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Correction of inverted nipple

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Correction of breast assymmetry and tuberous breasts

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Breast lift – mastopexy

Mastopexy (Breast Lift)

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Droopiness of the breast is a common legacy of motherhood, nursing and the force of gravity taking their toll, and the effect of pregnancy and a distension of the breasts with milk causes the fibrous bands which hold the breast in their youthful shape to break down and the skin to stretch. With the subsequent shrinking the unsupported breasts settle into the stretched skin and gravity pulls them down. Putting on weight and then losing it can have the same effect. So too does the aging process, which is why women dislike the appearance of their droopy breasts.

What can be done? Whilst it is not possible to recreate surgically the natural supporting structure of the breast, it is possible to reshape the breast into one which looks more youthful and feels more firm. The operation is called a Mastopexy

 

Breast reduction

Breast reduction is one of the most successful operations in plastic surgery and is associated with a very high degree of patient satisfaction.

It may count as a cosmetic operation in that its purpose is to create a beautiful shapely bust in proportion to the rest of the body, but it also has the functional benefit of relieving the pain and discomfort caused by heavy breasts. It may reduce breast tenderness, back pain, shoulder grooving from bra straps, intertrigo (inflamed, moist skin below the breast) and breast discomfort – but only if these symptoms are actually caused by large breasts.  Back pain for instance, if due to other causes, will be not helped by a breast reduction.

The operation is also useful to correct breast asymmetry, so that the breasts can be equalised and lifted at the same time.

With large breasts, the nipple often lies quite low on the breast, and the areola around the nipple may be stretched.  This can all be corrected as part of the breast reduction.  The nipple usually does not need to be detached from the breast, but just moved upwards into position with its blood supply still connected.

It is important not to underestimate the magnitude of a breast reduction operation.  It takes about three hours under general anaesthetic, and a stay in hospital of one to two nights is usually recommended.  After this, a good month is needed to regain one’s energy, and up to two months for a full recovery to normal.

What does a breast reduction entail?

For a breast reduction as for any other operation, it is important to prepare yourself, so that everything runs smoothly.  This means ensuring that you are fit and not anaemic, eat sensibly and stop smoking if you are a smoker.

Why stop smoking?  Apart from the general increased risk of chest infection, smoking causes a temporary narrowing or constriction of blood vessels, so that you carry less oxygen to the breast and you heal less quickly and may be more likely to heal with an infection or more scar tissue.

You may need to lose weight, as overweight people have a higher risk of deep vein thrombosis, chest infection, and wound infection as well as possibly not getting as nice a cosmetic result. You need to check your list of supplements and medication with your general practitioner, and myself, in order to ensure that you are not more susceptible to bleeding or other complications.

The operation itself is performed under general anaesthetic.  The anaesthetist will see you before your operation. Discuss any queries you have about the anaesthetic with your anaesthetist.  If you have had any difficulties during a general anaesthetic in the past make sure that the anaesthetist and I know about it.  On the evening after your general anaesthetic you will feel rather tired and sleepy and should warn your visitors not to visit you for too long.

During the operation a large quantity of tissue is removed from within the breast.  It is not possible to do this without creating scars. Your scar will run around the nipple, and possibly down the centre of the breast below the nipple and along the crease below the breast.  I try to limit the scars as much as possible, so that they don’t show with revealing clothes.   The scars will never completely disappear and may even stretch (widen) as the year goes by.  The scars start off red and noticeable.  Over a period of time they will fade – it will take about 12 to 18 months for this process to occur.  Some people’s scars fade better and faster than others.  If you scar badly there will be only slight fading and you will be left with red, thickened scars that remain noticeable (keloid or hypertrophic scars).  I do my best to advise how to reduce this.

Most if not all the sutures used are buried and dissolvable.  The sutures can make their way out through the skin instead of dissolving, or can cause small areas of inflammation or suture abscesses.  This is a temporary nuisance but is not serious.

Removing tissue from the breast interferes with the blood and nerve supply of the nipple.  This can result in an alteration in the nipple sensation. Some ladies find a decrease in sensation with a degree of numbness and others an increase in sensation with a degree of tenderness. Most experience no change in sensation.

Interfering with the blood supply to the nipple may occasionally result in small areas of breakdown of the nipple or areola.  These areas will be slow to heal but will heal leaving an area of scarring on the nipple or areola.  It is possible to lose all or nearly all of the nipple and areola on one or both sides.  This is a more serious complication and would require further surgery to reconstruct the nipple. Fortunately this more serious complication rarely occurs.

