Woman's breasts are associated with femininity and consequently women who possess little or no breast tissue may feel unfeminine & suffer from a lack self esteem.

Breasts may fail to develop, or, following pregnancy they may lose volume and shape. The primary reason for performing breast augmentation is to increase the breast size.

Secondarily, in some cases it may be possible to improve the shape and symmetry. Some breasts may appear to be droopy due to the fact that the distance between the nipple and the breast fold is very short; in such cases the droop may be corrected by increasing the breast size and lowering the position of the fold. In mild cases of nipple inversion the nipples may become everted.

Prior to breast augmentation it is necessary to ascertain that there is no breast disease and this is done thorough examination and in older women by x-rays and/or ultrasound. For women who have a strong family history of breast cancer, the decision whether to go ahead with the surgery is much more complex and will be explained in detail by the surgeon.

There are a choice of implants for augmentation and this will be determined by the surgeon and by patient's preference. In essence, breast implants are bags made of silicone either smooth or rough (textured) on the surface, filled with liquid or gel. The nature of the filling material and the thickness of the a shell will determine the "feel" of the implant.

Silicone gel implants have been in use for 35 years, but in recent years have been the subject of extensive negative publicity. In the light of recent extensive studies, especially in the United States, it has become clear that the likelihood of developing auto-immune disease due to silicone breast implants is very small. These diseases are extremely rare and there has been no appreciable increase in their incidence. Equally there has been no evidence that they may be associated with an increased chance of developing breast cancer. The implants probably have the best feel of all the implants and small incidence of encapsulation, particularly when the textured variety are used. The main problem is the difficulty in x-raying breasts, and what happens to silicone gel when they leak or rupture. Breasts with silicone implants can be x-rayed using special techniques because silicone obstructs the picture. There is no problem with leaking or ruptured implants providing the silicone is contained within the breast pocket. The difficulty arises when silicone escapes outside the breast pocket and travels within the body's lymph nodes.

More recently a new type of silicone implant, the cohesive gel, has been introduced which contains silicone in a less liquid form. All silicone implants now used in this practice contain cohesive gel which is slightly firmer.

Saline Implants
These implants do not have the disadvantage of containing silicone. However, saline does not have a natural feel and if there are pockets of air within the implant "sloshing" sounds may be heard under some circumstances. There is also the problem of valve through which the implant is filled with saline during surgery. When the valve fails the implant deflates and needs to be changed. It is not possible to remove the inflated implant without puncturing and this necessitates insertion of a new one that increases the cost of surgery.

Hydrogel Implants
These implants are made of a salt water and sugar solution, that when combined, form a gel. Again, this prosthesis is tolerated by the body without any side effects, and in fact, the contents of this implant could safely be eaten! Hydrogel feels similar to silicone as it is a gel, and may be inserted using the axillary approach.

Implants can be inserted through incisions placed in the fold of the breast, in the areola of the nipple, or in the armpit. The choice of the approach will depend on the surgeon's choice as well as experience. In most circumstances the armpit approach produces the most inconspicuous scar, but technically it is also the most difficult from a surgical point of view.

The implants are placed in a pocket made either in front of the chest muscle, the pectoralis, or behind. If possible, it is better to place the implants behind the muscle because it provides an extra cover and with aging the implant is less likely to produce visible wrinkling, especially in the lower and inner part of the breast. There is also some evidence that, if implant is placed behind the muscle, the likelihood of hardening (capsule/contracture) is lessened.

Breast augmentation is usually carried out under general anaesthesia and requires a one night stay in hospital. It may be painful especially when implants are inserted under the chest muscle. The pain is due to stretching of the muscle. Drains are left in breast pocket overnight and removed the following day. Sutures are removed 7-10 days post-operatively. Swelling will last for two to three weeks and softening of breasts may take up to six months, depending on the implant used.

Breast augmentation is a safe operation if carried out by an experienced surgeon. However, as in all surgery it is subject to complications:

1. Bleeding: this is uncommon and occurs in approximately 1% of patients. The most critical time is immediately after surgery when excess blood may accumulate in the breast pocket and needs to be evacuated. There should be no long-term problems arising from this complication.

2. Infection: surprisingly it is very rare and occurs in less than 0.5% of patients. In some cases it may be treatable with antibiotics but it may necessitate implant removal for a period of six to twelve weeks before the implants is re-inserted.

3. Implant rejection: this is very unusual, if it ever occurs.

4. Scarring: some individuals form unfavorable scars and these may have to be revised at some stage or may require injections of steroids to improve them.

5. Asymmetry: most breasts are of different size and this may become more apparent after surgery. If there is visible difference before surgery most surgeons will try and correct this by using implants of different sizes. However, it is not possible to make breasts completely symmetrical; asymmetry is "normal".

6. Encapsulation: sometimes also called hardening is the commonest problem that may arise following surgery, either early on, or many years later. It still occurs in between 0.3% and 10% of patients, and is due to behavior of scar tissue that surrounds the implants. When this capsule of scar tissue tightens around the implant the breast feels firm or hard. In extreme cases, when the capsule shrinks and becomes very thick, the breast may become painful and its shape distorted. In most cases the capsule can be treated by further surgery and only few individuals present with an intractable problem necessitating implant removal.

7. Malposition of implant: implants settle too high or too low necessitating repositioning by further surgery.

As in all surgery it is essential to see a surgeon who will be able to tell you whether your problem can be remedied by surgery, and what the risks are. Thereafter you will be in a position to decide whether you should go ahead or not.

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