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Breast Augmentation

Breast augmentation (Breast implants)

There is quite a body of information that I believe you need to know about breasts in order to make the informed choices if you are considering cosmetic surgery to your breasts

It is important to realise several facts:

  • Most women have one breast larger than the other.
  • Most women have one breast that sits lower on the chest wall than the other.
  • Breasts are composed of a mixture of fat and glandular tissue. The glandular tissue (the part which secretes breast milk) weighs more than the fat that surrounds
  • supports and pads out the glandular tissue
  • so the larger the proportion of glandular tissue your breasts have
  • the heavier they are and the more they will droop without support from a bra.
  • Breast fat increases and decreases in tandem with variations in body fat generally.
  • Breast glandular tissue increases and decreases in tandem with variations in female hormones (for instance before and after menstruation and pregnancy).

Armed with these pieces of information, you will find it much easier to decide whether this operation is for you, and which variant of this operation will suit you best.

Breast augmentation

Breast augmentation is one of the most commonly performed cosmetic surgical procedures.

It is an operation to enhance the size and shape of a woman’s breasts and involves placing a silicone gel implant behind each breast to increase its volume and enhance its shape. Breast augmentation can improve your physical appearance and enhance your self-esteem if either you have never had the volume and shape you desired, or having had it, you have subsequently lost breast volume and shape after childbirth, weight loss or, simply because of passing time and gravity, .

It is also a suitable operation for correcting breast asymmetry; improving the appearance of very small breasts or congenitally absent breast tissue and also, to correct deformity resulting from cancer surgery.

For suitable patients, breast augmentation enhances both appearance and self-esteem.

As you read further you will see a list of potential problems that women who undergo breast implant surgery may experience.  They are not to be taken lightly, but nor should necessarily be a reason not to go ahead.  The important thing is to weigh risk against benefit and to ensure that risks are mitigated as far as possible – and one more thing: I like to see my breast implant patients once a year, life-long to keep an eye on them and their results.  This means we can see if problems are developing and deal with them promptly.

Commonly asked questions about breast augmentation

  • Am I a good candidate for breast implant surgery?
  • Will silicone from my implants contaminate my breast milk?
  • Do implants increase my risk of breast cancer?
  • Will having implants mask a new breast cancer or delay breast cancer diagnosis?
  • What is Breast Implant-Associated Large Cell Lymphoma?
  • Do silicone implants cause Connective Tissue Diseases?
  • Will my breast implants stay the same forever?
  • Can surgery affect my nipples?
  • What should I expect from my consultation?
  • How is the surgery performed?
  • What does my operation involve?
  • What about my recovery and return to normal activities?

Am I a good candidate for breast implant surgery?

This is best decided during a consultation, but generally speaking, the best candidates for breast augmentation are women who are physically healthy and are seeking a realistic improvement in the size and shape of their breasts.

If your breasts are sagging, I may recommend a breast lift instead of, or in combination with augmentation.

Will silicone from my implants contaminate my breast milk?

There is no difference in elemental Silicon concentration in the breast milk of women with and without implants. Silicon concentrations are up to & 10x higher in cows’ milk & infant formula feeds, than in breast milk.

Do implants increase my risk of breast cancer?

There is no evidence to support this, with all published epidemiological studies showing cancer rates at the same levels as for women without implants, or lower.

The most recently published  by Noels, E.C. et al, is a meta analysis of 17 studies looking specifically at women who had undergone cosmetic augmentation found no evidence for any increased risk of breast cancer.

Noels, E.C. et al, Breast Implants and the Risk of Breast Cancer: A Meta-Analysis of Cohort Studies,(2015),  Aesth. Surg. J, 35, 55-62

Will having implants mask a new breast cancer or delay breast cancer diagnosis?

A study comparing breast cancer in women with and without implants shows both groups have the same 5 year survival rates from breast cancer, but women with implants present with smaller tumours and are 12 years younger at diagnosis on average – this is probably due to increased contact with their surgeons as a result of having had implants, meaning tumours are found earlier and younger.

After breast augmentation, you will be able to perform breast self-examination as before.

For women over 35, I advise you to have baseline mammograms before surgery and another 6 months after surgery, which will give screening services in the future a frame of reference to aid in detecting any future changes in your breast tissue.

If you have had implants and need mammography, a special displacement technique has been developed that maximises view of breast compared with standard mammography, so you should tell your radiographers so they can use this technique.

Do silicone implants cause Connective Tissue Diseases?

Analysis of 20 large studies shows no evidence to link silicone implants generally or gel-filled implants specifically, to connective tissue or autoimmune or rheumatoid-like diseases.

Do silicone implants cause Autoimmune Diseases?

