Breast implant surgery is not a case of one size fits all. We look at the essential components of choosing the right breast implant for you.
Breasts are beautiful in all shapes and sizes, but if your breasts are sagging, flat, asymmetrical or lacking the volume and shape you desire, you’re not alone. It’s estimated some 20,000 Australians undergo breast implant surgery every year. Some women seek implant surgery to correct congenital or developmental anatomical abnormalities, while others are striving to repair the toll of age or breastfeeding by restoring their breasts to a more youthful and upright position. Other women simply want to have a larger size bust, which is more proportionate to their overall body size. Implants may also be required to reconstruct a damaged or missing breast, from injury, illness or mastectomy. There are countless reasons women undergo breast augmentation and each one has unique importance to the individual.
If you’re considering breast implants, it’s important to know these are not lifetime devices and need to be replaced after around 10-15 years in many cases.
Careful discussion of your expectations and concerns with your chosen surgeon, along with planning and assessment, can help to achieve a successful outcome and natural-looking results. You should thoroughly discuss your goals and motivations with a surgeon you trust and with whom you feel comfortable. Listening to your surgeon’s feedback and advice, and seeking a second professional opinion, will go a long way in ensuring expectations and motivations are realistic. Satisfaction with breast augmentation results ultimately depends on your understanding of the capabilities and limitations of the procedure.
Implant Shape
Choosing the right implant is dependent on your existing breast size, shape, symmetry and projection, body type, and your personal preferences. There is no one breast implant shape that is best for everyone. Your surgeon is the best resource for determining what breast implant is best for you and your body type.
Round Implants
Round implants are circular with an even projection of volume. They are a good choice for those who want more fullness in the upper part of the breast and tend to give greater cleavage. Many surgeons agree that round implants are typically the best choice for those patients with well- shaped natural breasts who desire a straightforward breast enhancement.
Teardrop Implants
Teardrop, or anatomical, implants more closely resemble the natural shape of a breast, gradually sloping downwards to produce an attractive straight line from the collarbone to the nipple. Teardrop implants tend not to be as full as round implants but because they are fuller in the lower half they can also provide greater projection in proportion to the size of the base, making them particularly suitable for women with little natural breast tissue. Mild elevation of the breast and the nipple can also be achieved, making them particularly suitable for women who have mild droopy or tuberous breasts.
Silicone vs Saline
Saline and silicone breast implants both have an outer silicone shell; however they differ in material, consistency and techniques used for placement. Both types of implants have their own advantages and risks.
Silicone gel-filled implants are by far the most common in Australia. Silicone implants contain a cohesive gel, designed to mimic real breast tissue. It has a slightly firm, non-runny consistency, which can give a more natural feel. As the gel is not liquid, the risk of dispersal if the implant ruptures is minimised. It also typically maintains its shape better than a saline implant, especially in the upper part of the implant.
Saline-filled implants use a medical- grade saltwater solution, which makes the implant feel like a water-bed. This can be controlled to an extent by the volume of fill in the implant. If implant rupture occurs, the saline is absorbed by the body. However, saline implants feel firmer than silicone implants and have a higher risk of visible folds and ripples.
Smooth vs Textured
Implant shells can be smooth or textured. Smooth-shelled implants are easy to insert and may make the breast move and feel more natural than a textured shell in certain patients. However, they have increased risk of capsular contracture (hardening of the breast), which is a common reason for re-operation.
Textured implants have a thicker shell and the very nature of their surface means they can grab onto and adhere to the surrounding tissue, causing less friction between the implant and breast pocket and therefore helping to reduce the risk of capsular contracture. Many surgeons also believe it offers them greater control over the ultimate shape of the breast.
Implant Placement
The placement of breast implants has a significant impact on the final outcome of breast augmentation and therefore it requires individual consideration. Experienced surgeons base their implant placement decisions on factors such as the patient’s quantity of breast tissue, natural breast size and symmetry, dimension and shape of the chest wall, amount of subcutaneous fat and quality of breast skin.
Generally, there are three placement options: subglandular (in front of the muscle), submuscular (behind the muscle) and dual plane (partially under the muscle).
Subglandular
The subglandular pocket is created between the breast tissue and the pectoral muscle. This position resembles the plane of normal breast tissue and the implant is placed in front of the muscle. Sometimes the implant is covered by a thin membrane, the fascia, which lies on top of the muscle. This is called s ubfascial placement.
This position is suited to patients who have sufficient breast tissue to cover the top of the implant. This procedure is typically faster and may be more comfortable for the patient than submuscular placement. There is generally less post-operative pain and a shorter recovery period because the chest muscles have not been disturbed during surgery. The implant also tends to move more naturally in this position.
