Breast Augmentation

Women with small or medium-sized breasts, and patients with minimal sagging due to loss of breast volume after pregnancy, are ideal patients for breast implants. As breast size and/or the degree of sagging increases, placing an implant alone is not sufficient to correct the resulting deformity, and it must be performed together with a breast lift operation.

Breast augmentation for aesthetic purposes can generally be performed after breast development is complete. Since breast development in women is completed around the age of 18, it will be appropriate to wait until this age for implant operations except in special circumstances. When all patients who undergo breast surgery are considered, breast augmentation operations are the operations preferred more by patients in the young and middle age groups.

The silicone implants used in breast surgery have been developed since they were first produced in 1963 to eliminate the problems experienced and to increase their durability, and today silicone implants known as the fifth generation are used. Problems frequently encountered with earlier models, such as gel leakage, implant rupture and implant deformation, are not seen with the latest generation implants. Manufacturers give a lifetime warranty in this regard. A feature of fifth-generation implants is that they contain a cohesive gel, that is, a gel with low fluidity. Even if these implants rupture where they are placed, the gel inside does not leave the implant and does not spread in the body. The rates of capsular contracture, an unresolved problem, have been minimised thanks to the textured surfaces of the implants.

The implants used other than silicone are implants filled with physiological saline (salt water). After knowledge about silicone implants increased and scientific data were presented showing that silicone implants do not cause cancer or certain autoimmune joint diseases, the bans applied to silicone implants were lifted, and the saline-filled implants that emerged for a period have now gradually lost their prevalence.

In 1993 the US Food and Drug Administration (FDA) suspended the use of silicone implants for 10 years. The reasons for this were that their effect on breast cancer was unclear, the concern that they could interfere with mammographic examinations, and the suspicion that they could lead to certain joint diseases. The studies carried out during these 10 years proved that all these suspicions were unfounded. Since 2003 they have been permitted again in the USA. For this reason it can be said that silicone implants have no effect on breast cancer. On the contrary, the incidence of breast cancer in patients with breast implants is 30% lower than in other women. The reason for this may be that women in the high-risk group do not often choose implant operations. In addition, breast pathologies that occur in women with breast implants are diagnosed earlier. The reason for this is that women who want breast implants are more attentive to their own bodies and have their breast check-ups done more regularly.

The use of fat injections instead of implants in breast augmentation has been a topic on the agenda in recent years, but a result as clear as with implants cannot be obtained, and sufficient size cannot be achieved. For this reason the procedure frequently needs to be repeated several times. In addition, the fact that breast implant patients are generally slim and do not have a sufficient amount of fat in their bodies is another factor limiting the use of this method. Because the permanence of the results cannot be predicted with certainty, the standard method in breast augmentation is the placement of breast implants. Stem cell-enriched fat injections can be performed to increase permanence. In this case permanence of up to 80% can be achieved. However, this increases costs considerably.

Today, breast augmentation with fat injection alone can only be applied in selected patients and in those with marked breast asymmetry.

The combined use of fat injections and breast implants, on the other hand, is a method that has become increasingly common in recent years. It is preferred as a method that greatly increases the aesthetic gains, especially in the group of patients who have little breast tissue and in whom there cannot be sufficient soft tissue coverage over the implant or the edges of the implant cannot be fully camouflaged.

Another problem with fat injections is the risk that the calcifications that form may affect mammograms taken in the future. However, when fat injections are performed in the correct plane, this risk is reduced.

Every operation leaves a scar on the body. However, breast augmentation can be counted among the procedures with the least scarring. A 4-5 cm incision is made to place the implant. Implants can be placed through the fold under the breast, through the nipple or through the armpit. A very rarely used approach is placing the implant through the navel. Because only implants inflated with saline can be placed through the navel and the armpit, these are no longer much preferred approaches. Although the scar appears to be less with the nipple approach, because the breast tissue is cut and the rates of capsular contracture are higher, incisions under the breast are now preferred more. In addition, in patients with small nipples, implants cannot be placed through nipple incisions. Recently, incisions under the breast have been the most frequently preferred all over the world and are accepted as the safest approach. This scar remains exactly in the fold under the breast. In the long term all scars fade and do not bother patients. However, scar problems may occur in patients whose scars remain prominent due to their skin characteristics.

