FDA concluded, “there was no evidence that silicone gel filled breast implants are unsafe, but there was insufficient evidence to prove safety”. All the above was a result of pending law suits against the manufacturers of breast implants from women who had implants and were now allegedly suffering from a whole host of symptoms from a disease process arbitrarily termed “silicone related autoimmune disease”.

Since this time there has been much activity and debate within the medical community to try to ascertain whether silicone gel breast implants are safe. To this end there have been many numerous statements issued supporting silicone safety from, amongst other medical bodies, the Chief Medical officer, Department of Health( the full 36 page report can be obtained from Silicone Gel breast Implants Independent Review Group on 0207 972 8000 or  it can be downloaded on the internet on http://www.silicone-review.gov.uk) and the American College of Rheumatology. All concluded that silicone implants expose patients to no demonstrable additional risk for connective tissue or rheumatic disease” and " there is no reason to discourage women from considering breast implant surgery on the basis of acquiring or worsening a connective tissue or autoimmune disorder". Furthemore,  there is no evidence that silicone in breast implants causes cancer in humans. On the contrary recent studies have shown that implanted women seem to have up to 30% less breast cancer than the general population.

The finding of silicone in bodily fluids should also be viewed in perspective; silicon is found abundantly in our environment and indeed probably in most people. Our contact with silicone is extensive throughout all of our lives and it is used widely in medicine. Silicone is used as a lubricant in every disposable needle, syringe and intravenous tubing. Silicones are used in lipstick, suntan lotions, food processing, skin creams, hair spray, and cosmetics. Over 1000 medical products use silicone as a component or in the manufacturing process including artificial heart valves, joints, and pacemakers.

So do silicone implants actually cause any disease?

In summary it would be fair to accept that some women who have had Breast Augmentation surgery, may have subsequently developed at some point in their lives a connective tissue or autoimmune disorder. However as these disorders arise fairly commonly in individuals in the general population anyway, regardless of whether they have had breast implant surgery or not, it is very likely therefore that they would have have become ill anyway. Of course careful statistical analysis will be able to easily determine whether their illness was chance or related to silicone implants. At the moment however, after examination of all the relevant data, it seems safe to say that there is no conclusive scientific evidence that silicone materials in breast implants increases the risk of connective tissue diseases or for that matter breast cancer.

More reassuringly, recently On Nov. 17th  2006 the American Food and Drug Administration (FDA) issued a press release that  concluded that “it has reviewed an extensive amount of data from clinical trials of women studied for up to four years, as well as a wealth of other information to determine the benefits and risks of these products.” It suggests that “The extensive body of scientific evidence provides reasonable assurance of the benefits and risks of these devices and that in the past decade, a number of independent studies have examined whether silicone gel-filled breast implants are associated with connective tissue disease or cancer.  The studies, including a report by the Institute of Medicine, have concluded there is no convincing evidence that breast implants are associated with either of these diseases.” As a result it gave type approval for use of silicone gel implants. For the full press release please click: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01512.html

What about the shape and consistency of implants?

Traditionally, all implants were round. The majority of all implants used are still round. Viewed from the front, they are circular and in profile, they appear to be half moon shaped. The consistency of most round implants is semi-fluid like and termed “cohesive gel”.

Ten years ago, a newer, more cohesive silicone gel (McGhan type 410) was introduced which is became known as the tear drop shaped implant. As the composition of this gel is more set, compared to the more fluid gel of the round implants, it acts like a solid unit, and therefore a shape has been produced which mimics the natural profile of the breast. These implants are slightly taller than they are wide and are fuller in the bottom. There tends to be a smoother transition from the upper chest wall to the top of the breast and not quite so much of a "step-off" as can sometimes be seen with the round type implants. Therefore in theory this tends to give a slightly more natural shape. Of course, as a result of the preset shape of the tear drop implant, accurate positioning must be performed during the surgery to ensure the implant is placed precisely, and in the right orientation, in order for the benefits of the shape to be seen. In practice however there is not as much of a difference as one may think. Generally speaking, in comparison, the round implants give the breast a slightly more circular or rounded appearance with more upper half breast fullness, whereas the tear drop shaped implant gives a more sloping profile to the breast.
The disadvantages to the tear drop shaped implants are that:

  1. not all breast shapes will benefit equally from this particular type of implant.
  2. there have been reports of the implants moving out of place, or turning around within the pocket, with resultant loss of shape.
  3. The cohesive gel of the tear drop also feels slightly firmer to touch, sometimes making the edges of the implant more palpable.
The decision as to which one suits you best will be discussed at the consultation, but as a general guideline it would be right to say that in selected patients the anatomical implants may offer some benefits, but in the large majority of women seeking breast enlargement, round implants are very successful and produce an equally natural looking result.

It is reassuring to know that, as a result of the thick gel composition of all the newer cohesive-gel implants, in the unlikely event of any rupture or breakage of the shell, leakage of the contents does not occur in the traditional sense as it would in the standard liquid silicone gels.

What about the sizes of the implants and cup size?

Implants come in a wide variety of sizes and it is possible for any woman to comfortably carry a variety of sizes on her chest. Most women have a rough idea as to how big they may want to be in terms of bra sizes. Unfortunately, woman have different perceptions with respect to cup sizes and so it is impossible to use the concept of “cup size” alone in determing your ideal size.  The objective therefore, during the examination will be to determine what look you are trying to achieve with the surgery. As you can imagine different size implants in different framed women gives different results. The secret is to choose a size that will give you a more balanced, proportionate look overall and more inline with your desires. At the time of your consultation Mr. Karidis will take specific measurements of your breast and chest in order to try and determine which size would be suitable for you. In addition to these measurements he will take into consideration your rough vision of your ideal breast size. A wide range of sizer, sample implants will be then be demonstrated to you and inserted into your bra(please bring along a sports bra of your desired size), in order to try and give you an idea of the ultimate size you will have after your operation. Seeing this visual image of yourself in the mirror, wearing a sample implant is the closest you can get, before surgery,  of identifying what you will look like after- not cup size per say! As a final caveat, in the decision making for size, it is Mr. Karidis experience, that generally after taking all things into account, it is probably best to err on the side of going slightly bigger than slightly smaller, as most women, in retrospect, given a second opportunity would opt to have gone slightly bigger!

It is important to understand however that ultimately, the limiting factor in choosing implant size is the space available beneath your breast. It’s also important to remember that as the volume of any breast implant increases, then so does its width. Therefore if you choose an implant that is excessively large, the edge of the implant may then extend around beyond the breast and potentially even under the arm pit. This would be undesirable for most people. In addition the potential for rippling (see below) and other long-term adverse problems increases.

The vast majority of women however have a realistic outlook of what they wish to look like, and therefore it is not often that a surgeon cannot deliver the desired expectations to his patient.

Does a breast augmentation affect the means to detect Cancer?

Perhaps the most significant concern over breast implants is the possibility of delayed detection of breast cancer with silicone and saline filled breast implants. Both of these are radiopaque, meaning the implants obstruct the breast tissue viewing to varying degrees on mammogram. Mammography techniques however have improved over the last few years enabling the radiographer to minimise the amount of breast that is hidden by the implant. It is important however to realise that 10-20% of breast cancers is invisible to x-ray, and therefore most breast cancers are still being discovered by self or physical examinations. In this respect, interestingly enough, some clinicians feel that the implant can actually increase the ease of palpation. Furthermore many clinicians also request other types of scans, i.e. ultrasound and magnetic resonance scans (MRI) in addition to mammograms where appropriate to further visualise the breast tissue.
A woman with breast implants should be on the same schedule of routine mammography as all other women. The radiographer should be informed that she has implants and therefore special displacement (Eklund) views will be required for proper radiological evaluation.

Depending on your age you may be required to have a mammogram prior to surgery. This again will be advised at the initial consultation.

In conclusion, implants make the job of the radiologist more difficult but they do not prevent him from carrying it out.

What are the alternatives to Silicone Gel?

