Breast Augmentation Surgery

Breast hypoplasia is defined by insufficient breast volume relative to the patient's morphology. It may result from insufficient gland development at puberty, or appear secondarily through loss of glandular volume (pregnancy, weight loss, hormonal changes, etc.).

Insufficient volume may also be associated with ptosis (drooping breasts with glandular sagging, skin distension and low areolas).

The procedure may be performed at any age from 18 onwards. A minor patient is usually not considered eligible for aesthetic breast augmentation. However, it is possible in cases of severe hypoplasia or in the context of reconstruction such as tuberous breasts or breast agenesis.

This purely aesthetic surgery cannot benefit from health insurance coverage. Only rare cases of true breast agenesis (radical absence of all breast development) may sometimes receive social security participation after prior approval.

The breast implants currently in use are composed of a shell and a filler product.

The shell is always made of silicone elastomer. However, prostheses differ in their content, i.e., the filler product within the shell.

The implant is called pre-filled when the filler product has been incorporated in the factory (gel and/or saline solution). The range of different volumes is therefore determined by the manufacturer.

Inflatable saline implants are filled by the surgeon, who can adapt the prosthesis volume to some extent during surgery.

The vast majority of prostheses currently placed in France and worldwide are pre-filled with silicone gel.

They are composed of soft silicone gel, surrounded by a watertight, solid and elastic silicone elastomer shell that may be smooth or textured (rough).

The marked developments of new implants, conferring greater reliability, concern both the shells and the gel itself:
• Shells, with walls now much stronger, prevent gel "transpiration" outward (which was a major source of capsular contracture) and have far superior wear resistance;
• "Cohesive" silicone gels, with a less fluid consistency, greatly limit the risk of spreading in case of shell rupture.

In addition to improved reliability, the new generation of silicone implants is also characterised by the great diversity of shapes currently available, allowing personalised adaptation to each case. Thus, alongside the classic round prostheses, "anatomical" implants shaped like a teardrop, with varying heights, widths and projections, have appeared.

This great diversity of shapes, combined with a wide choice of volumes, allows near "made-to-measure" optimisation and adaptation of prosthesis selection based on the patient's morphology and personal expectations.

Prosthesis shells are always made of silicone elastomer; it is the filler product that differs. To date in France, only two alternatives to silicone gel are authorised:
• Saline solution: salt water (constituting 70% of the human body). These prostheses may be "pre-filled" (at the factory) or "inflatable" (by the surgeon during surgery). Due to their liquid (not gelatinous) content, they have an unnatural consistency, form many more palpable and sometimes visible "folds," and may sometimes suffer sudden and sometimes early deflation.
• Hydrogel: the very latest substance to receive ANSM approval in 2005. It is an aqueous gel, largely composed of water gelled by a cellulose derivative. This gel, of more natural consistency than saline, is also resorbable by the body in case of shell rupture.

Based on this anatomical context, the surgeon's preferences and habits, and the patient's expressed wishes, a surgical strategy will have been agreed upon. Scar placement, type and size of implants, and their positioning relative to the muscle (see below) will thus be predetermined.

• A preoperative blood test will be performed in accordance with prescriptions.
• The anaesthetist will be seen in consultation no later than 48 hours before the procedure.
• A breast imaging assessment is prescribed (mammography, ultrasound).
• Smoking cessation is strongly recommended at least one month before and one month after the procedure (smoking can cause delayed healing).
• No medication containing aspirin should be taken in the ten days prior to surgery.
• You will likely be asked to fast (no food or drink) for six hours before the procedure.

Type of anaesthesia:
It is most often a standard general anaesthesia, during which you sleep completely. In rare cases, a "twilight" anaesthesia (local anaesthesia deepened by tranquillisers administered intravenously) may however be used (to be discussed with the surgeon and the anaesthetist).

Hospitalisation:
The procedure usually requires a one-day hospital stay. Admission takes place in the morning (or sometimes the day before in the afternoon) and discharge is authorised the following day. However, in some cases, the procedure may be performed as a day case.

Each surgeon adopts a technique of their own, which they adapt to each case to achieve the best results. However, common basic principles can be identified:

Skin incisions:
Several surgical approaches are possible:
• areolar routes, with an incision in the lower segment of the areola circumference, or a horizontal opening contouring the nipple from below (1 and 2);
• axillary route, with an incision under the arm, in the armpit (3);
• inframammary route, with an incision placed in the crease beneath the breast (4).
Incision lines correspond to the location of future scars, which will therefore be concealed in junction zones or natural folds.

Implant placement
Via the incisions, implants can be introduced into the prepared pockets. Two positions are possible:
• pre-muscular, where prostheses are placed directly behind the gland, in front of the pectoral muscles;
• retro-muscular, where prostheses are placed deeper, behind the pectoral muscles.
The choice between these two locations, with their respective advantages and disadvantages, will have been discussed with your surgeon.

Complementary procedures
In case of associated breast ptosis (drooping breasts, low areolas), we have seen that it may be advisable to reduce the skin envelope of the breast to lift it ("mastopexy"). This skin resection will then result in more significant scars (around the areola +/- vertical).

Drains and dressing
A small drain may be placed depending on the surgeon's habits. This device is designed to evacuate blood that could accumulate around the prostheses.

At the end of the procedure, a "shaping" dressing is applied with an elastic bandage.

Depending on the surgeon, the approach and the possible need for associated complementary procedures, the operation may last one to two and a half hours.

Postoperative recovery may sometimes be painful in the first days, particularly when implants are large and especially when placed behind the muscles. Analgesic treatment, adapted to pain intensity, will be prescribed for a few days. In the best case, the patient will feel a strong sensation of tension.