However, subglandular breast implants may be more visible, especially if the patient has little breast tissue, little body fat and thin skin. With subglandular implants, there tends to be more of a pronounced ‘roundness’ to the breasts, which may look less natural than those placed under the muscle, but this is a matter of personal preference.
Submuscular
The implant is placed under the pectoralis major muscle after some release of the inferior muscular attachments. Most of the implant is positioned under the muscle. This position can create a natural-looking contour at the top of the breast in thin patients and those with very little breast tissue. The implant is fully covered, which helps to camouflage the edges of the implant, as well as rippling. With this placement, data has shown there is less chance of capsular contracture occurring. There may be more post-operative discomfort and a longer recovery period. The implants may appear high at first and take longer to ‘drop’.
Dual Plane
This is where the implant is placed partially beneath the pectoral muscle in the upper pole, where the implant edges tend to be most visible, while the lower half of the implant is in the subglandular plane. This placement is best suited to patients who have insufficient tissue to cover the implant at the top of the breast but who need the bottom of the implant to fully expand the lower half of the breast due to sag or a tight crease under the breast.
This position minimises the rippling and edge effect in thin patients while avoiding abnormal contours in the lower half of the breast. Generally, this placement is able to achieve a more natural shape to the upper portion of the breast instead of the ‘upper roundness’ that can be more common with subglandular implants. However, it involves more complex surgery, which if not performed correctly may result in visible deformities when the pectoral muscles are contracted.
Incision Site
The three main incision options are the inframammary crease (under the breast where it meets the chest), periareolar (around the nipple) and transaxillary (inside the armpit).
Inframammary
The inframammary incision is by far the most common breast augmentation incision used today, made in the crease under the breast close to the inframammary fold. The surgeon creates a pocket for the breast implant, which is slid up through the incision, then positioned behind the nipple. This incision offers the best exposure for visualisation and allows the implant to be placed over, partially under or completely under the chest wall muscle. The scar is hidden in the crease under the breast.
Periareolar
For the periareolar incision, an incision is made just beyond the areola, which is the darker area of skin surrounding the nipple. The incision should be made at the very edge of the areola where the dark tissue meets the lighter breast tissue, which makes the scar least visible.
Similar to the inframammary incision, the periareolar incision allows the surgeon to work close to the breast. It is possible for the surgeon to easily and precisely place the breast implants in various positions in relation to the chest muscle. However, this is the only incision that involves cutting through breast tissue and ducts, and sensitivity in the nipple may be reduced.
Transaxillary
The transaxillary incision is made in the natural crease of the armpit and a channel is created down to the breast. This may be performed with an endoscope (a small tube with a surgical light and camera in the end) to provide visibility. The implant is inserted and moved through the channel into a prepared pocket.
The greatest advantage of an underarm breast augmentation incision is that no scar is left on the breasts. The scar is virtually invisible in the armpit fold and lack of tension generally makes for straightforward healing.
The transaxillary site is relatively far from the breast, where the surgeon needs to create a pocket for the implant, so visibility is limited. There is also a higher incidence of the implant being positioned too high and a greater risk of breast asymmetry after surgery.
Breast implant surgery: risks & complications
While breast augmentation is typically a predictable procedure, all surgery carries some level of risk. As well, breast implants should not be viewed as one-and-done devices – they will likely need to be removed or replaced after approximately 10-15 years. Complications arising from breast augmentation can include the following.
Capsular Contracture
Capsular contracture, or hardening of the breast, is thought to be the most common complication of breast implant surgery. It can occur at any time but more commonly in the months immediately after surgery.
During surgery, a pocket is made for the implant in the breast tissue. After the implant has been inserted, the body naturally forms a capsule of fibrous tissue around the implant. This lining, or capsule, is formed by the body’s living tissue, and is the body’s natural response. The capsule allows the implant to look and feel quite natural. In some cases, however, the capsule begins to tighten, causing a shrink-wrap effect and squeezing the implant that it surrounds.
Depending on the severity, the breast can feel firm or hard, become distorted and cause pain. It is not actually the implant that has hardened – the shrinking of the capsule compresses the implant and causes it to feel hard, but if the implant is removed it is still in its original soft state.
Though the exact causes of capsular contracture are unknown, there are factors that may lead to this complication, including seroma (the development of extra fluid around the implant), haematoma, infection and smoking.
To treat capsular contracture, there are both surgical and non-surgical options, although generally most cases of capsular contracture will require secondary surgery to remove the implant. If the implants are replaced, to prevent reoccurrence a new pocket should be made as fresh tissue needs to be in contact with the implant.
