Article 1. Breast Implants - How long do they last
Article 2. Facial Rejuvenation - an open letter to patients
Article 3. Breast implants - an open letter to patients
By Allan Kalus F.R.C.S., F.R.C.S. (Ed.), F.R.A.C.S.
Plastic & Reconstructive Surgeon
With many thousands of women having had breast implants inserted since the 1970s, I am often asked:
"How long will my implants last?" and
"When should my implants be replaced?".
With many different types of implants having been used over the past 30 years there is no simple answer, as each implant will obviously have a different life span. There are however 2 broad classifications:
1. Silicone implants
Because of the high cohesiveness (or stickiness) of the Silicone inside these implants, it is usually not at all obvious that an implant is leaking. Therefore, an ultrasound, CT, or MRI scan may be required to determine whether or not the implant has leaked.
2. Saline implants
In the case of Saline implants, any leakage will be obvious as the implant, and therefore the breast, will decrease in size.
The above 2 groups can be further analyzed as follows:
1. Silicone implants
A) Silicone implants manufactured between 1975 and 1985 (thin wall)
These implants were designed with a very thin wall in order to make them as soft as possible. We now know that this wall breaks down after about 10 years, causing the silicone within the implant to leak out and lie free within the pocket of scar tissue which always surrounds the implant. So long as this liquid silicone remains within an intact pocket of scar tissue there are usually no problems and it may not be at all obvious that the implant has in fact ruptured and begun leaking. If, however, the scar tissue should tear, due to trauma, then the free silicone (which resembles a sticky jelly like substance) migrates into the tissues in and around the breast. This usually results in a hard swelling called a siliconoma. These hard swellings can be uncomfortable and usually require surgical removal resulting in a scar and some loss of the surrounding breast tissue. If the siliconoma is large, or if there are multiple siliconomata, then the scarring and loss of breast tissue can result in considerable deformity of the breast.
Because of this risk, it is recommended that silicone implants manufactured between 1975 and 1985 be replaced even if you have no symptoms.
B) Silicone implants manufactured after 1985 (thick wall)
These implants were designed with a thick wall and called "low bleed" implants as the thicker wall resisted silicone leakage. These implants last approximately 15 years before breaking down and causing the same problems as the thin walled implants in group A. It is therefore recommended that these implants be removed at or before 15 years.
Over the last 2 years silicone implants have been available with a "high cohesive" gel. These implants are firmer than normal silicone implants as the gel inside does not flow. In addition some of these implants feel "moist" to the touch indicating a thin wall which permits silicone ooze even when new! As these implants have only been available for approximately 2 years it is not possible to say how long they will last and what the consequences of leakage will be.
2. Saline implants
Because leakage of these implants is obvious (the breast will decrease in size) and harmless (only salt water is released into your body and this is safely absorbed) replacement of these implants is only required if complications occur. The most common complication is excessive firmness developing due to a thickening of the scar tissue capsule surrounding the implant. (This complication also occurs with silicone implants). In this situation it is often possible to retain and reinsert the original implant after the scar tissue has been surgically divided and a new pocket made for the implant.
There are 2 categories of saline implants.
A) Textured saline implants
These implants were manufactured with a roughened or "textured" surface so that they would adhere to the surrounding tissue. Complications seen with this type of implant include visible wrinkling of the skin (which has become attached to the implant) and swelling of the breast due to an abrasive effect of the implant on the surrounding tissues. These implants have a relatively high deflation rate as folds can form in the implant resulting in abrasion of the implant surface and subsequent leakage. If one groups all of these conditions together the need for re-operation on patients having textured implants has been reported to be as high as 44.6% at 3 years (in a study of McGhan implants).
B) Smooth-walled saline implants
These implants have been designed with a smooth shell so that they do not adhere to the surrounding tissue and therefore move in a way which more naturally simulates the normal breast. Because of this, complications such as wrinkling and swelling are extremely rare. Excessive firmness of the breast due to thickening of the scar tissue capsule can occur but interestingly the risk varies greatly according to whether the implant has been placed in front of or behind the pectoral muscle. If the implant has been placed in front of the pectoral muscle, then studies have reported a 60 percent risk of excessive firmness (capsule contracture) at 2 years. If the implant has been placed behind the pectoral muscle then the risk of capsule contracture is less than five percent!
