Breasts

The popularity of breast augmentation has increased significantly in recent years. It is therefore extremely important that you are confident in your surgeon and are fully informed of the type of implants used in your surgery.

The PIP scandal demonstrated the importance of being able to trust that the implants used are of the highest quality and from a reputable company. Mr Ramakrishnan has never used PIP implants. He uses implants manufactured by Mentor which is a subsidiary of Johnson and Johnson. Mentor is a global leader in the design and manufacture of breast implants which have been used for over 20 years in millions of women. They are silicone gel filled implants which come with a lifetime product replacement policy. This means that regardless of the age of the implant if a confirmed rupture occurs you would be eligible for a no-charge replacement breast implant product of any size in a similar style.

Increasingly Mr Ramakrishnan is being approached by women who have had surgery outside of the UK and have significant issues with the quality and outcome of their surgery. This again underlines the importance that your choice of surgeon takes into account their reputation, expertise and accessibility. For example you will be seen by Mr Ramakrishnan at all of your pre-operative and follow up consultations. Mr Ramakrishnan believes that it is important for you to have a full understanding of what is involved in your surgery. Therefore no procedure will be carried out until he is confident all of your questions have been answered.

Choosing to change the way you look through cosmetic surgery is probably one of the most important decisions you will make.

Why and when is a breast enlargement performed?
Many women find that the size and shape of their breasts affects their self-confidence. If you feel that your breasts are out of proportion with the rest of your body, or that age or breastfeeding have caused them to shrink or lose their shape, a breast enlargement operation (also known as breast augmentation or having breast implants) can help.

What can you expect?
Breast implants are used to make your breasts larger, firmer and fuller. Breast implants are available in a variety of types and sizes and their shape is either “round” in profile and base, or oval shaped with an anatomical contour. They are usually made of an outer layer of silicone, filled with cohesive silicone gel. This is a soft gel which is highly elastic with the approximate specific gravity and feel of normal breast fat. Silicone materials have “memory” ie the shell and gel components of an implant can be stretched and they will return to their normal state when relaxed.

You’ll be able to see different examples of breast implant and discuss the advantages and disadvantages of each before you decide which one is best for you. There are different techniques available which result in different scars either under the breast, around the nipple or in the armpit.

You will be given a further consultation in two weeks, at no additional cost to you, to discuss any queries you may have following your initial consultation. You can bring along your partner, parent or friend for any of these consultations.

You will have to undergo an examination and may have some simple health checks such as blood tests and in some cases a mammogram. If you decide on surgery you will be required to sign a consent form giving permission for the operation. This requires that you are aware of the risks and complications involved with the procedure, which will have been explained to you.

Are there any reasons for a patient not to have this procedure?
Patients who are actively smoking or on blood thinning medication such as aspirin or warfarin have a higher risk for postoperative complications such as bleeding, wound infections and delayed wound healing. It is advisable not to consume nicotine in any form for at least two weeks before this procedure and at least two to three weeks after. Medication such as aspirin or warfarin may need to be stopped if they are not absolutely essential at the appropriate time before surgery. This should be discussed with your Consultant or GP.

What is involved in the operation?
Breast enlargement surgery will be performed under a general anaesthetic, usually takes about an hour and in many cases is performed as a day case without the need for an overnight stay in hospital. The surgery involves placement of an implant either under the skin and breast tissue or deeper under the muscle under the breast. There are many different types and sizes of implant available. They all have a silicone outer layer but may be filled with silicone (cohesive gel that doesn’t run if cut).

What are the complications for this procedure?
The insertion of breast implants either for breast re construction or for cosmetic purposes presents the same health risks common to any surgery, such as adverse reaction to anaesthesia, haematoma (post-operative bleeding), DVT and infection. Complications specific to breast augmentation include scarring and reduced sensation; capsule formation and rupture of the implant.