Breast implants can be placed both under and over the muscle. Both methods have advantages and disadvantages. In slim patients with thin subcutaneous tissue, implants are placed under the muscle so that the edges of the implant do not remain visible and the implant can be better camouflaged. In patients whose subcutaneous tissue is thick enough and in whom the aim is to correct sagging as well as to enlarge the breast, the implant can be placed under the breast tissue or under the muscle fascia. In order to combine the advantages of both methods, the technique called “dual-plane”, in which the upper part of the implant lies under the muscle and the lower part under the breast, is the most preferred technique in modern breast surgery.

In the human body, procedures that create tension, particularly in deep tissues, are perceived by patients as pain. For this reason, patients should be informed before the procedure that there may be pain after breast augmentation. When the implant is placed over the muscle, pain is so little as to be almost non-existent. Submuscular placements are more painful. However, to minimise pain, long-acting and strong anaesthetics are given during the operation. Thanks to these, the patient does not feel severe pain on waking. The pain becomes more noticeable the next day. However, it can be controlled with painkillers and is not unbearable. The pain may last about 3 days. In the following days, what is generally bothersome is a feeling of pressure rather than pain, and depending on the size of the implant placed and the tightness of the patient's skin, this may be felt during the first 3 weeks.

Three hours after the end of breast augmentation, the patient can eat and get up. Usually the patient is discharged from hospital within 24 hours. There is a small dressing on the patient's incision site. They can shower after two days. They come for a check-up after three days and can then return to work, resume normal daily activities and drive. They should not do any sport other than walking for the first 3 weeks. Also for the first 3 weeks they need to wear a sports bra day and night. After the third week they can do all sporting activities except arm and chest movements. After the sixth week, all kinds of sporting activity are allowed.

For the first 3 weeks the implants sit higher than normal and their appearance is not natural. After the third week they begin to soften and descend to their normal position. The breasts only take on their full shape in the 3rd month. Unless there is a special situation, subsequent check-ups are carried out at the 3rd week, 3rd month, 6th month and at the end of the first year. When a year has passed since breast augmentation, a follow-up mammogram/ultrasound can be performed.

In the early period, bleeding, infection and wound healing problems may occur. However, these are rarely observed problems.

The most common long-term problems with breast implants are capsular contracture, asymmetries and aesthetic problems. Implant leaks and ruptures are no longer observed with good-brand implants, and the two companies that are the most important implant manufacturers in the world (Allergan and Mentor) give a lifetime product warranty in this regard.

Capsular contracture is the body perceiving the implant as a foreign body, surrounding it with a hard capsule and pushing it to one side. When capsular contracture develops, depending on its severity it leads to hardening, asymmetry and distortion of appearance in the breast. Its incidence varies between 1% and 5%. If it occurs, the patient needs to be operated on again to remove the capsule and replace the implant. If it recurs, another operation can be performed, but if it recurs a third time the implant procedure is abandoned. Persistent capsules are not a very frequently encountered situation. Capsule rates are low with new-generation implants. In addition, capsules develop less with access through incisions under the breast, submuscular placement and textured-surface implants. Using a careful technique in surgery and not placing implants of exaggerated size also reduce the risk of capsule formation.

Other problems that may be encountered after implants include asymmetries, implants being visible from the outside, rippling seen over the implant, the patient not being satisfied with the size of the implants, and the breasts not looking natural. All these problems can be reduced by guiding the patient correctly in implant selection and avoiding excessively large implants, using fifth-generation stable implants, better camouflaging the implants in slim patients by placing them under the muscle or by fat grafting, and by careful surgery.

Another problem that may occur is sometimes temporary loss of sensation or excessive sensitivity in the nipples. These complaints usually resolve completely within a few months. Permanent loss of sensation is very rare. The most important cause of sensory loss is the use of excessively large implants. In addition, there may be loss of sensation and pain in patients who develop capsular contracture.

Neither mother nor baby is affected by the implant during pregnancy and breastfeeding. However, there may be sagging of the breast after pregnancy. In this case, a breast lift procedure can be performed after breastfeeding has ended. Research shows that breast augmentation operations have no effect on breastfeeding. Even if the silicone implant has been placed under the breast, no silicone passes to the baby through breast milk.

Regular radiological follow-up can continue after breast implants. Breast implants do not adversely affect mammography. New digital mammography devices, in the hands of radiologists experienced in this area, can easily be used in patients with breast implants. In addition, ultrasonographic examination and MRI can be applied to all patients. When the implant is placed through the fold under the breast, since the breast tissue is not cut, it does not leave any mark either.

Replacement was an issue for old implants, and they needed to be replaced within 8-10 years. However, this does not apply to the 5th-generation implants used in recent years. Unless problems arise, implants can be used for life. Some implant manufacturers give a replacement guarantee if any problem arising from the implant occurs.