In 1982, a paper was published suggesting it was (1).  It was a shockingly bad publication postulating “Human Adjuvant Disease” based on observations in 3 patients.  It should never have been published or allowed to influence the debate and it did great damage, not least because as evidence for a causal link between silicone and autoimmune disease is increasingly likely, the adverse reaction to this paper, especially among plastic surgeons, has set back research that might find it.


In 2000, a meta-analysis of 20 large studies found no evidence to link silicone implants generally, or gel-filled implants specifically, to connective tissue, autoimmune or rheumatoid-like diseases (2).  However, more recently, the American FDA multicentred cohort study of outcomes in 99,993 which represents the largest study of outcomes to date for patients who had breast implants used for primary aesthetic augmentation and for breast reconstruction after cancer, revealed that patients who had primary implants also had higher rates of 3 autoimmune conditions: Rheumatoid Arthritis, Sjögren’s Syndrome and Scleroderma (3).


The pendulum has swung back and forth for 40 years with seemingly no clear evidence either way, because “association” is not the same as “cause” and because most studies that were published, were flawed in design despite passing the peer review process and being published – for example many were retrospective reviews of data from women who had their implants for too little time to draw meaningful conclusions.


However, now that it is clear that (however rarely) implants can cause BI-A ALCL, a tumour of immune cells, logically there must be an interaction between the immune system and (textured) silicone implants and in recent years, there have been studies published which point to an association between breast implants and autoimmune disease.


In Israeli study in 2008 (4) compared women with implants compared with otherwise matched women without implants.  This showed a statistically significant  increase of 22%  autoimmune disorders, and the prevalence of Sjögren’s syndrome, Multiple Sclerosis and sarcoidosis each increased by at least 60%.


In their report Breast Implant Illness: what’s the evidence? (download here) for the National Center for Health Research, Zuckerman and Srinivasan conluded: “Despite the controversies about autoimmune and CTD diseases, the evidence is quite consistent, finding increases between 22%-200% or more. When patient-reported symptoms are evaluated rather than classic diagnoses, and when studies with large numbers of women with implants for 7 years or more are included, the associations tend to be stronger and statistically significant. “


The best advice I can give is that a patient who already has an autoimmune condition or a family history of one, should carefully weigh the risk that silicone implants may in some way stimulate their immune system and affect their autoimmune disease.  Other patients can realistically conclude that risk of developing one will be increased significantly by implant surgery.


(1) van Nunen, S.A. et al. (1982) Arthritis Rheum, 25, 694-7


(2) Janowsky, E. C., et al. (2000) N Engl J Med, 342, 781-90


(3) Coroneos, C. J. et al, (2019) Ann. Surg. 269 30-6


(4) Watad, A. et al, (2008), Int, J Epidemiol. (2018) 47 (6) 1846-54

What is Breast Implant-Associated Anaplastic Large Cell Lymphoma (BI-A, ALCL)?

Women with breast implants seem to be more likely to develop anaplastic large cell lymphoma, a rare cancer of the immune system. This apparent link was confirmed, in 2016 and at that stage the WHO recognized “Breast Implant-Associated ALCL (BIA-ALCL) as a T-cell lymphoma that can develop in breasts following breast augmentation. The risk of developing ALCL is very low, but much higher in women with implants than it is in the general population.


Subsequently research has linked it to some of the textured implants that were previously considered to be safe, state of the art and the least likely to cause any complications when they we’re used.  In time, it became clearer that the Allergan texturing seemed particularly prone to what was and is still a relatively rare condition.


BI-A, ALCL is a variant of non-Hodgkin’s lymphoma and although an individual’s risk of developing the condition is considered to be low, for those who do, it can, if not treated promptly, be a serious and life threatening condition.  That said, in most patients it is treated successfully with surgery to remove the implant and the surrounding scar tissue and in some patients there is also the need for some chemotherapy and radiotherapy.


The main symptoms of BI-A ALCL are persistent swelling and the presence of a mass or pain in the area of the breast implant.  Clinically the sign most often associated with an examination of the breast by a surgeon is a seroma, however, 1 in 5 patients with BI-A ALCL present with late onset capsular contracture.


Overall any one individual’s risk is low – only 1 was found in the FDA study of outcomes published in 2019 for 99,993 patients who had had Allergan or Mentor implants (Coroneos, C. J. et al, [2019] Ann. Surg. 269 30-6).


If you are reading this having found a link to my site because you are reading up about BI-A ALCL having had breast augmentation in the past and this hasn’t set your mind at rest, then I urge you to seek out your surgeon and consult with them if you have any symptoms that have appeared sometime after your surgery – having previously had a settled result.  If that isn’t practical, then by all means come and see me.

Will my breast implants stay the same forever?

Breast implants are treated by the human body as foreign material and so they are walled off by the body’s cells which weave a fibrous capsule around them. In a proportion of patients these capsules become firm, painful and cause distortion of the breast mound – so-called adverse capsular contracture. This can happen at any stage after surgery, but usually happens in the first 2 years after implantation.