Removing breast tissue damages the milk ducts of the breast.  More often than not breast-feeding is no longer possible after a breast reduction operation.  You must be satisfied in your own mind that you will not want to breast feed in the future.  If you are unsure about this it is perhaps best to delay your breast reduction operation until you have completed your family.

Sometimes the fat tissue in the breast forms hard tender lumps after surgery.  This is called fat necrosis.  These lumps usually settle on their own over a period of time (which may be several months).  Occasionally further surgery is required to remove particularly troublesome areas.

Any operation can result in infection or bleeding, and breast operations are no exception.  Simple infections will settle with dressings or a course of antibiotics.  Some infections will require further treatment.

If you notice increasing redness of your wound and it is painful make sure to get it checked as soon as possible – infections caught early are easier to cure.  Bleeding after your operation can result in a collection of blood called a haematoma.  Haematomas must be drained in theatre otherwise they can cause wound problems later on.

I try to size your breasts in proportion to your general shape but will take into account whether you prefer to be ‘bigger’ or ‘smaller’.  If you look carefully at your breasts before your operation you will notice there is some asymmetry.  This is normal.  After your operation it is inevitable that you will have some asymmetry. This is seldom noticeable to other people.  I try to reduce any obvious preoperative asymmetry.

Sometimes there are little folds at the ends of the scars.  These are called ‘ dog ears ’.  If they do not settle over a period of about 6 months they can be removed as a small operation under local anaesthetic.

 

What to expect when you return from theatre

  • A drip – this stays in until you are eating and drinking normally – usually just overnight
  • Drains – one to each breast.  These stay in until they stop draining – usually about 48 hours, but may be longer – sometimes you do not require drains.
  • Dressings – a firm dressing will be applied to support the breasts after the operation.  This usually stays on until after you go home and will be removed in due course at the first follow up appointment.  I will provide you with comfortable soft (not underwired) but supportive bras once you are up and about.
  • Heparin – lying in bed increases the chance of the veins in your legs clotting. To counteract this you will have tiny heparin injections under your skin twice a day until you are mobile.  You will also be given firm TED stockings to wear until you go home.
  • Home – once your drains are out and you are up and about and feeling well enough you will be able to go home.

 

What to expect after you return home

At first you will feel rather tired and should spend the first week or so taking it very easy.  Thereafter you will be able to build up slowly to doing your usual activities.  A breast reduction is a big operation, which does take time to get over. Expect to feel more tired than usual for up to 3 months.

You will be able to start driving once you feel up to it.  For most people this will take about two weeks. Do not drive if you are not well, alert and able to take emergency action safely.  It is advisable to check with your insurance company before you start driving. You will, likewise, be able to start work again once you feel up to it.  If your job involves a lot of lifting or heavy work this will take longer.  Most people get back to work after about a month.

Conclusion

Breast reduction is an excellent operation when done under the right conditions.  Not only does it enable you to finally go shopping for clothes without spending hours trying to minimize a chest, which is out of proportion to the rest of your body, it can also give you a lovely looking breast once the scars have matured.  It may relieve back and neck ache, and the loss of the extra weight may facilitate running and playing sports and other activities.

 

 

Breast enlargement – augmentation

Breast augmentation – technically known as augmentation mammaplasty – is a surgical procedure to enhance the size and shape of a woman’s breast. You may choose to undergo it for a number of reasons:

· To enhance your body contour and enlarge your breast size

· To correct a reduction in breast volume after pregnancy or weight loss

· To balance a difference in your breast size

· As a reconstructive technique following cancer breast surgery

 

The shape and size of your breasts prior to surgery will influence both the recommended treatment and the final results. If the breasts are not the same size or shape before surgery it is unlikely that they will be completely symmetrical afterwards.

Before committing yourself to surgery you must think carefully about your expectations. Breast augmentation may enhance your appearance and improve your self-confidence, but it won’t necessarily achieve the ideal you expect, or improve a relationship.

The best candidates for breast augmentation are women who are looking for improvement, not perfection, in the way they look.

 

What is involved in the operation?

Breast enlargement surgery is performed under a general anaesthetic, takes one to two hours, and usually involves an overnight stay in hospital. It is accomplished by inserting a breast implant either behind the breast tissue or under the chest muscles. In Norwich it is now also possible to move local skin and fat from the back or from the abdomen or buttock as a “perforator flap” to increase the size of the breast. I usually do this in the context of breast reconstruction for cancer however, as this is a fairly complex operation.