The risk of smooth-walled implants leaking is extremely low and in my own experience with over 1000 Mentor saline implants inserted over the last 10-15 years I have had only one case of implant deflation.
All women contemplating breast augmentation should be aware that "nothing lasts forever" and that, therefore, their implants may need to be replaced either due to complications or to leakage. The best implants currently available, according to our current knowledge, can be expected to last for at least 10 years - although they may last considerably longer.
Breast implants and the ageing breast.
As a woman ages she often puts on weight, especially in the bust. This weight gain, together with the repeated enlargement of the breast which may have occurred during pregnancies, often results in women in their 40s feeling that they no longer require the extra breast size provided by their breast implants. In these situations there is often sufficient natural breast tissue to provide for a "C" cup size breast even without the breast implants. As the breast has usually sagged with age, the procedure most commonly performed is to remove the implants and, at the same time, to perform a breast uplift procedure where the natural breast tissue is reshaped and repositioned in order to produce a firmer breast in a more youthful position.
Dear Patient,
Each year we see many people, both men and women, who have become concerned about their facial signs of ageing. They may be aware of facial lines, sagging of their cheeks or a bagginess of their eyelids. Sometimes friends or family have also noticed the changes and this can lead to a person becoming very self-conscious. For example, the changes that occur in the eyelids can make you always look tired even when you feel bright and alert. Looseness and wrinkling of the neck skin makes some people feel very embarrassed and feel they need to "cover up" with a scarf or high necked clothes.
These changes all occur due to the loss of elasticity of the skin which comes with increasing age. In addition, the fat which is naturally present in the face tends to absorb as we age and this leads to thinning of the lips and deepening of the cheek furrows.
The texture and pigmentation of the skin also changes, especially if there has been a lot of exposure to the sun.
Because every person's concerns are different, I think it is important for you to try to prioritize your concerns - in other words to list your concerns in order of importance. During the examination I find it very helpful for patients to look down into a mirror. This allows the skin to sag to its full extent and gives us a "window" into the future - showing us how you will look in years to come. The next step is to hold the mirror above your head and look up into the mirror. This gives an excellent indication of the likely improvement that will be obtained from a facelift.
Indeed a facelift is the corner stone of facial rejuvenation surgery. By lifting the skin and underlying muscle (called the superficial musculoaponeurotic system) we are correcting for the loss of elasticity of the skin and the stretching of the muscle. Of course it is critical that scarring be kept to a minimum and be invisible where possible. Therefore the procedure is performed through incisions in front of and behind the ear and extending slightly into the hairline.The extent of the procedure varies according to individual need but basically is designed to remove the excess skin and lift the underlying muscle which is then fixed in place.
If there has been some loss of facial fat with thinning of the lips and prominent cheek grooves then transferring some fat into these areas greatly improves the result. There have been great improvements in the technique of fat transfer over recent years and I much prefer the use of your own fat to the use of artificial substances such as wrinkle injections. The fat is taken from the abdomen, thigh or buttock, prepared by centrifugation and then injected with a special blunt ended needle so as to cause minimal trauma. The fat becomes incorporated into the tissues and restores the fullness which has been lost due to the ageing process. More fat than is needed is transferred to allow for some absorption to take place and the area is therefore a little swollen for 1-2 weeks.
For some people the ageing process seems to begin first in the eyelids.The upper eyelids, the lower eyelids or both may be affected. In the case of the upper eyelids a fold of skin forms which hangs down over the eyelid, occasionally even covering the eye lashes. The upper eyelid feels heavy and the upper part of the visual field may even become obstructed. The natural reaction is to try to hold up the upper eyelid by raising the eyebrows and this causes multiple creases in the forehead. The best way to treat the upper eyelid is to remove the fold of excess skin which usually also contains a little muscle and some underlying fat. In some cases the eyebrows have also descended and a brow lift may be required. This can be performed through 2 or 3 small incisions within the hairline.
The lower lids also may sag due to stretching of the skin and underlying muscle.In addition, the lower lids may bulge due to fat which is normally situated behind the eye pro lapsing forwards. The lower lid is best treated by removal or rearrangement of the excess prolapsed fat and tightening of the skin and muscle.
