Breast augmentation is a procedure designed to increase the size of the breasts, usually for women either with naturally small breasts or whose breasts have diminished in size following pregnancy (providing that they have not 'dropped' too much, in which case an operation known as mastopexy would be necessary).

The procedure involves the insertion of a prosthesis (implant), which is put behind the breast or the pectoralis major muscle. In either case, it is not within the breast tissue itself and therefore should not interfere with breast feeding or a further pregnancy. The degree to which the presence of an implant will affect mammography depends on the type of implant used (see later). Mammography is possible with any type of breast implant, but it is important that, should it be required, a radiographer is aware that the implants are present so that the direction of the x-rays can be altered slightly to accommodate for it.

Silicone Gel
Breast augmentation has a very long history, prosthetics (artificial material) having been in common usage since 1962. By far the most frequently used since this time has been silicone gel contained within a silicone envelope.

Recently there has been a great deal of publicity, mainly emanating from the United States, about the safety or otherwise of silicone gel in breast augmentation. Some of what has been written is accurate and reasonable, but much of it is not. It is important to stress that there is certainly no association between breast augmentation and breast cancer - if anything, women who have had an augmentation have a slightly lower incidence of breast cancer than the population at large.

The concerns have been mainly about auto-immune or collagen disease, otherwise known as human adjuvant disease (HAD). This is a difficult condition to define but is probably most easily considered as part of the rheumatoid arthritis group of diseases. It is very difficult to be sure whether or not silicone gel predisposes such conditions. They occur, very rarely, in the population at large and so inevitably they will occur, very rarely, in a population who have had a breast augmentation. The difficulty is to find out whether they are more common in the breast augmented group. It is the rarity of these conditions, which makes this such a difficult task when compared with breast cancer which, unfortunately, is a common condition. To date, there has been no firm evidence published linking silicone gel with systemic or local disease.

The government in the UK set up an Independent Review Group (IRG), which reported in the latter part of 1998 and found no association between the use of silicone gel for breast augmentation and any disease process. As far as human adjuvant disease is concerned, it concluded that there was no justification for continuing epidemiological studies into a link since, having reviewed the evidence available, they felt that there was no reason to suspect any such association. The work of the IRG continues and there is also a National Breast Implant Registry in the UK, established some years ago, to collect statistics.

Alternatives to Silicone Gel
There are alternatives to the use of silicone gel, which are either a semi-solid silicone (Cohesive gel) or a saline (salt water) filled prosthesis. The Cohesive gel implant is, in consistency, rather like 'jelly' served at children's tea parties. The implant itself is 'breast shaped' rather than being globular as most implants are and has the advantage that, if cut, the gel will not 'run' or 'leak' because of its consistency.

I have found these implants the most useful for most women undergoing breast augmentation since they produce a natural looking shape. They are available in a number of different shapes and sizes and so can be matched fairly closely to an individual’s anatomy. The only significant disadvantage in comparison with other implant types is that should they displace, i.e. rotate or flip, then clearly the breast would have an inappropriate shape. This is however an extremely uncommon complication and, in the unlikely event that it occurred, it can be corrected surgically.

Saline implants have the advantage that, if they were to leak, the saline would simply be absorbed by the body, then excreted in the usual way since it is a 'physiological' substance. Unlike all other implants, they are filled by the surgeon at the time that the operation is carried out. This has the advantage that they may be inserted 'flat' and then inflated once inside the body, which enables a very small incision to be used. The disadvantage, however, is that there must necessarily be a valve to fill them, through which is potentially a weak point for leakage (though this is extremely uncommon).

Saline implants suffer with the disadvantage in comparison to silicone that the filling material is much less viscous (i.e. it is thinner). The implication of this is that it may be possible to feel the implant through the skin if there are places where the breast tissue is particularly thin. For this reason, I would not advocate the use of saline implants unless they are placed behind the pectoralis major muscle (i.e. further away from the skin). If this is not done, then visibility of the implants through the skin or 'rippling' is a likely event and they will almost certainly be felt.

Which implant is right for me?
The choice of which implant to use is not a simple one. It is best reached in discussion with the patient to take in to account individual circumstances. There are advantages and disadvantages to each type and careful consideration needs to be given before a choice is made. However, it must be accepted that, by its very nature, no implant is ideal.

How long will an implant last?
Although they are all durable and made to a high standard, they cannot be considered 'lifetime devices'. Any woman undergoing a breast augmentation should assume that at some future date it will need to be revised or adjusted, either because her anatomy has changed (e.g. because of pregnancy and breast feeding) or because the implant 'wears' with time and, therefore, needs to be replaced. This time interval is currently not defined, but it is known that the older the implant becomes, the more likely failure (ie leakage) becomes. It is impossible to predict for certain the behaviour of any implanted material over the course of a patient's lifetime and, although statistics are being gathered constantly to improve our knowledge, patients must accept that there is always a degree of uncertainty in the long term.

What size of implant is right for me?
The selection of the most appropriate size of implant depends on a number of factors. Most important, of course, are the patient's wishes. However, one should not attempt to over stretch the skin since this will produce a very unnatural appearance and a breast that does not move normally. In general, patients who have had children are likely to have more scope for enlargement than those who have not, since the breast tissue and skin will have been stretched during pregnancy and/or breast feeding.

From a corsetiere's point of view, the measurement of breast size is the bra 'cup' size not the 'inches' dimension, which rather represents a measurement of the chest beneath the breasts. It is important to bear in mind that cup sizes are not uniform from one bra manufacturer to another. Because of these various factors, the planning of the post-operative breast size must necessarily be an approximation. The implants themselves are measured by volume (cc's). Placing them inside a bra pre-operatively is little help in gauging post-operative size since clearly when the implant is inside the body the skin tension and that of the tissue surrounding it will have a significant effect. In general, however, following discussion with a patient it is usually possible to predict reasonably accurately what would be achieved by the operation.