Open Letter to Patients

Open Letter to Patients


An open letter to patients

The  following  is  an  open  letter  to  prospective patients regarding  breast enlargement  or  breast  augmentation.

If you are contemplating  breast  enlargement, you have  probably been   self-conscious about your appearance for a number of years.  Sometimes, the breast never develops fully and you may recall  being teased about your small breasts when you were at school.  Or, your breasts  may  have  been normal but then lost their shape following pregnancy or after breast-feeding.  In either case, you may feel anxious because of your lack of  breast  fullness  and   feel  compelled to  modify  your life  in  many  ways.   For example, you may wear  padded  bras  or  push-up  bras and  feel  unable to wear certain types of clothes, such as low-cut tops or dresses with a low  neck-line.    You may feel too  embarrassed  to  wear  bathers  during  summer.  You may even have  feelings  of  envy  towards other women with larger breasts. These are all reasons why women consider breast augmentation.

With  a  breast  augmentation  procedure,  we  are  aiming to produce a breast which is not only larger but also looks and feels natural.  We also aim to do this in the safest possible manner.

If you are  contemplating breast enlargement, you probably already have quite a bit of knowledge about the subject.  There have been numerous articles in magazines and programmes on television, not to mention the large amount of information that is available on the Internet.  You know that there are many options available and you may feel  confused  and unable to make a proper choice.

Over the last 25 years, I have inserted more than 4000 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 choices 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 cutting through or  damaging the breast in any way. The resulting scar is only about 3 cm long and, with time, becomes almost invisible.

Other possibilities for the incision 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, the surgeon has  actually to  cut through the breast tissue and, in the process, 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 so that it looks natural.  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 3 choices, a small incision under the breast is favoured 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% 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 1% develop capsular contracture.  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. Also in thin women, placing the  implant under the muscle makes it much more difficult to detect. This means that it is difficult to tell the difference between the various types of implant (such as round vs anatomical, silicone vs saline), so you are free to choose whichever is safest. Another reason to place the implant behind the muscle is that  it does not interfere with mammography or breast screening.

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 lifespan.  Whether that device is a heart pacemaker, an artificial hip or a breast implant, its lifespan can be expected to be limited. With breast implants, the risk is that they will leak.  With a silicone implant,  if  the implant leaks, then the silicone can spread into other tissues such as the lymph glands in your armpits. Often, the first sign of a leaking silicone gel implant is a firm lump under the arm. An MRI can detect, but cannot predict, implant leakage.

Some MRI studies have shown that 40% of silicone gel implants are leaking after 8 years! I have personally seen silicone implants leak after only 3 years, with the silicone causing lumps under the arm. These were modern high cohesive gel implants. The gel had liquefied after only three years at body temperature! This is the reason many women prefer saline implants.  Saline implants have one  remarkable safety  feature.  As they are filled with salt water (intravenous saline solution), if they leak, for  whatever  reason,  then  the  salt water 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 it is difficult 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.

What about the so called “textured implant”, where the surface is covered with a fine texture? Not only is it unnecessary, it is dangerous! Textured implants have been associated  with a rare but serious condition known as Anaplastic Large Cell Lymphoma (ALCL). This is a cancer of the capsule around the implant and is believed to be caused by bacteria that colonize the textured surface. We see about six cases a year in Australia and these women require radical surgery and chemotherapy. The risk increases with time and it presents with swelling of the breast, often years after the implant has been inserted. Many women have not been warned of this risk but fortunately fewer surgeons are using textured  breast implants.

As “Anatomical” or “Tear Drop” implants must be textured to stay in position, these are not recommended. A round implant adopts  a tear-drop shape when you stand  and  becomes flatter  when  you lie down – just as the  normal  breast does.  Thus  a smooth round implant actually looks and moves  more naturally.

The  next  choice  is  one that women worry about a lot – “What size  implant  should I 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 your height, your build and how much breast tissue you already have. At your consultation, I will take a number of measurements but, as a guide, a simple method  to try at home, is  to  fill  an  old  stocking  with  a  measured  amount  of  rice  (say 250  or 300 ml) and to place this inside a sports bra. Add or subtract 25ml at a time until you feel comfortable with the result.

So far I have discussed the many choices available to women contemplating  breast  enlargement  surgery. 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 25 years, we have been performing breast enlargement  surgery  as  a  Day Case, which  means  that you can have your  operation in the morning and are able to go home in the afternoon. Your hospital stay may be even shorter!  As you will have had an anaesthetic, it is necessary that  someone  pick  you  up  and  look after you on your first night.  The operation takes about one hour 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  so that any blood or fluid that might form post-operatively, is drained away from the breast.  In this way,  bruising  is  minimised  and  recovery  is  enhanced.  In addition, you  will  be given  antibiotics during and after the operation in order to prevent post-operative infection. ( This is extremely rare).

To  prevent  pain,  you  will  be  given  a  powerful  anti-inflammatory  and  pain-relieving  tablet  just  before  the procedure and afterwards, as required In  addition,  at  the conclusion of the operation, a long-acting local anaesthetic called Marcain is instilled around the implants.  This  means  that  although there  may be  a  feeling  of  tightness or a slight ache as if you have had a work-out at the gym, pain should be well controlled. Once  you  get  home,  we suggest that you go to bed  and  get  a  good night’s rest.

When  you  leave  our  hospital,  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 required over the next few days.

You can expect to return to gentle normal activity after 3 days and, after 1 week,  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.  You should be able to return to work after 1-2 weeks (depending on what you do) and do more strenuous activity after 3-4 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 should be changed  once a week, and Rosehip Oil  should be applied to the healing scar. A course of LED light therapy  is offered and your post operative check is about 6 weeks after surgery.

I  hope   that,   having   read   this  letter,  you  will  feel  more  informed  and   better   able   to  make your  decision  regarding  breast  enlargement.  If  you  have  any  other  questions,  my  staff and  I  would  be  delighted  to  answer  them for you.  We realise 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.

  1. If you only desire a small volume increase (eg 1 cup size) then you may be able to avoid implants altogether by having an Autologous Fat Transfer. Fat can be transferred from your abdomen, hips or thighs to provide the most natural breast augmentation of all! And you also get a liposuction! To find out more Click here.