Incisions are made to keep scars as inconspicuous as possible, usually under the breast, with modern implants.  The method of inserting and positioning breast implants will depend on your preferences, your anatomy and my recommendation.

Patients undergoing augmentation mammaplasty surgery must consider the possibility of future revisionary surgery and the expense involved.  Good breast implants last ten to fifteen years and sometimes longer, but do not expect them to last forever.  I do not use cheap poor quality implants (“You get what you pay for”).  The implants I use are manufactured to FDA standards.

All implants have a silicone coating – some are silicone gel filled and others saline filled. The silicone gel filled implants give a more natural appearance.  Implants come in different varieties of shaped and round versions. Polyurethane coated implants are also available; they do not move in the chest and may reduce the chance of scar capsule correction.

Before the operation, depending on your age and fitness, you may have to undergo some simple health checks such as blood tests and a mammogram. If you decide on surgery you will be required to sign a consent form giving permission for the operation. This requires that you are aware of the risks and complications involved with the procedure.

Plastic surgery patients are always photographed pre and post operatively as this is standard good practice.

Operation and recovery

The operation is performed under general anaesthetic.  You may have a drain, which stays in the breast one or two days.  The average stay in hospital is one night after surgery.  You will have some swelling and discomfort after the operation for which you will be given painkillers.  You will have a scar under the breasts, but this normally is hidden in the crease line.  You should abstain from upper body physical activity for six weeks and bouncing movements for three months.  You can resume driving by agreement with your insurance company – usually two to three weeks after surgery.  I will give you a couple of specially made supporting bras to reduce discomfort.  You should avoid long air flights a month before and a month after surgery.

 

Risks of augmentation mammaplasty surgery

Every surgical procedure involves a certain amount or risk and it is important that you understand the risks involved with augmentation mammaplasty.  Additional information concerning breast implants may be obtained from package insert sheets supplied by the implant manufacturer, or other information obtained on the Internet.

I personally will ask patients to stop smoking at least a month before surgery because smoking is associated with many of the complications of infection, wound breakdown and capsular contracture, and I feel that these reduce the chance of obtaining a nice cosmetic result. Smoking will make you cough when you wake up from the anaesthetic, and so you may bleed.  Every puff causes narrowing of the blood vessels bringing oxygen for healing, so you heal less well.

An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit.   Although the majority of women do not experience the following complications you should understand the risks, potential complications and consequences of breast augmentation.

 

Bleeding

It is possible to experience a bleeding episode during or after surgery.  Should post operative bleeding occur it might require a return to theatre.  I will ask you not to take any aspirin or anti-inflammatory medications, such as Ibuprofen or Voltarol, for ten days before surgery as this may increase the risk of bleeding.

 

Infection

Infection is unusual after this type of surgery.  It may appear in the immediate postoperative period or at any time following the insertion of a breast implant.   Subacute or chronic infections may be difficult to diagnose.  Should an infection occur, treatment including antibiotics, possible removal of the implant, or additional surgery may be necessary. PROMPT TREATMENT IS THEN ESSENTIAL: you may need intravenous antibiotics in order to promote a better response. If an infection does not respond to antibiotics the breast implant may have to be removed.  After the infection is treated a new breast implant can usually be reinserted after a suitable interval.  It is unusual that an infection would occur around an implant from a bacterial infection elsewhere in the body, however prophylactic antibiotics may be considered for subsequent dental or other surgical procedures.

 

Capsular contracture

Scar tissue, which forms internally around the breast implant, can thicken and tighten and make the breast round, firm and possibly painful.  Excessive firmness of the breasts can occur soon after surgery or years later.  Although the occurrence of symptomatic capsular contracture is not predictable, it generally occurs in less then 10 per cent of patients in the first five years.  The incidence of symptomatic capsular contracture can be expected to increase over time.  Leakage of silicone from an implant can irritate tissues and encourage the capsule to thickent. Capsular contracture may occur on one side, both sides or not at all.  Treatment for capsular contracture may require surgery, implant replacement or implant removal.

 

Change in nipple and skin sensation

Some change in nipple sensation is not unusual right after surgery.  After several months most patients have normal sensation.  Partial or permanent loss of nipple and skin sensation may occur occasionally.

 

Skin scarring

Excessive scarring is uncommon.  In rare cases abnormal scars may result. I will advise on methods to reduce thick scars.