Before and After

video

Facts at a glance

Surgery time	1 hour
Hospital stay	Day case or 1 night
Anaesthetic assessment	No
Pre admission tests	Yes
Sleeping position	Sleeping on back recommended for 4 weeks.
Reasonably mobile	1 day
Washing	Shower after 1 day. Bath only after 2 weeks.
Driving	3 weeks
Exercise including gym	8 weeks
Full recovery	6-8 weeks
Time off work	2 weeks
Bras and garments	Fitted bra worn for 1 week. Sports bra worn for further 2 weeks. Wired bra only after 2 months
Long term issues	Risk of capsulation.

Update on ALCL

Anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin’s lymphoma (NHL), a cancer involving the cells of the immune system. It accounts for less than 1% of all breast malignancies.

In January 2011 the FDA published a Safety Communication entitled ‘FDA Medical Device Safety Communication: Reports of Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants’.

In a review by the FDA of scientific literature published from January 1997 to May 2010, they identified 34 cases of ALCL in women with breast implants worldwide. The FDA’s adverse event reporting system also contained 17 reports of ALCL in women with breast implants.

In May 2014 the final report on PIP silicone breast implants was published by the European Commission and its non-food Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) which identified 130 case reports worldwide of patients with all types of breast implants who had developed ALCL. This is a very small proportion of the 5-10 million women who have received breast implants worldwide.

The MHRA will analyse any further reports in order to build a fuller picture of the occurrence of this rare disease in association with breast implants.

Click here to download Post Op Care Sheet for Breast Augmentation.

Why does the female breast become ptotic or droopy?
The female breast undergoes enlargement during pregnancy and lactation and due to weight gain. It subsequently undergoes involution once breast-feeding stops or weight loss occurs. As a result of this the breast decreases in size, the skin becomes lax, stretch marks appear and the breast becomes saggy in appearance. The upper part of the breast appears hollow due to loss of volume and appears unattractive.

What is the treatment for breast ptosis or droop?
Breast ptosis can be corrected by a procedure called mastopexy which involves removal of excess slack skin and repositioning of the breast tissue and nipple resulting in a more youthful appearance of the breast.

What does the operation involve?
A mastopexy is carried out under a general anaesthetic and usually involves one night in hospital. Following the operation a tube drain may be placed within the breast to remove any fluid or blood that collects after surgery. This tube drain is removed one or two days after surgery and the patient is allowed to go home. Most patients are able to shower daily and replace their own dressings at home.

What is the normal postoperative course?
Most patients have minimal discomfort, which is well controlled with painkillers. They may have slight difficulty in lifting heavy weights or stretching the arms above the head which normally resolves within a few days. The breasts are usually bruised and swollen for two to six weeks after the operation. During this period patients are advised to wear a sports bra or a soft bra with no under wires. The vast majority of patients are virtually back to normal in three to six weeks and are able to participate in gym, aerobics and swimming six weeks after the operation.

How much time do I need off work?
Most patients are able to return to work within two weeks of the surgery.

What are the complications of this operation?
Just like any other operation mastopexy has its own complications such as bleeding, haematoma (blood clot in the substance of the breast), infection, delayed wound healing, visible or unfavourable scars, minor asymmetry in size, shape or position of the scars and loss of sensation in parts of the breast or the nipple. These complications are relatively unusual. Sometimes patients may require a small secondary revision procedure to trim parts of the scar under the breast. This is usually undertaken under local anesthetic.

Before and After

Facts at a glance

Surgery time	2 1/2 hours
Hospital stay	1 night stay
Anaesthetic assessment	No
Pre admission tests	Yes
Sleeping position	Sleeping on back recommended for 2 weeks.
Reasonably mobile	1 day
Washing	Shower after 1 day. Bath only after 2 weeks.
Driving	2-3 weeks
Sport & exercise including gym	6 weeks
Full recovery	6-8 weeks
Time off work	2 weeks
Bras and garments	Fitted bra worn for 2 -3 weeks
Long term issues	May require scar management

Click here to download the Patient Post Op Care Sheet for Breast Lift

Occasionally mastopexy is combined with augmentation. This needs to be discussed with your surgeon as it may not be possible in all patients.