For the last 10 years we have been performing facial rejuvenation surgery as Day Surgery. This means that patients have their operation in the morning and are able to go home in the afternoon at about 4:00 pm. Because you will have had an anesthetic it is necessary that someone pick you up and look after you on that first night. The operation takes between 1 1/2 and 2 1/2 hours depending on what requires to be done. A number of steps are taken during the surgery to prevent post-operative complications. Drain tubes are always placed under the facial skin in order to drain away any blood or fluid that might form post-operatively. In this way bruising and swelling are minimized and the recovery period is shortened. A special dressing which consists of a firm bandage overlying foam padding is placed around the face as a further measure to reduce bruising and swelling. All patients are given intravenous antibiotics during the operation in order to prevent post-operative infection.The use of intravenous antibiotics is far more effective then taking tablets after the operation. Although you will be asleep during the operation, a long acting local anesthetic called Marcaine is injected into the facial skin during the surgery so that when you wake up you should feel no pain .A light pressure dressing is usually applied to the eyelids following the surgery, again to minimize bruising and swelling and this is removed about an hour after you wake up At this stage a cool pack is applied to the eyelids to reduce the swelling.Once you are able to eat or drink, usually after one or two hours, you will be given a tablet such as Panadol or Panadeine to reduce inflammation and to prevent discomfort. High blood pressure is a common cause of post-operative swelling and bruising and if there is any sign of your blood pressure being high after the anesthetic then you will be given special medication to keep the blood pressure normal over the next few days. Once you arrive home we suggest that you go to bed and get a good nights rest. Taking Panadol or Panadeine every 4 hours is good insurance against soreness the following morning.
When you leave our clinic, you will be given an appointment to return the following morning when the drain tubes will be removed, your hair washed and your facial skin and sutures lines checked for bruising, swelling and tenderness. A light elastic stocking- like bandage is then applied to the facial skin and worn over the next few days to reduce swelling. Ultrasound may also be administered to help with swelling and tenderness. It is unusual for pain to be present but Panadol or Panadeine can always be taken if required.
The stitches in front of the ears are removed after five days and those in the hairline are removed after seven days. In other words, we aim to have you substantially healed by the seventh post-operative day - although a little bruising and swelling may persist at this time and it's probably wise to arrange to have two weeks away from work or other important social engagements. Once the sutures have been removed, the incision lines continue to mature and are usually red for several weeks or months. They usually resolve into fine white scars that are barely visible, although sometimes thickening of the scars can occur especially behind the ears where most of the tension has been applied. These thickened areas usually settle with a little extra time although occasionally treatment with. Cortisone or scar revision under local anesthetic is required. There is a large variation in the healing process amongst individuals.
Having read this letter you will be better informed regarding the many options available for facial rejuvenation. Sometimes simple treatments such as Anti-wrinkle treatments injection into forehead wrinkles, or Restalyne® injection to the lips, may be all that is required. Fat injections into the lips and surrounding facial creases is a common procedure and can be performed under local anesthetic.
Should surgery be required our aim is to perform the procedure safely, effectively and with minimal discomfort and disruption to your lifestyle. My staff and I will be very happy to assist you in arriving at the best decision. Please do not hesitate to contact us if we can help in any way. We realize that facial rejuvenation is more about improving your self-confidence and happiness than just tightening the skin.
Allan Kalus
Dear Madam,
The following is an open letter to prospective patients regarding breast enlargement or breast augmentation.
Most women contemplating breast enlargement have been self-conscious about their appearance for a number of years. Sometimes the breast never develops fully and a woman can recall being teased about her small breasts when she was at school. In other cases, a woman's breasts may have been normal but then lost their shape following pregnancy or after breast feeding. In either case women often feel very anxious because of their lack of breast fullness and they feel compelled to modify their lives in many ways. For example, women often wear padded bras or push-up bras and many women say that they are unable to wear certain types of clothes. Some feel too embarrassed to wear bathers during summer. Some women even say that they have feelings of envy towards other women with large breasts.
With a breast augmentation procedure, we are aiming to produce a breast which is not only larger but also which looks and feels natural. We also aim to do this in the safest possible manner.
Most women who are contemplating breast enlargement already have quite a bit of knowledge about the subject. There have been numerous articles in magazines and programs on television, not to mention the large amount of information that is available on the Internet. Women know that there are many options available and many women feel confused and unable to make a proper choice.