Saline-filled implants are currently the most common implant used in the United States. They are also the only alternative to silicone implants. However with the lifting of the ban on silicone implants from Nov 2006, this is likely to change in favour of silicone implants. Good to excellent results may be obtained with saline implants, but as compared to silicone gel implants, saline implants are more likely to cause cosmetic problems such as rippling, wrinkling, and be noticeable to the eye or the touch. They also have a more “slushy” consistency compared to silicone gel implants. Furthermore if the shell of the implant should develop a small leak the salt water is absorbed by the body but the risk of this is about 5% over a ten year period. This results in the breast becoming flat and another operation is needed to insert a new implant. Particularly for women with very little breast tissue, or for post-mastectomy reconstruction, plastic surgeons believe that silicone gel implants are the superior device. In patients with more breast tissue, however, saline implants can look very similar to silicone gel.

How long do implants last?

Like all man made products, breast implants do not last forever. Despite being very robust and resistant to even extreme pressures, they are susceptible to daily wear and tear over time. What this means in simple terms is that the outer shell or coating of the implant eventually wears thin and ultimately disappears. If this happens then the contents of the implant leak out. This is usually termed disintegration, leakage or rupture of the implant. Clinically however this may be difficult to spot. Occasionally one may detect a slight flattening of the breast or an alteration of the shape, but this may only be very slight and hardly noticeable. Sometimes if there is a large amount of leaked silicone then large lumps may occur in the form of swollen lymph glands. These are described as granulomas and are associated with implant ruptures.

Capsule formation (see below) is the main reason that ruptures of an implant can sometimes be tricky to detect. Concurrently, capsule formation can also occasionally be the result of a rupture. As previously stated, a capsule forms a type of “biological bag” encompassing any breast implant.  Should leakage of the implant therefore occur, the contents will still be contained in the same location by the body’s own bag or capsule. Despite being difficult to detect clinically however, thankfully an ultrasound scan will most times be able to accurately assess the condition of any implant when necessary. Another entity to be aware of is Gel Diffusion. Gel Diffusion occurs from minute quantities of silicone which diffuse through the implant shell. This is different from granulomas described above and is usually clinically insignificant. Moreover, with advances in implant technology and shell design, gel diffusion has been drastically reduced.

There are many quoted figures as to how long ultimately any implant lasts before disintegrating. An average figure for modern breast implants is probably in the order of 15- 20 years. There are however variations in the wear and tear amongst different individuals. A women therefore who subjects herself to extreme physical exercise for many hours a day on a regular basis with resultant excessive movements of her breasts (i.e. aerobics instructor, marathon runner, regular horse riding etc.) will naturally subject her implants to more wear and tear over a given period of time, than someone who does very little exercise. In the first situation it would be reasonable to assume that the implants may disintegrate sooner than in the latter case. Indeed there is such variability at times, that Mr. Karidis has encountered patients requiring change of implants as early as 2-3 years (very rare) as well as patients needing changing at 40 years!

In order therefore to have a proper assessment of the state of your implants it is best advised to have your implants examined by a specialist on a regular basis from about 10-15 years after your operation and an ultrasound or MRI performed as necessary.

Are breast implants alone enough for me?

For many women, breast implants alone are not enough to achieve a satisfactory result. This is because, in addition to the requirements for a volume replacement, which undoubtebly the implants provide, there is also a requirement to correct an element of “drooping”(also called ptosis), and many ladies require a “lift”. In Mr. Karidis’s opinion, breast implants alone will not give you a lift, if your breasts have a tendency to droop. Many ladies who have undergone pregnancies or who have lost weight or who are unfortunate to have just developed this way naturally, also require a breast lift as the breasts have over a period of time dropped. In these situations it is best to have a combination breast augmentation and uplift (also called mastopexy). Mr. Karidis will of course be able to determine this for you at the consultation and advise you accordingly.

This operation involves lifting, but not removing, the nipple/areola to a slightly higher level and tightening the breast skin envelope by removing the excess, redundant, portion of skin and some breast tissue in the lower half of the breast. This operation carries with it slightly different scarring than an a standard breast augmentation only procedure. In the combination Breast augmentation/uplift procedure, Mr. Karidis utilises a lollipop incision which means a scar around the nipple and then a vertical scar down to the crease. Even though all scars are generally red to start with, scars usually fade as the months go by. Please see examples of Mr. Karidis work in the Photo Gallery. Do I need an uplift too?