Adverse capsule formation has been related to several factors and implant manufacturers and surgeons have developed strategies to minimize it. The outer shells of implants are textured and antiseptic irrigation is used to minimize infection and inflammation in order to combat adverse capsule formation but in a small percentage of patients this becomes problematic enough to warrant re-operation and occasionally, patients choose to have their augmentation reversed.

Breast implants have a finite life. At some stage they will break and need to be replaced. This is not a complication it is to be expected with passing time – unless a particular implant has been manufactured with a fault and ruptures unreasonably soon. Currently research findings and the claims of manufacturers of gel implants suggest they may last over 15 years – this may be less or more in practice. The corollary of this is that implant surgery may need to be repeated several times over the life-time of a patient who embarks on this surgery when relatively young, and that all possible complications associated with this operation may occur at each operation.

A very small proportion of implants migrate from where they were placed during the operation, leading to breast asymmetry that may need surgical correction. This can be secondary to trauma soon after surgery, but it can also occur for no apparent reason. If caught early, it may be treatable using skin strapping for several weeks.

Can surgery affect my nipples?

Up to 15% of patients experience altered (usually diminished) nipple sensation after implant surgery. This is due to nerve damage and may never improve – so if nipple sensitivity is an important factor in your sexual arousal, weigh this carefully before embarking on surgery.

Breast feeding should not be affected by implant surgery, but could be, at least theoretically, by inserting an implant through a peri-areolar incision.

What should I expect from my consultation?

During your consultation, I will take a full medical history. I will ask you specifically about any breast disease you have suffered, as well as any previous surgery you may have undergone and about your family’s history of breast diseases such as cancer. If you have had mammograms, I will need to know the results. I will also ask about your desired breast size and shape and anything else related to the appearance of your breasts that you feel is important.

I will examine you completely, then focus on your breasts to assess their size, symmetry and shape and the quality of their skin envelope. I will then take standardised photographs in order to help plan and discuss your operation. Finally I will measure you for a sports-type bra, which you will choose and bring with you to be used as a comfortable dressing over your surgical dressings in the days immediately after your surgery.

By all means bring pictures from magazines to show me examples of women who seem to have breasts of a size that equate with your desired breast size – these will be useful in discussion.

How is the surgery performed?

Implants can be placed between the breast and the chest (pectoral) muscles, or beneath both the breast and the chest muscles, lying just superficial to the ribs. Skin incisions can be made in the skin crease below the breast mound (at the lower junction of the breast with the chest wall) or at the junction between the areolar and normal skin.

The method used to insert and position your implant will depend on your anatomy.

What does my operation involve?

Before surgery, you will meet and be assessed by your anaesthetist who will prescribe medications for your comfort and to lessen anxiety if need be.

On the evening before, or the morning of your operation I will review what we have discussed and planned previously and we will both sign your operative consent forms. Then I will measure and draw guidance marks for surgery on your chest and breasts with you sitting upright.

The operation is performed under General Anaesthesia – you will be asleep. The operation usually takes less than an hour, depending on the technique used. After surgery, you will awake in a recovery area and soon afterwards you will be returned to your room. A drain is placed under the incision in each breast that will remain overnight to remove the normal healing fluid that the body produces and be removed the next day. Once drains have been removed you can shower normally. Most patients go home the day after surgery on simple pain relieving medications and a short course of antibiotics.

What about my recovery and return to normal activities?

You will feel tired and somewhat sore for a few days following your surgery, but you will be able to move around and function quite normally, and a proportion of patients feel well enough to go back to (light) work within a day or so.

You will have buried, soluble stitching which will dissolve and doesn’t need to be taken out.

Generally, so long as you can do so with due care and attention, you can begin driving 7 – 10 days after surgery. You should restrict yourself to light exercise for 2 – 3 weeks – avoiding lifting anything over 5Kg and aerobic exercise for at least 3 weeks.

Your breasts will be swollen for at least 4-6 weeks, but at that stage your new breasts will have attained almost their final appearance. Your final operative result will continue to mature for 3-6 months and your scars will continue to mature for up to a year.

New scars benefit from friction-free massage (using vaseline, for instance, to lubricate the massaging process). Beginning to massage scars two to three weeks after surgery, will help them mature, soften and flatten faster than if left to their own devices. New scars should be protected from sunlight for 2 years to avoid them pigmenting differently from the surrounding skin and becoming a different colour permanently. Factor 15 sun block should be applied whenever they are exposed – even to a British winter sun.

In the longer term, final size, shape, symmetry and aesthetic result of breasts after implant surgery will vary according to individual factors which are due to genes, life style, life events and gravity. After surgery, lack of support, alterations in weight or hormonal variation may alter your breasts’ appearance and symmetry markedly.