 

Implants

Breast implants, similar to other medical devices, can fail.  Implants can break or leak.  When a saline filled implant deflates, the body will absorb its salt-water filling.  Damaged or broken implants cannot be repaired.  Ruptured or deflated implants require replacement or removal.  Breast implants cannot be expected to last forever, as they are synthetic.

 

Implant extrusion

Lack of adequate tissue coverage or infection may result in exposure and extrusion of the implant.  Skin breakdown has been reported with the use of steroid drugs or after radiation therapy to breast tissue.  If tissue breakdown occurs and the implant becomes exposed, implant removal may be necessary.   Smoking may interfere with the healing process.

 

Mammography

Breast implants may make mammography more difficult and may obscure the detection of breast cancer.  Implant rupture can rarely occur from breast compression during mammography.  Inform your mammography technician of the presence of breast implants so that appropriate mammogram studies may be obtained.  Patients with capsular contracture may find mammogram techniques painful and the difficulty of breast imaging will increase with the extent of contracture.  Ultrasound, specialised mammography and MRI studies may be of benefit to evaluate breast lumps and the condition of the implants.  Because more X-ray views are necessary with specialised mammography techniques, women with breast implants will receive more radiation than women without implants who receive a normal examination.   However, the benefit of the mammogram in finding cancer outweighs the risk of additional X-rays.

 

Skin wrinkling and rippling

Visible and palpable wrinkling of implants can occur.  Some wrinkling is normal and expected.  This is often more pronounced in patients who have saline filled implants or thin breast tissue, or are very slim.

 

Pregnancy and breast feeding

Although many women with breast implants have successfully breast fed their babies, it is not known if there are increased risks in nursing for a woman with breast implants, or if the children of women with breast implants are more likely to have health problems.  There is insufficient evidence regarding the absolute safety of breast implants in relation to fertility, pregnancy or breast-feeding.  Some women with breast implants have reported health problems in their breast fed children.  Only very limited research has been conducted in this area and at this time there is no scientific evidence that this is a problem.  Do however be aware that if you breast feed and develop mastitis of pregnancy you should have a very low threshold for seeking advice regarding taking antibiotics.

 

Implant displacement

Displacement or migration of a breast implant may occur from its initial placement and can be accompanied by discomfort and/or distortion in breast shape.  Difficult techniques of implant placement may increase the risk of displacement or migration.  Additional surgery may be necessary to correct this problem.

 

Surgical anaesthesia

Both local and general anaesthesia involve risk.  There is the possibility of complications, injury and even death from all forms of surgical anaesthesia or sedation.

 

Chest wall deformity

Chest wall deformity has been reported secondary to the use of tissue expanders and breast implants.  The consequences of chest wall deformity are of unknown significance.  This is not a common problem with cosmetic augmentations. On the other hand many women have preexisting minor chest wall differences between the two sides, and the differences may become more apparent after augmentation.

Asymmetry

It is not uncommon to have preexisting differences between the two breasts, be they in size, shape or consistency.  I can do my best to reduce but I cannot eliminate the differences.

Unusual activities and occupations

Activities and occupations, which have the potential for trauma to the breast, could potentially break or damage breast implants or cause bleeding.   Good quality implants will withstand pressure changes from ordinary scuba diving.  Trauma from a seat belt injury may rupture an implant.

 

Breast disease

Current medical information does not demonstrate an increased risk of breast cancer in women who have breast implant surgery for either cosmetic or reconstructive purposes.

Breast disease can occur independently of breast implants.  It is recommended that all women perform periodic self-examination of their breasts, have mammography according to our national guidelines and seek professional care, should they notice a breast lump.

 

Seroma

Fluid may accumulate around the implant following surgery, trauma or vigorous exercise.   Additional treatment may be necessary to drain fluid accumulation around breast implants. I therefore recommend that you limit upper body activity in the post-operative period.

 

Long term results

Subsequent alterations in breast shape may occur as the result of ageing, weight loss or gain, pregnancy or other circumstances not related to augmentation mammaplasty.  Breast sagginess may normally occur.

 

Immune system diseases and unknown risks

Some women with breast implants have reported symptoms similar to those of known diseases of the immune system, such as systemic lupus erythematosis, rheumatoid arthritis, scleroderma, and other arthritis-like conditions.  A connection between implanted silicone and connective tissue disorders has been reported in the medical literature.  To date there is no scientific evidence that women with either silicone gel filled or saline filled breast implants have an increased risk of these diseases, but the possibility cannot be excluded.  If a causal relationship is established the theoretical risk of immune and unknown disorders may be low.  The effects of breast implants in individuals with pre-existing connective tissue disorders is unknown.