What kinds of Incisions are there?

There are generally 3 types of incisions used for inserting the breast implants.

The inframammary incision, and Mr. Karidis's preference, is made under the breast at the fold or crease line. The incision is about 4 cm in length. This is the most common incision, and the natural fold of the breast usually hides the scar quite well. It will probably always be covered by any clothing-even the smallest of bikini tops. Because the incision gives immediate access to the space where the implant will be placed it is possible to very accurately create the size and shape of the pocket for the implant, and the carefully control the position of the implant within that pocket.

Another method is the peri-areola incision, which is made around the edge of the areola (the darker skin around the edge of the nipple). The disadvantage is that the scar is not hidden by any folds, and subsequent scarring may interfere with milk expression in breast-feeding.

The third method is the axillary incision, which is made in one of the crease lines of the armpit. This is used less often because it is more difficult to get proper placement of the implant in some patients, and if there is a problem in the future, an additional incision on the breast may be required. Although some patients thinking about this surgery may believe this approach is the least conspicuous, in truth this may not always be the case, particularly in light of sleeveless open type clothing which expose the armpit area quite readily and frequently.

Regardless of where the incision is placed it is important to remember that a scar will always be present. As such there are people with good scarring ability(most people) and people with poor scarring tendencies(thankfully quite unusual). This cannot be predicted before the surgery. It is Mr. Karidis opinion, that in the event of poor scarring it is best that the scar is positioned in the most hidden and least exposed of positions. This is why Mr. Karidis prefers inserting the scar under the breast, right in the fold, as this is the least conspicuous place. All scars are red initially, but then scars normally settle quite well and become less conspicuous with time. However no surgeon can ultimately predict the appearance of any particular scar.

Where do you place the implant? In front of or behind the muscle?

There are four locations or pockets which are made and where the implant may be placed;

  1. Directly under the breast tissue, or the subglandular (in front of the pectoralis muscle),
  2. the subfascial(behind the breast tissue but in front of the muscle in a space developed by lifting the front lining of the pectoralis muscle-the fascia) ,
  3. the submuscular (behind the pectoralis muscle) and
  4. the dual plane position(partly under the muscle and partly under the breast or fascia). The pectoralis muscle is the chest muscle that is commonly developed in body builders.
Mr. Karidis positions the implants behind the muscle(submuscular) in approximately 50% of his patients and the remaining 50% under the fascia(subfascial) or breast tissue(subglandular).

In the submuscular placement the implants are placed between the muscles of the chest wall and the rib cage. The advantage of submuscular placement is that it increases the padding overlying the implant offering more coverage and camouflage to the shape and outline of the implant. This is particularly helpful in women bearing very little or no breast tissue at all. By providing this extra padding in these circumstances, one then substantially decreases some of the adverse effects on the appearance mentioned above. Another advantage is that mammography has been reported to be slightly more effective. The disadvantages are that there may be a bit more pain, or discomfort, after surgery, the breast feels slightly firmer than when the implant is placed in front of the muscle, and that the breast will move with certain actions of the muscle.

In the subfascial or subglandular placements, the advantage is that there is usually less pain after the operation, and that the breasts usually feel slightly softer.
The disadvantage is that the outline of the implant may be more prominent or visible in very slim women. In these situations one can therefore sometimes detect a "step-off" appearance or "stuck-on" look of the breasts on the chest. In these situations you will be advised to have the implant placed submuscularly.

There are however some breast shapes that are better suited to the subglandular approach. These women typically have breasts that at one time were much larger than the present. When there is a very large volume decrease and there is little or no shrinkage in the size of the skin envelope surrounding the breast tissue, then the shape approaches that of an "empty bag". Under these circumstances it is sometimes better to place the implant in the subglandular position in order to allow the implant to fill out the skin envelope of the breast. However in most of these circumstances, a simultaneous breast uplift or mastopexy is usually recommended to give the optimum result(see above). In this event, as well as when  the skin envelope has stretched to the point where the nipple is below the breast fold, it will be necessary to reposition the nipple upward again and reduce the size of the skin envelope by means of an uplift or mastopexy. Again, this will be determined at the time of the consultation. (Please see breast uplift section)

The decision, as to which location the implant should be placed in your case, will be discussed at the time of the consultation. Mr. Karidis’s primary concern is to give you as NATURAL a look as is possible!

