Breast Enlargment (Breast Augmentation)

Causes of small breasts

The size of breasts is genetically determined. Once developed, the breasts may fluctuate in size in response to changes in weight, pregnancy and breast feeding.

The aging process causes the shape of the breast to change so that they gradually droop (called ptosis). This effect is greater following pregnancy, breast feeding and in particular after a large weight loss. Most women have breasts of slightly different sizes, but occasionally a very marked difference may develop.

The operation

Breasts can be made larger by placing an implant either under the breast tissue or behind the muscle on which the breast lies. Implants can be inserted through a variety of incisions, however Bryan Mayou has found that the incision made around the areola gives a scar that it reliably better than scars made elsewhere and usually settles to become barely visible within a few weeks.

Implants placed either under
the breast tissue or behind
chest muscle
  Possible incision areas
for breast implant

Breast implants

A breast implant is made of an outer layer of silicone, but may be filled with silicone gel or salt water. Some implants are round and others are shaped more like a natural breast. Either can give excellent results. The implant manufacturers tend to guarantee their products for 10 years. However most implants stay in place for much longer and they only have to be replaced if there is a specific indication such as the patient's wishes or the rare leakage.

Expectations and complications

Leakage of silicone can occur either as a slow seepage, or following rupture of the implant. This silicone is almost always contained within the fibrous capsule which the body forms around the implant. Silicone leakage has never conclusively been linked to serious health problems.

The capsule which the body normally forms around the implant can become thickened and contracted. The newer designs of implants have features to reduce the likelihood of this happening. This occurs to some extent in around five to 10 percent of patients and usually starts six or more months after surgery. This can lead to pain, and/or an abnormally hard feel of the implant in the breast. Treatment may be needed and occasionally removal of the implant.

Breast augmentation does not usually interfere in breast feeding, and there is no evidence that any silicone is found in breast milk. The presence of breast implants does interfere in mammography, which is an X-ray screening method for breast cancer. Special X-ray views can be taken to minimize this interference. Soya filled implants do not interfere to such an extent, but this type of implant is not suitable in all patients.

Most women have some degree of asymmetry between breasts and breast augmentation may occasionally exaggerate this difference. A breast that has an underlying implant will not necessarily feel like a normal breast, and some women may be acutely aware of the implant as a foreign body within the breast. Although there is usually a difference in skin and nipple sensation following breast augmentation this is rarely a problem for the patient. The size and shape of the breast following breast augmentation surgery will adjust with time and is to some extent unpredictable. It is also not always possible to create a cleavage with breast augmentation. The weight of the implant may influence the age-related changes that normally take place in breasts. Movement of the fluid which fills the implant ripples and folds in the outer shell may occasionally be seen through the skin, this being more likely in the saline (salt water) filled implants, and less likely in the more viscous silicone implants, which also have a more natural feel. This is one of the reasons why saline filled implants are less popular, the other is that they readily deflate spontaneously.

Breast augmentation will always leave scars on the breast or in the armpit, and although the scars will settle over 12 or more months, the appearance of the scars does vary between different individuals. This scarring is placed in such a position as to minimize visibility even when wearing a swimming costume.

Complications that occur with breast augmentation include those associated with all forms of surgery, as well as the specific problems of bleeding and infection. Any infection that may occur in the tissue around the implant can usually be treated with antibiotics, but may require surgical removal of the implant.

Safety of silicone

Whatever the filling of the implant, the outer layer is made of silicone. Silicon is a naturally occurring element which becomes silicone when it is combined with carbon hydrogen and oxygen. Silicone is manufactured into many items including cosmetics, foods and medical implants. Many studies have been conducted to establish whether silicone breast implants cause certain diseases. As a result of these studies we can say that at present there is no evidence to suggest that silicone breast implants are associated with an increased incidence of breast cancer. There is also no evidence to suggest that these implants cause autoimmune diseases such as rheumatoid arthritis.

For more information see the Medicines and Healthcare Regulatory Agency (MHRA) website.

Breast Lift (mastopexy)

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 support the breasts 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 ageing process, which is why women dislike the appearance of their droopy breasts.

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Before 3 months after    

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. Pleats of surplus skin are removed from underneath the breast, the breast itself is remodelled into a tighter cone and the nipples are repositioned at a higher level so that they lie at the points of the tightened breasts. Mastopexy can also reduce the size of the areola ( the darker skin surrounding the nipple). If the breasts are too small as well as droopy, their size can be increased during the operation by placing silicone breast implants underneath the tightened breasts. The best results are achieved in women with small sagging breast although breasts of any size can be lifted. The results may not last as long with heavy breasts. Many women seek mastopexy when their families are complete so if you are planning to have further children it may be a good idea to postpone the operation for though there is no risks for future pregnancy and mastopexy does not usually interfere with breast feeding, pregnancy is likely to stretch the breast again and reduce the effectiveness of the procedure.

What are the consequences?

This is a good operation to improve the appearance of droopy breasts but you would be left with scars, possibly some numbness of your nipples and you may not be able to breast feed again. Mastopexy can be carried out by a number of different techniques and the scars will differ accordingly. Bryan Mayou prefers to use a short scar technique avoiding the worst and most obvious incisions that are frequently used leaving visible scars in areas where scarring is least good. Bryan Mayou also used dissolving sutures to avoid stitch marks and to simplify post operative care.

Droopy Breasts Breasts after a mastopexy Different types
of scarlines after
a Mastopexy

What are the limitations?

