BREAST AUGMENTATION - RISKS & LIMITATIONS
Ideally, before coming for a consultation, you should consult with your GP in order to identify any concerns about your fitness to undergo surgery. Please note that your GP will be kept fully informed by correspondence before and after your surgery as he or she may occasionally need to be involved in some aspects of your aftercare.
All surgery carries some risks of complications. Some are potentially serious and can harm your health while others are less so. During the consultation before surgery you should work with your surgeon to identify all risk factors and, where possible, correct them. The better prepared you are in getting yourself fully fit before surgery the greater the chance of you coming through surgery safely.
Risk factors before surgery
There may be occasions, where your fitness to undergo surgery gives rise to concern, your surgeon or anaesthetist may advise against surgery. Significant medical conditions include:
Chronic heart diseases – uncontrolled raised blood pressure, angina, previous heart attacks, irregular heart rates and heart valve problems -
Chronic lung diseases – bronchitis, unstable asthma
Chronic gastro-intestinal diseases
Crohn’s disease, ulcerative colitis
Chronic neurological and musculo-skeletal diseases – slipped discs, MS
Autoimmune diseases – rheumatoid arthritis
Active treatment for cancer
History of deep vein thrombosis (blood clots)
Chronic psychiatric conditions – severe depression
Significant life changing events - recent bereavement
The prolonged taking of certain drugs for the above and other conditions may predispose to complications:
Aspirin, clopidogrel, warfarin – uncontrolled bleeding, haematoma (collection of blood)
Steroids such as prednisolone in high doses – poor wound healing, infection risks
Other immuno-suppressant drugs – ability to fight infection
Complications during surgery
General anaesthetic risk – You will be seen before surgery by your anaesthetist and you may have to undergo a pre-assessment in order to identify any issues so that they can be sorted before surgery. If you have had previous general anaesthetics before and if there had ever been a problem, then it is very important that you draw this to the attention of your surgeon and anaesthetist at your consultation and pre-assessment.
When compared with having a local anaesthetic, a general anaesthetic carries an inherent risk. You will be looked after by a consultant anaesthetist, who is a senior and experienced doctor. If you are generally fit and well and your anaesthetist has no concerns, then the procedure should be safe. To put things in context, many thousands of patients undergo operations under general anaesthetics safely every day throughout the UK.
Complications in the early post-surgery period
Deep vein thrombosis (DVT) and pulmonary embolism (PE) – Swelling and pain in your calf may indicate the presence of a DVT and if the blood clot in your leg travels to the lungs (PE) you may suddenly become breathless and experience pain on breathing. These complications can make you acutely unwell and very occasionally a massive PE may be fatal. Smoking, the oral contraceptive pill, obesity and prolonged immobility for whatever reasons are some of the pre-disposing factors.
Precautions that will be taken at surgery include the use of TED stockings to be worn until you are fully mobile again. During surgery, where possible, a calf compression device will be fitted and it will serve to keep your circulation going and prevent blood stagnating which is one cause of DVT. After surgery, as soon as you are able, you should practise regular circular movement of your ankle, avoid crossing your leg and you should try to mobilise out of bed by the next day.
If the pre surgery assessment (according to a scale of risks) indicates that a blood thinning agent (a heparin derivative) should be given, this will be administered by injection by the nursing staff after surgery daily until you are discharged.
After discharge home you should remain mobile and active around the house, avoid prolonged bed rest and you should keep up with your leg exercises. However you should avoid being overactive (e.g. housework, heavy lifting) too soon as it may cause a problem with your wound healing and could cause a build-up of blood (haematoma) or fluid (seroma) around the implants.
Chest infection – Smoking increases the risk of you developing a chest infection after a general anaesthetic. Stopping smoking before surgery is therefore strongly recommended and after surgery you should practise deep breathing exercises.
If you find yourself having a productive cough then you should contact the hospital as soon as possible for advice in case you need to take antibiotics.
Bleeding and haematoma – Through careful and unhurried surgery the blood loss during surgery should be modest. Occasionally bleeding in the post-operative period can lead to a haematoma and this manifest itself as an increasing swelling of the breast and pain. If this happens it may be necessary to take you back to the operating theatre so that the clot can be removed and the bleeding points cauterised.