Watch the procedure in Virtual 3d
Will I have the cleavage I desire afterwards?

This is a question that often arises. The bottom line is that breast implants can only be placed directly beneath where your existing breasts lie. So if your breasts have a natural propensity to look outwards(as some do) and you have a large space between them because of this, a breast augmentation will not fill this space sufficiently to give you that “tight” or close together cleavage. Unfortunately breast position in each individual is more of less set. Mr. Karidis will be able to inform you accordingly at the consultation. Nonetheless even in the aforementioned individuals, the cleavage area will be somewhat better after the breast implants. However if the distance between the breasts is too great then there will always be a gap between the breasts. Of course after the operation, and once everything has settled, you can always wear a push up bra to help place the breasts closer together if you wish.
If on the other hand your breasts are naturally close together and the and the natural distance between the breasts in the cleavage area is small, then you will get a significant improvement and boost in the cleavage area.

What type of anaesthesia is used and how long does the surgery take?

The operation is performed under general anaesthesia and can be performed as a day case procedure or if you prefer you can stay overnight. The procedure takes approximately 30-40 minutes to perform.

What happens after the surgery?

Your breasts will be somewhat swollen postoperatively. This usually settles in about two to three weeks. Sometimes swelling may be slightly different between the two sides. This is normal and settles with time. However if a great difference develops between the two sides then you must contact us for advice.
Following a Breast Augmentation, the breasts may appear to be placed quite high up. This is also normal. During the first two months postoperatively the implants will gradually lower and settle from the effects of gravity into a more natural position. Do not be alarmed if one side settles quicker than the other, as this sometimes occurs.

Following the operation you will have a light dressing in place which will need to be kept dry for 2 weeks. At two weeks your dressing will be removed and the wound inspected and lightly cleaned. There are no stitches to remove, as these are internal and dissolvable. Always remember to read and follow the postoperative instructions that will be given to you.

Post Operative Instructions

What kind of after effects should I expect?

Changes in nipple and breast sensation (feeling) can occur. Some patients may loose sensation entirely, others report only a slight decrease, and some even report heightened sensation. In the majority of cases where sensation changes occurs, these are only temporary and soon recover. The recovery period can sometimes take up to 18 months to complete. In a small minority of patients, however, permanent loss of sensation may occur.

Breast Feeding can proceed following a breast augmentation providing of course that you are able to produce enough milk in the first place. You must understand that regardless of whether you have implants or not, all women cannot breast feed satisfactorily.

Pregnancy: Should you become pregnantfollowing your operation then your existing breast tissue will be subjected to the normal hormonal influences of this period and therefore your breast will enlarge and the skin will stretch accordingly. Likewise, once the pregnancy and any associated breast feeding ceases, your own breast tissue will then shrink down. It is impossible to predict to what degree these changes will occur; however, the breast implant volume will remain the same throughout these.

Rippling or wrinkling of the skin over the implant may occur in women who have little or no breast tissue or ones that have recently lost weight. This has no medical implications in itself but can be cosmetically undesirable. This can occur in any location of the breast. In order to minimise this effect and if deemed appropriate at the time of the consultation, you may be advised that the best placement of the implant should be in the submuscular position as previously described. It is important to understand however that rippling or wrinkling can still occur even when this precaution is taken, and should this then occur it might be difficult or impossible to eradicate.

Palpation of the implants may occur in thinner women following breast augmentation. In these situations the implants are more likely to be felt at the lower part of the breast near the fold. Again this has no medical implications, although women who do not bear this in mind may suddenly become worried about feeling a “lump” in their breast. In any instance of uncertainty it is always best to contact your surgeon to have this examined.

There is no chance of the implant exploding or bursting whilst travelling in an aeroplane, swimming, diving etc.

What about the scars?