Before and after

Why do women seek treatment for large breasts?
Women who have large breasts are often physically uncomfortable due to neck ache and backache or when the straps of the brassiere cut into the shoulders. They often sweat excessively in the crease underneath the breast resulting in irritation of the skin in the area. They find it difficult to buy comfortable brassieres off-the-shelf and often have to go to specialist shops which are expensive. They are embarrassed because they feel a large bust attracts unwelcome attention (‘ men speak to my breasts and not to me’) and they are self-conscious both in the workplace and while participating in leisure activities. They do not like to participate in exercise or aerobics due to discomfort while exercising and often do not like to take their children swimming due to embarrassment. They also find it difficult to find clothes that fit their overall frame due to the disproportionately large bust.

What is the treatment for large breasts?
The size of a breast can be reduced by an operation which involves a general anaesthetic and one or two nights in hospital. This is a common procedure in which excess breast tissue is removed and the skin of the breast is tightened resulting in a smaller and better shaped breast with a more youthful appearance.

What is the normal postoperative care?
Following surgery a tube drain is inserted into each breast to remove any fluid blood that collects underneath the skin. This tube drain is normally removed within 24 to 48 hours following surgery. Most patients are able to have a shower before they leave hospital and every day at home. An outpatient appointment is made for removal of sutures one week to ten days following surgery.

How does the appearance of the breasts change after surgery?
Following surgery the breasts are swollen and bruised and will appear larger and higher than the final result. It is important to bear this in mind for the first six to eight weeks after a breast reduction. The swelling and bruising gradually subsides over a period of two to four weeks. The breast feels firm to start with and gradually becomes more supple and natural in appearance over six to twelve weeks following surgery.

How do patients feel in the first couple of weeks following surgery?
Most patients experience mild discomfort in the first few days after an operation which is adequately controlled by painkillers. There may be some restriction of movement especially while lifting heavy weights or stretching above the head which gradually returns to normal over seven to ten days. Most patients returned to normal activities within three to six weeks following surgery and are able to undertake normal exercise regimes including gym, aerobics and swimming approximately six weeks following the operation.

How much time do I need off work?
Most patients are able to return to work which does not involve heavy lifting in approximately two to three weeks after surgery.

Are there any reasons for a patient not to have this procedure?
Patients who are actively smoking or on blood thinning medication such as aspirin or warfarin have a higher risk for postoperative complications such as bleeding, wound infections and delayed wound healing. It is advisable not to consume nicotine in any form for at least two weeks before this procedure and at least two to three weeks after. Medication such as aspirin or warfarin should also be stopped if they are not absolutely essential at the appropriate time before surgery.

What are the complications of this procedure?
Breast reduction can have complications just like any other surgical procedure. These include bleeding, haematoma (blood clot within the breast), infection, visible scars, asymmetry and loss of sensation over the breast of the nipple. Although it is very unusual there is a small possibility of partial nipple loss or fat necrosis (painful lump) in the breast. Very rarely is it necessary for patients to have a revision procedure following a breast reduction. Your surgeon will discuss potential complications with you in detail at the time of the consultation.

Before and After

Video

Facts at a glance

Surgery time	3 hours
Hospital stay	2 nights
Anaesthetic assessment	Possibly
Pre admission tests	Yes
Sleeping position	Sleeping on back recommended for 2 weeks.
Reasonably mobile	2 days
Washing	Shower after 1 day. Bath only after 2 weeks.
Driving	2-3 weeks
Sport & exercise including gym	6 weeks
Full recovery	6-8 weeks
Time off work	2 weeks
Bras and garments	Fitted bra worn for 3 weeks
Long term issues	May require scar management

Click here to download the Patient Post Op Care Sheet for Breast Reduction

The nipples are connected to the underlying breast tissue by means of tiny tubes called ducts. Nipple inversion occurs when these ducts are too short and pull the nipple inwards. It is important for the entire breast to be examined carefully for nipple inversion that occurs over a short period of time as it can sometimes be a sign of an underlying cancer.