Over the last 20 years, I have inserted more than 2000 breast implants, both silicone and saline and in this letter I would like to share some of my thoughts with you so that you can feel confident about the choice that you make.
The first choice is where to make the small incision through which the implant will be inserted. The most popular site is just above the skin fold on the underside of the breast. This site is the most practical because the surgeon can go straight down onto the chest wall and then make the pocket behind the breast without damaging the breast in any way. The resulting scar is only about three cm long and, with time, comes to resemble a bra strap mark.
Other possibilities for siting the surgical scar are around the nipple and in the armpit. A scar around the nipple is used if a lot of loose skin is present and it has been decided to remove some skin together with a breast enlargement operation. It is not the site of first choice because in order to make a pocket behind the breast from this position, one has to actually cut through the breast tissue and, in the process, one inevitably damages some of the breast ducts and nerves to the nipple. Also, the scar is situated on the front of the breast and may therefore be more visible.
The incision in the armpit is not our first choice because women worry about the scar being visible in bathers and sleeveless dresses whenever they raise their arms. Also, in some women, the armpit can be a long way from the breast and it can be difficult to insert the implant low enough on the chest wall. A third reason not to use this approach is that there is a higher risk of infection when the implant is placed through the armpit.
So, given the three choices, a small incision under the breast is favored by most women.
The next choice is whether the implant should be placed in front of or behind the pectoral muscle. This decision is made easy if you know that when implants are inserted in front of the pectoral muscle, 60 percent will develop a condition known as spherical capsular contracture. This means that the breasts will feel hard due to scar tissue forming around the implant. On the other hand, when the implant is placed behind the pectoral muscle less than 5 percent develop capsular contracture. There is a huge difference between 60 percent and 5 percent and this is the reason why most surgeons who do a lot of breast implant work prefer to place the implants under the muscle. This simply gives you the best chance of having a breast which looks and feels soft and natural. Some people are concerned about alteration in function of the muscle but this very rarely happens even in athletic women who do a lot of sport.
The next decision, and one that I know causes a lot of anxiety, is what type of implant to use - silicone or saline, textured or smooth.
The first thing you need to understand is that any medical device when implanted in the human body is going to have a certain life span. Whether that device is a heart pacemaker, an artificial hip or a breast implant, its life span can be expected to be about 10 years. Some devices may last longer but no-one can be sure what will happen after about 10 years. With breast implants, the risk is that they will leak. This may happen after 10 years or at some time sooner if, for example, the woman has an accident, breaks a rib and the rib punctures the implant. With a silicone implant, if the implant leaks then the silicone can spread into other tissues. The consequence of this may be that the patient will develop multiple small lumps of silicone called silicone granulomata and these can be very difficult to remove without also removing some of the surrounding tissue. Even if silicone granulomata do not form, the silicone can be very difficult to remove as it sticks to the tissues like chewing gum. This was the reason saline implants were developed. Saline implants have one remarkable safety feature. If they leak, for whatever reason, then the salt water (intravenous saline solution) which they contain is simply and harmlessly absorbed by the body. The shell of the implant can easily be removed and another implant inserted in its place.
With such an overwhelming safety advantage, the only other consideration is whether saline implants are as soft as silicone implants. This depends on the design of the saline implant and on where it is placed. If the implant has a smooth-wall and is placed under the muscle, then it is very difficult to feel the actual implant and patients are unable to tell the difference between a silicone and a saline implant. If, on the other hand, the implant has a thicker, textured surface and especially if it is placed in front of the muscle in a thin person, then not only will the implant be palpable but rippling may also be visible and the result may not be satisfactory.
For these reasons most women, when presented with this information, have a clear preference for saline implants with a thin smooth wall placed behind the pectoral muscle.
Recently two new implants have been made available. The first is the high cohesive gel silicone implant which has a much higher viscosity than the original silicone implant and thus may not travel into the tissues if a leakage occurs. This implant however is much heavier and firmer than other implants and some models may also leak silicone oil and other residues into the tissues with time.
The other new development is the tear-drop implant. This is supposed to resemble the breast more closely however, studies have shown that it looks artificial as it does not move the way the normal breast moves. For example, a round implant adopts a tear-drop shape when the person stands and becomes flatter when the person lies down - just as the normal breast does. Thus the implant moves with the person the way a normal breast moves. The tear-drop implant on the other hand always maintains its shape and this is the reason it appears firm and unnatural. A further complicating feature is that the implant may move after insertion and in some cases even settle in an upside down position. This will require re-operation in order to achieve a reasonable result.