Scars are not a complication but a normal event after any surgery. Thankfully the scars in a Breast Augmentation operation are short, being about 4 cm in length. You should always expect these to be red, raised, lumpy and even itchy to begin with but with time they should fade and flatten. This is the natural evolution of the healing process. However it is important to keep in mind that this may take up to two years to complete. Daily massage of the scars during this time period is advised to expedite and facilitate this process. You must understand however that no responsible surgeon will ever be in a position to predict any scars ultimate appearance. Although as mentioned, scars do fade and improve in time, it is not very often however that these are ever characterised as being only "hairline" in nature.

What could go wrong?

As with any operation, normal risks of surgery and anaesthesia can occur with breast augmentation. These include infection, haematoma, and skin necrosis. Infectioncan occur despite our normal routine of administering antibiotics at the time of surgery as well as post-operatively. In Mr. Karidis’s experience, this happens in about 1 in 500 breast implants placed. Signs such as pain, redness, swelling, or fever, following augmentation should be reported immediately to the hospital. Infection not reported could easily compromise the success of any surgery. If infection was to be serious and fail to respond to antibiotics, removal of the implants would be required and replacement would not be effected until such time as the infection had cleared.

Bleeding, as a result of a leak in a blood vessel will give rise to swelling and bruising of the breast. If this is slight then your body will be able to absorb it in time. If it is significant (termed haematoma, and in Mr. Karidis’s hands, occurs in about 1 in 500 breast implants) then it may be necessary to drain this. Your surgeon will be able to assess this.

Skin necrosis or skin decay occurs when there is not enough blood to supply the skin. This could happen if the surgeon were to select an implant size too that was too large for the pocket created. This is extremely rare and in fact, Mr. Karidis has not experienced this problem and nor does he expect to.

What is Capsular Contracture (Hardening)?

This is the most common complication of breast implants. A capsule or capsule formation is a layer of scar tissue that normally forms around any artificial material placed in the body. It is important to realise that this is the natural response of the body to foreign material. Most times this capsule is so soft that it is virtually undetectable and therefore does not affect the implant in any way. Capsular contracture or hardening occurs when this layer of scar tissue shrinks around the implant, squeezing it so that it starts to feel firm, or in some cases, quite hard. Most capsular contractures experienced today stem from the smooth shell silicone implants placed some years ago. The capsule contracture rate in the past was 30-35%. With the onset of textured shell implants, better operative technique,  the problem of capsular contracture has been significantly reduced. In Mr. Karidis’s hands and in his personal experience this occurs about 1% of the time.

The cause of capsular contracture is not totally clear, but seems to be multifactorial. It is important to realise that there are degrees of contracture and that the majority of women, who do develop this hardening, develop it only to a mild extent. In the minority however, it may be severe enough to be bothersome, even painful and may cause distortion of the breast. The condition may occur in one or both breasts and to a different degree either side.

It may develop any time, even years later although it is most likely to happen in the first 3 years after surgery. Unfortunately at this time there is no effective way to prevent capsular contracture if it is going to occur. However as mentioned previously, encapsulation is no longer the problem that it was. Having mentioned all the above:
It is important to note that capsular contracture is not in itself a health risk other than its possible interference with mammography.

There are two ways to reduce or relieve the firmness of a contracture. These are the closed and open capsulotomy. In the closed capsulotomy, the firm implant is manually squeezed tightly from the outside, in an attempt to disrupt or tear the scar envelope. When successful the result is instantaneous and the implant immediately feels soft. The tear resistance of the scar envelope however varies from woman to woman. Some tear easily but in others the scar is so tough that it cannot be torn. In others, only a partial tear is possible which can lead to a small outpouching of the implant, with a resultant unsightly appearance. A closed capsulotomy may also result in bruising, bleeding, or even rupture of the implant itself. If rupture occurs then you will need surgery to remove and replace it. In light of these unpredictable outcomes, Mr. Karidis does not perform this.

The other method, which is much more controlled and thus the preferred method, is the open capsulotomy, performed under general anaesthesia. In this procedure the old incision is reopened and the thickened capsule is removed or loosened. The implant is then reinserted again into the breast pocket. Unfortunately, even after a successful capsulectomy, there is again the possibility of recurrent hardening in about 5% of patients.