Problems that may develop some days after surgery
Wound infection – Smoking can deprive tissue of oxygen and predispose the wound to infection and it is another good reason for giving up before surgery. Every care will be taken by your surgeon and his team to minimise the risk by gentle handling of tissue and careful suturing. Antibiotic prophylaxis will be given at the start of surgery. Post operatively antibiotic is not given routinely for such clean procedures as this could encourage the development of resistant bugs (e.g. MRSA). It should be reserved for any clinical sign of infection.
Minor wound infection, indicated by a localised area of redness or discharge, is not serious and relatively simple to treat with regular cleaning and antiseptic dressings. Sometimes a buried suture knot that irritates the wound is responsible and this may either come out by itself or it may need to be removed by your surgeon. The wound usually settles uneventfully thereafter. Antibiotic is not usually needed.
Significant infection may be present if you become unwell with a temperature, there is severe and increasing pain that is not controlled by painkillers, if you notice spreading redness in the tissue around the wound or there is discharge of blood or pus. Patients with diabetes or chronic immunity suppression are at increased risk. If seen and treated promptly with antibiotics the infection can be rapidly brought under control. On the other hand if there is considerable delay between you feeling unwell with the above symptoms and the start of treatment then the infection may settle around the implant and it is likely that the affected implant will then need to be removed in order to allow the infection to settle. The key message is - if you experience symptoms which causes you concern then you must call the hospital immediately, day or night, so that you can be seen right away and antibiotic treatment started without delay. That way the infection can be rapidly brought under control and the chance of saving the implant is increased.
Fluid collection around the implants (seroma) – During the recovery period the breast implants normally integrate (stick together) with the breast tissue as well as the muscle. The use of the sports bra helps this process and it is important to wear it constantly. However if there is too much movement too soon (e.g. starting exercises, getting back to work early) then a seroma may form causing the breasts to swell more. This may require further surgery in order to drain the fluid. There is also a small risk of the seroma getting infected.
Longer term effects
Scar – Scars are inevitable as a result of surgery and the position and extent of the scaring will be pointed out to you during the consultation. You must be clear about that and accept there will be scars although your surgeon will do his best to make the scars as neat as possible and hide them, usually in the skin crease under each breast.
Once the wounds heal the scars will initially be pink fine lines. Gradually, over one to two years, the colour will fade and when fully matured, they will become pale scars. While the scars are still pink it is advisable to hide them from the sun since the ultra-violet rays may irritate produce dark pigmentation them more noticeable. Once the scars are pale it will not matter if they are exposed to the sun.
Scar stretch - some scars start off as fine lines but then gradually stretch out and become wider and thinner over time. Hypertrophied scarring – this happens with some scars which gradually get thicker, raised and quite red. They may also be itchy or slightly tender to touch. If troublesome they can be helped with the use of silicone tape, occasionally supplemented by steroid injection to help control the symptoms. Over time, usually about a year, the scar will soften, become pale and flatten.
Keloid scarring – this is an extreme form of scarring which initially behaves like a hypertrophied scar. The difference between the two is that a keloid scar does not soften or flatten with time – on the contrary it continues to grow larger and spread out. There is a genetic and racial predisposition to keloid scarring and it is more common in Afro-Caribbean and some Asian races. If you have any pre-existing keloid scar it may indicate that you are at risk of developing further keloids after your surgery and you should then decide whether to proceed with surgery fully aware of the risks. Treatment can be difficult and may ultimately not be very effective.
Numbness – In creating the pocket to accommodate the implant some of the sensory nerves may be stretched or cut. Consequently there is likely to be some numbness of the breast skin between the scar and the nipple. There may also be some loss of sensation of one or both nipples. With time the numb area may decrease as some of the sensory nerves recover. You may experience some stabbing pain as well as a period of “burning” sensitivity to the skin as a prelude to the return of more normal feeling. It is possible that the numbness could be permanent. In general the bigger the size of the implant chosen the more extensive is the area of numbness likely to be.