For these reasons most women prefer not to experiment with these types of implants.
The next choice and one that women seem to worry a lot about, is what size implant to choose. Some women want only a slight increase but most women feel that if they are going to have the procedure then it should be worthwhile! Most women though are concerned that the result should look natural. Of course, when choosing the size of implant, a lot will depend on a woman's height, her build and how much breast tissue she already has. From experience, I find it best to use a combination of two methods. The first is to measure the width of the woman's chest on one side as this determines the desirable width of the implant. The implant manufacturers supply us with a table where, from the width of the implant we can determine its volume and therefore the likely size increase. Most women would like to increase their breast size by two cup sizes. Once we have determined the most appropriate implant by using this technique of measurement we can then take a sample implant, place it inside the woman's bra and see how it looks in real life. Using this method most women are able quickly to determine what size implant will look best for their particular shape and build.
So far I have discussed the many choices available to women contemplating breast enlargement surgery. I have discussed the site of incision, the placement of the implant in front of or behind the muscle, the type of implant to be used and the way in which the size can be determined. If you do decide to undergo breast enlargement surgery, I would like to explain a little about what you should expect on the day of surgery and afterwards.
For the last 10 years, we have been performing breast enlargement surgery as a Day Case which means that patients have their operation in the morning and are able to go home in the afternoon at about 4:00 pm. Because you will have had an anesthetic it is necessary that someone pick you up and look after you on that first night. The operation takes about 45 minutes and a number of steps are taken during the surgery to prevent post-operative complications. Specifically, a drain tube is always placed into the breast just so that any blood or fluid that might form post-operatively is drained away from the breast. In this way bruising is minimized and recovery is enhanced. In addition, all patients are given intravenous antibiotics during the operation in order to prevent post-operative infection. The use of intravenous antibiotics is far more effective than taking tablets after the operation. A long acting local anesthetic called Marcaine is injected around the implants at the conclusion of the operation and this means that patients wake up without pain. There may be a feeling of tightness or a slight ache as if you have had a work-out at the gym but this should not be too troublesome. Once you are able to eat and drink, usually after one or two hours, you will be given a powerful anti-inflammatory and pain relieving tablet, the effect of which lasts for approximately 24 hours. Once you get home we suggest that you go to bed and get a good night's rest. We usually recommend that you take Panadol or Panadeine, 2 tablets every 4 hours even if you do not have any pain just as an anti-inflammatory and to prevent soreness the following morning. . When you leave our clinic, you will be given an appointment to return the following morning and at that time the drain tubes will be removed and your breasts will be checked for bruising, swelling and tenderness. Further pain relieving medication will be given as required over the next few days. Ultrasound may also be administered to help with swelling and tenderness.
Importantly, you will be shown how to massage your breasts in order to achieve the best possible softness and naturalness in the final result. Massaging the implants around inside the surgically created pockets helps to maintain the pockets at a larger size than the implants. In this way the implants are able to move freely inside the pockets and simulate normal breast movement. Most patients are seen two or three times a week for the first 2 weeks after surgery but you can come as often as you like until you feel confident in caring for your implants. You should be able to drive and do light work after two to three days, but should avoid strenuous exercise for two to three weeks. We will provide you with some skin coloured micropore tape and we suggest that you keep your small surgical scars covered with tape for 6 months in order to obtain the finest, most inconspicuous scar. This tape is easily removed and should be changed two or three times a week at which stage some rosehip oil should be applied to the healing scar.
I hope that, having read this letter, you will feel better informed and better able to make your decision regarding breast enlargement. If you have any other questions, my staff and I will be delighted to answer them for you. We realize that breast enlargement surgery is not just about enlarging the breasts but about improving your self-confidence and happiness. Our aim is to do so safely, effectively and with minimal discomfort and disruption to your lifestyle.
Allan Kalus
If you would like to ask a question about Plastic Surgery, or you would like to arrange an appointment, contact us on 03) 9521 1777 or fill in the form below
Avenue Plastic Surgery
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Windsor 3181,
Victoria, Australia.
Ph. 61-3-9521-1777
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