Because it is not possible to recreate the natural attachment of the breast to the tissues underneath, a mastopexy alone will not greatly increase the fullness of the breasts above the nipples. Fullness above the nipples can be achieved, however, by increasing the size of the breasts with silicone implants. The extra weight of the silicone implants may accelerate the return of the droopiness of the breasts and in any event there is a tendency for the breast to sink downwards as time goes by. You can lessen the rate at which this happens by supporting your breasts in a bra as much as possible.

What are the risks?

As with any operation there is a small risk of bleeding and infection, delayed healing of the wound can require dressings for a few weeks but this would rarely reduce the patient's ability to return to work. The dissolving stitches can occasionally cause an irritation in which case the problem suture can be removed.

Some people have an inborn tendency for scars to stretch or become thick and red for a long time. Scar revisions can occasionally be carried out under local anaesthesia

What you should do before the operation?

If you smoke, you should stop now. If you are taking the contraceptive pill, you might discuss changing to an alternative method at least six weeks beforehand. If you are overweight, reduce it beforehand.

What you can expect at the time of the operation?

This surgery is normally carried out under a general anaesthetic and will often involve an overnight stay in hospital depending on the extent and size of the procedure. Bryan Mayou will need to mark the size and shape of your breast while you are sitting or standing and following the operation you may find that you have one small tube emerging from each of the breasts so that any collection of blood can drain. These will remain in place for a short period of time. You will be given painkillers for the discomfort you experience in the first few days. You will be encouraged to wear a firm bras following surgery. The first dressing is carried out at a week after surgery after which you can take a shower or bathe. You should refrain from strenuous physical exercise including swimming, for a month and you will probably require at least two weeks off work. Over the next 6 to 12 months the scars will gradually fade from red to pale. Every effort is made to make your scars as inconspicuous as possible. It is not possible to reshape droopy breasts without significant scars for although the use of breast implants alone will improve the fullness they will not deal with any significant drooping. Breast lift will not last forever and the effects of gravity, pregnancy and weight gain will take their toll, as will time.

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Before 3 months after    

Breast Reduction (Mammoplasty)

The size of women's breasts may be determined by several factors, such as inherited genes, body weight and hormonal influences. They can, therefore, be a problem to some women early in adolescence or may not become uncomfortable until middle age following the menopause or the use of HRT. The problem of large breasts, however, may cause similar problems at all ages and these are chiefly backache, neck pain, grooves in the shoulders from bra straps, rashes under the breasts and the feeling of self consciousness. Because of the sexual nature of breasts the undue prominence may attract unwanted attention from the opposite sex, comments and sexual innuendoes. These can cause psychological distress to many women. One of the commonest complaints of women with large breasts is that it is very difficult to wear fashionable clothes and indulge in active sports, particularly in the summer months.

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Before 3 months after    

What can be done?

Liposuction alone - this is suitable for breasts that are made up of more fat than gland where the skin is still elastic. Liposuction is carried out through a stab incision near the armpit and therefore avoids all obvious scars. The skin will retract following liposuction, not enough to avoid some increased droopiness of the breasts.

Short scar technique

This is a technique used to avoid obvious scars in areas where scarring is both visible and poor. Therefore there should be no scars visible from the front extending towards the mid-line or outwards towards the armpit.

Before the operation After the operation, showing the
scar lines around areola of the
breasts in a 'T' shape

Free nipple grafts

This is used for very large breasts and where healing of the nipple is likely to be poor. There will be similar scars as with the short scar technique but the nipple is not kept in continuity with the gland beneath, being put back as a skin graft. The nipple will therefore have very little sensation.

What are the consequences?

Apart from the change of shape and reduction in size the most obvious consequences are the scars. These are designed to be invisible whilst wearing normal clothing and as far as possible are designed to lie under the average bra or bikini top. Over the months following surgery the scars will fade from being red, possibly thick and uncomfortable, to becoming much more pale and less obvious. However, they will always be present and visible when clothing is not worn and the scars will vary from one woman to another. In some they may be very thin, in others they may stretch and become quite red and possibly ugly. This explains the value of the short scar technique. In the vast majority of women, however, the scars are acceptable and a small trade off for the benefit of dealing with the problems of large breasts. These techniques also keep the nipple in continuity with its glandular tissue and therefore breast feeding is often possible. Breast reduction is no contra indication to pregnancy.

The nipples are likely to be very much less sensitive following surgery due to the nature of the cuts and the nerve supply and it is quite possible that numbness will extend over part of the breast as well.

Will the improvement last?

Unless your operation is done at an age when your breasts are still growing, they should not regrow afterwards. They will however, increase in size if you put on weight, become pregnant or occasionally when taking HRT and decrease on size if you lose weight. Even normal breasts have a tendency to droop with time and you can expect some change in shape to occur after a reduction mammaplasty.

What are the risks?

A small risk of bleeding and infection. Normal breasts do contain bacteria which can occasionally cause inflammation and require antibiotics. Healing can be delayed as a result. Poor scars can sometimes be improved by a simple scar revision under local anaesthetic a few months later. The risks of poor healing are much greater in heavy patients and those who smoke. Patients are requested to try and lose weight before surgery although it is accepted that it is not always possible however every effort should be make to stop smoking for at least two weeks before surgery.

What can you expect at the time of the operation?

This procedure is carried out under a general anaesthetic and when you wake at the end of the operation there will be some mild to moderate discomfort lasting two or three days. You will be given suitable pain killing injections or tablets. Drainage tubes will be removed the day after surgery before you leave hospital. Mr Mayou uses dissolving stitches to avoid scars of stitchmarks and also to simplify post operative care. A well fitting bodice is supplied over the dressings at the time of surgery and will be left in place until the first dressing a week later. It is usually possible to bathe or have a shower after this dressing. The shape of the breast evolves over the next few months and the pink scars mature to become pale and less visible over the next year.