Residual or accentuation of breast asymmetry – Before surgery you may be aware that there has always been some difference in size of your breasts and nipple position (asymmetry) – for some this quite obvious, for others it is more subtle. If the volume difference between the two sides is quite noticeable it may be possible to improve the size match by inserting different sized implants. Your surgeon will be able to guide you on that. It is important not to expect perfect symmetry after surgery and some residual asymmetry will usually persist. Sometimes the difference in the position of the nipples may be accentuated by the insertion of implants.
Symmastia – sometimes when patients insist on choosing large implants there is a risk that the extra large pockets that need to be created in order to accommodate the implants can communicate across the area of breast bone and the implants can touch each other with loss of the normal cleavage. This is known as symmastia. This can affect the aesthetic result and may be quite invasive and difficult to correct. The message therefore is to be sensible and choose an implant size appropriate for your body size.
Breast implants capsular problems – a breast implant is a foreign material (just like a hip or knee implant) and the normal reaction of the body is to form an internal scar (a capsule) around it. Usually this does not cause any problem and modern breast implants which have a rough textured surface are designed to reduce the capsular reaction. Occasionally the capsule become very thick and active or fails to integrate with the implant and a capsular contracture occurs. With a mild capsular contracture patients will experience occasional tightness and discomfort around the implant. In a small group of patients the contracture is severe and this produces significant discomfort associated with a visible distortion of the implant. The problem, which can arise months or years after implant insertion, usually affects only one implant although both can be affected. Remedial surgery may be needed to resolve the problem and your surgeon will discuss this with you.
Creasing and wrinkling of implants – the effect of the capsule around the implants can sometimes result in wrinkles or folds being visible on the surface of the breasts. This is more likely if a large implant is chosen and there is very little breast tissue to cover the implants. The outer edges of the breasts are the areas where the wrinkling are most likely be seen and the creasing felt as there is not much breast tissue between the implant and the skin. Thin people are more likely to notice this. Generally nothing need to be done except monitor the areas.
Replacement of implants – it is important to realise that breast implants are not permanent and will, inevitably need to be replaced in future. The manufacturers of breast implants suggest that the normal life expectancy of breast implants are between 10 – 15 years. Some patients do not seem to have any problem for longer than that while others start to notice a problem sooner. They will gradually harden and may eventually leak. If you have any concerns then you should consult with your surgeon who may organise some investigations to visualise the status of the implants. Generally it is not a problem to remove and replace them. It is important to be aware of the future cost that may be incurred with further surgery.
Your tolerance of risks of surgery
Before you decide to undergo any surgery you will need to accept that every procedure carries with it a risk of complications. To ignore that possibility could result in you bitterly regretting ever going ahead. It is therefore important that you evaluate your personal tolerance of the risks. If your attitude is that you cannot accept the possibility of anything going wrong, or that you would not be able to cope psychologically with any problem, then my advice is that you should not proceed with surgery.
When performing your surgery I will always take my time to do it with care and try to get the best possible result. However I cannot give you a guarantee that there will never be any complication. What I can promise is that I will do my best to avoid it and if there is a problem after surgery I will do my best to put it right.
Some complications can arise after successful surgery and may be beyond the surgeon’s control. It is important that you work with your surgeon and his team and by adhering to the advice given before and after surgery the risks can be minimised.
You are encouraged to visit the Department of Health website and type “breast implants” to access publications containing advice for women considering breast augmentation and reports on the safety of silicone gel breast implants – www.dh.gov.uk
Results to expect and the limitations of surgery
Surgery is performed on living tissue and consequently the interaction between your body and the implants during healing can result in a certain degree of unpredictability about the outcome. Factors that influence the outcome include the behaviour of the internal scar, the effect of gravity and stretching of the tissue around the implants.
It is important that to note that no guarantee can be given to achieve a particular breast size and it is particularly important to realise that it is not possible to achieve perfect breast symmetry. What you can expect is a significant improvement to the size and shape of the breasts. Most patients are realistic and breast augmentation remains one of the procedures that result in a high level of patient satisfaction.