Is it painful?

Pain, will be experienced following a Breast Augmentation. It is always difficult to quantify how much pain any one individual will experience. Whilst some women find this procedure painful others report very little or even no pain postoperatively. Placement of the implant behind the pectoral muscle is usually, but not always, associated with a greater degree of pain, as it is necessary to cut the muscle in order make space for the implant.

It would be fair to suggest that most women experience a moderate degree of pain for the first five days, which is easily controlled with regular painkillers. After a week however most women report a considerable improvement in their symptoms and in fact do away with any regular painkillers.

What about Pregnancy and Breast Feeding?

Breast implants do not interfere with breast feeding as the implants are placed behind the breast tissue and milk ducts. Therefore lactation (breast feeding) can proceed without any problems. Of course care should be taken to maintain the shape achieved by the surgery. If pregnancy should occur particular care should be taken in supporting the breasts in order to maintain the best possible shape subsequently. This is achieved by wearing a supportive bra day and night during pregnancy and also whilst breast feeding to provide constant support. If you can limit breast feeding to three months or less this will also reduce the stretching of your breasts and therefore preserve your shape.

How long before I can get back to normal?

Although you can generally walk about and do light general duties from the next day, please avoid any extreme stretching or lifting during the first 7 days. Depending on your job many ladies go back to work at about this time, sometimes sooner. Obviously if this involves excessive stretching and lifting you are then advised to refrain for a further 7 days. You can usually commence light lower limb exercise after 2 weeks. Upper arm exercises and swimming can begin after four weeks. When exercising always try and wear a good sports bra. Driving is allowed after 5-7 days. Sexual activity, involving manual handling of the breasts can be commenced at around 4 weeks although at this stage only very gentle handling of the breasts is advised. More vigorous handling can be commenced only after 2 months!

How many breast implant procedures does Mr. Karidis perform?

In accordance with the National Healthcare commission guidelines, according to the last five years of annual audit figures submitted to the Hospital of St. John and St. Elizabeth in London, Mr. Karidis inserted on average 300 breast implants a per year. In the last 10 years he has inserted nearly 3000 breast implants.

Are there any alternatives to surgery?

There are a number of non surgical treatments that have appeared over the years, purporting to enhance, enlarge, or fill out the breasts. Some of these treatments are in the form of pills, others in creams, others use injectable products and others use devices.

The simplest of these is the herbal supplements. They are for the most part natural. Unfortunately the results derived from these are subtle and too often, none at all. How you respond to herbal supplements depends entirely on your body chemistry. For women seeking a substantial increase in the size of their breasts, herbal supplements are not going to do the job.

Next we have breast firming creams. These creams usually contain a plant extract called Pueraria Mirifica and which has a high concentrate of phytoestrogens. These are not hormones but supposedly they provide the same benefits as the female hormones called oestrogens. Oestrogen is what increases breast size during ovulation along with the birth control pill and doctor prescribed hormone supplements. However, there is little documented evidence to show that these creams really do much of anything at all. So firming creams are probably more hype than anything else.

Next we have injectable fillers. Plastic surgeons have been using injectable fillers for years to fill out lines, creases, and irregularities or depressions on the skin. These are mostly safe, soft tissue fillers that are made up of stabilized hyaluronic acid. These are much safer than the silicone injections that were used many years ago and which had some disastrous results.  However although fairly, it is hard to say for certain what long term side effects could turn out in the future of women who have had these fillers injected into them. Furthermore it is important to remember that these fillers are not permanent and therefore require “regular” top ups to maintain the volume. More recently fat injections taken from another part of your body have been used to fill out breasts. However trials are currently still taking place and it will need to determined whether or not fat injections will have a place in our armamentarium.