Oedema (swelling), ecchymoses (bruising) and difficulty raising the arms are frequent initially. The first dressing is removed after a few days and replaced by a lighter dressing. A bra may then be recommended day and night for a few weeks.

Most often, sutures are internal and absorbable. Otherwise, they will be removed after a few days. A convalescence with activity interruption of five to ten days should be planned, and it is advisable to wait one to two months before resuming sports activity.

A period of two to three months is necessary to appreciate the definitive result. This is the time needed for the breasts to regain all their suppleness and for the prostheses to stabilise.

The goal of this surgery is to bring about an improvement, not to achieve perfection. If your expectations are realistic, the result obtained should give you great satisfaction.

Result stability
Independently of prosthesis lifespan (see below) and excepting significant weight variations, breast volume will remain stable long term.

However, regarding shape and "hold" of the bust, "augmented" breasts will, like natural breasts, undergo the effects of gravity and ageing, with variable rapidity depending on age and skin support qualities, but also on implant volume.

Certain imperfections may occasionally be encountered:
• residual volume asymmetry, incompletely corrected despite implants of different sizes;
• excessive firmness with suppleness and mobility judged insufficient (especially with large implants);
• a somewhat artificial appearance, particularly in very thin patients, with excessive visibility of prosthesis edges, especially in the upper segment;
• palpability of implants is always possible, especially when the tissue coverage (skin + fat + gland) overlying the prosthesis is thin (particularly with large implants).
• worsening of breast ptosis may be observed, especially with voluminous implants.

In case of dissatisfaction, some of these imperfections may eventually benefit from surgical correction after a few months.

• Autoimmune diseases
The very numerous large-scale international scientific studies on this subject have unanimously proven that there is no greater risk of these rare diseases occurring in implant-bearing patients (particularly silicone) than in the general female population. In the current state of knowledge, it can be stated that breast implant placement, including silicone, does not increase the risk of breast cancer.

However, as part of cancer screening after implantation, clinical examination and palpation may be disrupted, especially in cases of peri-prosthetic capsular contracture or siliconoma. Similarly, the presence of implants may interfere with performance and interpretation of screening mammograms. You should therefore systematically specify that you have breast implants. Thus, certain specialised radiological techniques (particular views, digitised images, ultrasound, MRI, etc.) may be used as needed.

• Implant lifespan
Even though some patients may keep their implants for several decades without major changes, breast implant placement should not be considered as something permanent "for life." Thus, a patient bearing implants can expect to eventually need to replace her prostheses to maintain the beneficial effect. Implants of any kind have an uncertain lifespan that is impossible to predict precisely since it depends on wear phenomena of variable speed. Implant lifespan therefore cannot be guaranteed in any way.

It should be noted, however, that new-generation implants have made significant progress in terms of resistance and reliability. From the tenth year, the question of prosthesis replacement should be considered if a consistency change appears.

• Monitoring
It is essential to attend the follow-up visits planned by your surgeon in the weeks and months following implantation. Subsequently, the presence of implants does not exempt from usual medical monitoring (gynaecological follow-up and breast cancer screening), even if it does not require additional examinations beyond those related to this monitoring. However, it is indispensable to specify to the various involved physicians that you have breast prostheses.

A surveillance consultation specific to implants with your plastic surgeon is recommended every two to three years, but apart from this follow-up, it is primarily essential to consult as soon as a change in one or both breasts is detected or after a violent trauma.

Breast augmentation with prostheses, although performed for essentially aesthetic motivations, remains a genuine surgical procedure, which implies the risks associated with any medical act, however minor.

A distinction must be made between complications related to anaesthesia and those related to the surgical procedure:

Regarding anaesthesia, during the mandatory preoperative consultation, the anaesthetist will personally inform the patient of the anaesthetic risks. Anaesthesia may induce sometimes unpredictable reactions. However, having recourse to a competent anaesthetist-resuscitator, practising in a truly surgical setting, means that the risks incurred have become statistically very low.

Regarding the surgical procedure, by choosing a qualified and competent plastic surgeon, trained in this type of intervention, you minimise these risks as much as possible, without however eliminating them entirely.

In practice, the vast majority of breast augmentations performed according to standard practice proceed without any problems. However, complications may arise, some inherent to breast surgery and others specifically related to implants:

Complications inherent to breast surgery:

• Effusions, infection
- haematoma: blood accumulation around the prosthesis may occur in the first hours. If significant, a return to the operating theatre is preferable.
- serous effusion: lymphatic fluid accumulation around the prosthesis is fairly common, often associated with significant oedema. It resolves spontaneously and progressively.
- infection: rare after this type of surgery. It may require reoperation for drainage and implant removal for a few months.

• Skin necrosis: rare but feared, may locally expose the prosthesis. Reoperation is often necessary.

• Scarring anomalies: scars may not always be as discreet as expected.

• Sensitivity changes: frequent in the first months but usually regress. Rarely, some degree of dysaesthesia may persist, particularly at the areola and nipple level.

Risks specifically related to implants:

• "Folds" or "rippling": implant shells may fold and these folds may be palpable or visible.

• "Capsular contracture": the normal physiological reaction of the body to a foreign body is to isolate it by forming a hermetic membrane. Sometimes this capsule thickens, becomes fibrous and contracts, compressing the implant, resulting in firmness, constriction or visible deformation.

• Rupture: implants cannot be considered permanent. Loss of shell integrity may eventually occur due to progressive wear.

• Malposition, displacement: may sometimes warrant surgical correction.

• Rotation: pivoting of an "anatomical" prosthesis remains theoretically possible.

• Late peri-prosthetic seroma: may very rarely occur and require ultrasound-guided puncture with appropriate cytological study.