Why do patients request correction of inverted nipples?
Patients are embarrassed by the appearance of the nipples especially if just one side is affected. This results in asymmetry since the inverted nipple does not respond to cold weather or stimulation. Patients are self-conscious about this especially in beachwear or swimwear. Patients also find it difficult to breast-feed with an inverted nipple.

What does surgery for this condition involve?
Correction of inverted nipples can be carried out either under local anaesthesia or general anaesthesia as a day case procedure. A small incision measuring a few millimetres is made just below the nipple and the shortened ducts are divided. The nipple is everted and held in place with a dissolving suture, which is placed under the skin. A small dressing is applied which is removed the following day.

What is the normal postoperative course?
There may be slight bruising or swelling and tenderness at the site of surgery. This usually resolves within a few days. Patients can have a shower as normal and change the small dressing over the nipples themselves every day.

How much time do I need off work?
Patients can return to work within a couple of days of the operation.

Are there any complications of this procedure?
Just like any other operation this procedure could have complications such as bleeding, haematoma formation and infection. Following this procedure there can be a loss of sensation in the nipple and it may not be possible to breast-feed. In a small percentage of cases the inversion of the nipple can recur.

Facts at a glance

Surgery time	45 mins
Hospital stay	Day case
Anaesthetic assessment	No
Pre admission tests	No
Reasonably mobile	Immediate
Washing	Shower as normal
Driving	1 Day
Sport & exercise including gym	2 weeks
Full recovery	2 weeks
Time off work	2 days
Bras and garments	No
Long term issues	Recurrence of inversion

Why and when is removal and replacement of implants performed?
Breast implants have a life expectancy of 10 – 15 years although this can be longer. If there are no issues with the implants then they will not need to be routinely replaced. However, in some cases following breast augmentation surgery, one or both of the implants may need to be removed and replaced. This can be due to rupturing of the implant or sometimes capsule formation which is caused by collagen fibres within the body creating a capsule around the implant. This can tighten and squeeze the implant which could result in pain, discomfort and affect the aesthetic appearance of the implant.

What does the operation involve?
Following a diagnosis that one or more implants need to be replaced, surgery similar to a breast augmentation is required to remove the affected implant and replace with a new one. This is a more involved procedure than a breast augmentation especially if there is capsular constriction. Surgery is performed under general anaesthetic, usually takes to two to two and a half hours, and can be either a day case or require a one night’s stay in hospital.

Are there any reasons for a patient not to have this procedure?
Patients who are actively smoking or on blood thinning medication such as aspirin or warfarin have a higher risk for postoperative complications such as a bleeding, wound infections and delayed wound healing. It is advisable not to consume nicotine in any form for at least two weeks before this procedure and at least two to three weeks after. Medication such as aspirin or warfarin may need to be stopped if they are not absolutely essential at the appropriate time before surgery. This should be discussed with your Consultant or GP.

What are the complications for this procedure?
Removal and replacement of implants presents the same health risks common to any surgery, such as adverse reactions to anaesthesia, haematoma (post-operative bleeding), DVT and infection. Specific complications to implant surgery continue to be rupture of the implant and capsule formation.

Facts at a glance

Surgery time	2.5 hours
Hospital stay	Day case or 1 night
Anaesthetic assessment	No
Pre admission tests	Yes
Sleeping position	Sleeping on back recommended for 4 weeks.
Reasonably mobile	1 day
Washing	Shower after 1 day. Bath only after 2 weeks.
Driving	3 Weeks
Exercise including gym	8 weeks
Full recovery	6-8 weeks
Time off work	2 weeks
Bras and garments	Fitted bra worn for 1 week. Sports bra worn for further 2 weeks. Wired bra only after 2 months
Long term issues	Risk of capsulation.

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Providing expert care
in Reconstructive and
Cosmetic Surgery

Providing expert care in Reconstructive and Cosmetic Surgery

Providing expert care
in Reconstructive and
Cosmetic Surgery