Infection
Infection is a serious risk of any surgery and occurs when wounds become contaminated with microorganisms, such as bacteria or fungi. When infection occurs, it generally appears within six weeks of the procedure. Most infections can be treated with antibiotics, but in the worst cases the implant may need to be removed and the infection eliminated before the implant is replaced.
It’s important to keep an eye out for signs of infection, which may include redness at the site, fatigue and fever. Increased pain and swelling are also typical signs of infection but, because these symptoms are typical of all breast surgeries, they can be difficult to detect.
Rippling
Rippling occurs when the filling inside the breast implant moves, creating a winkle or fold on the outer shell of the implant which then can be felt by the patient, or which becomes outwardly visible. Rippling can also occur when adhesion to the envelope restricts its movement.
Various factors govern the likelihood of rippling, including the implant type, texture and position. It occurs less with silicone gel-filled implants, smooth-surfaced implants and those that are positioned under the chest muscle. If it occurs, the appearance of rippling is dependent on the patient – their physique and the thickness and quality of their skin. If there is little muscle or fatty tissue to cover the implant, any rippling that results will be more noticeable. Rippling generally appears on the outer and bottom sides of the breast and in the cleavage.
Implant Displacement
Displacement refers to the implants moving out of their desired position, and is more prone in women who have teardrop-shaped or very high- profile implants. Displacement may occur due to the implant being misplaced in the tissue pocket, or from excessively stretched tissue, or trauma. Displacement can occur at any time after the procedure, and will generally need to be surgically corrected.
Breast Implant Associated ALCL
Breast implant-associated anaplastic large cell lymphoma (ALCL) is a rare and highly treatable cancer of the immune system that can develop around breast implants; it is not breast cancer. When diagnosed early and treated properly, this disease is curable. Most cases of breast implant-associated ALCL are cured by removal of the implant and the capsule surrounding the implant.
According to the Therapeutic Goods Administration (TGA), current expert opinion puts the risk of breast implant- associated ALCL at between 1-in-1,000 and 1-in-10,000. Based on currently available data, most (95%) of cases of breast implant-associated ALCL occur between 3 and 14 years after the implant (median: 8 years; range: 1-37 years). According to the TGA website, over the past 10 years, three Australian women have died from breast implant- associated ALCL.
All reported cases of breast implant- associated cancer in Australia involve patients who have had a textured (vs smooth) implant at some point in their life. Based on current evidence, experts do not think breast implant-associated ALCL is related to either the contents (saline/silicone) or shape (round/ teardrop) of the implant.
Breast implants with a higher risk of BIA-ALCL have either been removed or suspended from the Australian market. In addition, some suppliers have also decided to remove particular types of breast implants from the market. For up-to-date information on which breast implants and tissue expanders are affected, see tga.gov.au/hubs/breast-implants.
If there are changes in your breasts associated with breast implants, and especially if there is general swelling or a lump, contact your specialist for further investigation.
Because breast implant-associated ALCL is rare, experts do not recommend removal of breast implants for women who have no problems with the implant. The risk of undergoing surgery to remove your implants could be higher than the risk of developing BIA-ALCL. If you are concerned, you should discuss your options with your doctor.
Breast implants shouldn’t be viewed as lifetime devices, regardless of breast implant-associated ALCL. Typically, they are removed after 10-15 years.
Breast Implant Illness
There have been anecdotal accounts of breast implants causing a variety of general health issues, known as “breast implant illness”, but scientific evidence is lacking to support this. Symptoms are non-specific and include general fatigue, joint aches, headaches and brain fog.
To date, there is no distinction between the types of breast implant and the likelihood of a patient developing an autoimmune response to the medical devices being inserted, and there is no known link between these symptoms and BIA-ALCL.
Long-term safety & monitoring of implants NSW Health has recently published a ‘ToolKit for the Management of Breast Implants’ for doctors, which focuses on patient safety. The Toolkit warns patients that by proceeding with implant surgery, you are also required to undergo regular follow-up with your treating doctor for clinical and radiological assessment of your breast implants for as long as you have breast implants.
In addition, the Toolkit advises all implant patients to ensure their doctor registers their breast implants at the time of surgery with the Australian Breast Device Registry. This will allow tracking of outcomes and safety and will allow notification of any important information on the safety of your breast implants to you directly.
When all is said and done
The psychology behind the decision to have a breast augmentation is one of the most important aspects of the procedure. Many women view their breasts as a vital component of their gender identity, as the female breast is one of the prime symbols of femininity, motherhood and sensuality. However, women are notoriously critical of their bodies and some may be especially so of their breasts. When contemplating breast augmentation, ensure it’s for the right reasons. CBM