 

Anaplastic Large Cell Lymphoma (ALCL) The American Food and Drug Administration (FDA) has identified an extremely small but possible association between breast implants and the development of anaplastic large cell lymphoma (ALCL), a rare type of non-Hodgkin’s lymphoma.  ALCL is not a cancer of the breast tissue but arises near the implant.   Worldwide 170 cases have been identified out of 5-10 million women who have had breast implants as of 2015.  Further data is needed:

 

Rare association not cause for alarm

 1 in 100,000 risk shouldn’t worry breast implant patients unduly, say surgeons

London – 25 May, 2014 – Despite reports of a theoretical link between an extremely rare form of cancer (anaplastic large-cell lymphoma, or ‘ALCL’) and textured breast implants, the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk); the only organisation based at the Royal College of Surgeons solely dedicated to the advancement and education of cosmetic surgery; today warns 150 cases out of more than 15 million should not cause alarm in patients.

The BAAPS has performed close to 80,000 breast augmentations (‘boob jobs’) in the last decade, with not one case of ALCL ever recorded in that period. According to consultant plastic surgeon and BAAPS President Rajiv Grover;

“Breast augmentations have in recent years acquired a reputation for being an ‘off the shelf’ procedure, but meticulous technique from an experienced surgeon is essential to avoid complications. All BAAPS members are aware of the importance of antibiotic use and minimal handling when dealing with implants, known to be significant factors in reducing the risk of biofilms, which can result in capsular contracture. Biofilms are an area we have studied in depth and even held lectures on at our Annual Meeting last year, as we know that comprehensive training is essential to improve outcomes and minimize problems.

 Published infection rates in breast augmentation, for example, are 2.5% across Europe but the BAAPS’ own statistics show only a rate of 0.5% and less than half the re-operation rates of the US (2.6% v 5.1%).”

According to consultant plastic surgeon and former BAAPS President Fazel Fatah;

“It is important to remember that the number of breast implant patients globally is considered to be higher than 15 million, yet these tumours are extremely rare. The risk of death is only 1 in 2 million from it and cure available for 94% of sufferers, so women should continue to feel that their implants are safe. ALCL is normally slow to progress and not aggressive, with a good likelihood of recovery. BAAPS members have been made aware of this extremely rare association for a while and are vigilant to make sure the right steps are taken if the condition is suspected in a patient with breast implants. Women can be reassured of the very nature of the rare association and there is no need for concern unless they develop sudden unexplained changes or swelling – although this could be for a number of reasons not related to ALCL at all.”

According to consultant plastic surgeon and President of the BAAPS Rajiv Grover;

“It is down to the surgeon to evaluate the most salient risks they need to warn a patient about, depending on individual circumstances such as age and other particulars – however all are, or should be, made aware that breast cancer in general occurs in one out of tenwomen; independently of whether they have implants or not. The risk of ALCL is infinitesimally small in comparison.”

The BAAPS is also the first in the world to have devised an insurance policy (www.asurgerycommitment.com) which covers all the most common complications of cosmetic surgery, including capsular contracture.

The Medicines and Healthcare products Regulatory Agency (MHRA) has continued research into what has been deemed ‘uncertain evidence’ of a link between the implants and increased risk of ALCL, and have no corresponding reports of a disease association: http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con108790.pdf

The French regulatory body, the National Security Agency of Medicines and Health Products (ANSM) also recently published the results of their manufacturer inspection programme and vigilance data analysis, confirming ‘no strong association’ between ALCL and the implantation of prostheses.

 

Unsatisfactory result

Most patients are happy with the result obtained.  Occasionally asymmetry in implant placement, breast shape and size may occur after surgery.  Pain may persist following surgery.  It may be necessary to perform additional surgery to improve your results.

 

Additional surgery necessary

1- Additional surgery may be necessary to lift the breasts if they are saggy (mastopexy) or to correct differences between the two breasts.

2- Should complications occur, additional surgery or other treatments might be necessary.  Even though risks and complications occur infrequently, the risks cited are particularly associated with augmentation mammaplasty.  Other complications and risks can occur but are even more uncommon. Correction of these may entail more expense.  The practice of medicine and surgery is not an exact science, so always think carefully before committing yourself to an operation for purely cosmetic reasons.

 

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