After supplements we have what are called breast shaping systems such as the BRAVA system.  It's a clinically proven device used as a non-surgical alternative for breast enhancement. It consists of 2 plastic semi rigid domes with silicone gel rims containing a small microprocessor. The system is applied over the breasts and applies a gentle sustained pull to the breast area resulting in growth of new breast tissue. It is based on the principle that all types of body tissue will grow and generate new, normal tissue when gentle sustained uniform tension is applied(i.e. skin and muscle over abdominal area during pregnancy). The system is held in place with a sports bra and must be worn for at least 11 hours a day for 15 weeks. It can result in an increase of up to 1 cup size. Although initial studies have shown that this effect has been maintained for more than one year even after discontinued use, some patients require further treatments. The disadvantages are that it is very cumbersome and unwieldy to use, and doesn’t always give the patient the size that they desire.

Then of course there are the women who don't want to take any kind of drugs, have any kind of surgery or for that matter do anything to their bodies at all and still want to have larger breasts. Well, for these women there are the breast forms, or what are commonly referred to as "falsies" or “chicken fillets”, which you can place in your bras. For the most part, these are comfortable and can be worn with confidence that they're not suddently going to come loose and fall off at the wrong moment. Obviously however undressed and without your bra these breast forms are of no use.

Possible association with rare cancer

Reports in the scientific community have suggested a possible association between a rare form of cancer, Anaplastic Large Cell Lymphoma ("ALCL") and breast implants. But with an estimated 5 to 10 million breast implant recipients worldwide, experts say the known ALCL cases (approximately 60 to date) are too few to say conclusively that breast implants cause the disease. The number reported of ALCL is difficult to verify because not all of them were chronicled in scientific publications and some reports may have been duplicated.

Anaplastic Large Cell Lymphoma ("ALCL") is a rare type of Non-Hodgkin Lymphoma ("NHL"), a cancer involving the cells of the immune system. According to the Surveillance, Epidemiology, and End Results ("SEER") Program of the National Cancer Institute in the United States, approximately 1 in 500,000 women is diagnosed with ALCL in the United States each year. ALCL in the breast is even more rare; approximately 3 in 100 million women per year in the United States are diagnosed with ALCL in the breast (Altekruse et al., 2010). This means it is incredibly hard to get enough patient numbers to make firm conclusions regarding whether the risk of ALCL is truly higher in women with breast implants, and a report by the respected Food and Drug Agency ("FDA") in the United States, titled: Anaplastic Large Cell Lymphoma ("ALCL") In Women with Breast Implants: Preliminary FDA Findings and Analyses, reflects this uncertainty. Although ALCL is extremely rare, the FDA believes that women with breast implants may have a very small but increased risk of developing this disease in the scar capsule adjacent to the implant. Based on available information, it is not possible therefore to confirm with statistical certainty that breast implants cause ALCL. At this time, data appears to indicate that the incidence of ALCL is extremely low, even in breast implant patients. Currently it is also not possible to identify a type of implant (silicone versus saline, textured or smooth) or a reason for implant (reconstruction versus aesthetic augmentation) associated with a smaller or greater risk. The small numbers of ALCL has been found more frequently in association with breast implants having a textured outer shell rather than a smooth outer shell. However, most of the ALCL cases reported in all breast implant patients failed to include information about the texture of the shell. Therefore, the FDA cannot determine whether ALCL may be found more or less frequently in women with textured breast implants than in women with smooth breast implants.

So in summary and based on available information, it is not possible to confirm with statistical certainty that breast implants cause ALCL. Because ALCL is so rare, even in breast implant patients, a definitive study would need to collect data on hundreds of thousands of women for more than 10 years. Even then, causality may not be conclusively established.

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Summary

The chances are excellent that you'll be happy with your surgery. Most patients understand the advantages and benefits of this type of surgery. However, despite assurances by competent British Plastic Surgeons and the UK’s Department of Health, many women are still concerned about the safety aspect of silicone and implants in general. If this is your case, you have no alternative other than to err on the side of caution and either not undergo breast augmentation or alternatively choose an implant, which you feel happy about.

If you do decide to proceed, the decision as to what type of implant to use ultimately rests with you. A surgeon can only inform and advise what implant he feels is best. Unfortunately, the perfect implant has yet to be made and as already described there are some drawbacks associated with all implants. One must therefore try to balance all these against the benefits, by trying to examine any evidence in a rational and impartial way. Patients should never allow themselves to be swayed by any form of media hype or scaremongering.

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