Mr Adrian Richards details the different types of breast surgery procedures and demonstrates treatment outcomes with patient case studies
This article will provide an overview of the different types of breast surgery and the reasons why patients seek these. Although this topic is most relevant to cosmetic surgeons, it is also useful for non-surgical aesthetic practitioners who may discuss initial concerns with an existing patient and will therefore be able to give them a brief introduction of information before referring to a surgical colleague.
The Cambridge English dictionary defines cosmetic surgery as ‘any medical operation that is intended to improve a person’s appearance rather than their health.’1 But some questions to consider are: does this include psychological as well as physical health? Would breast reconstruction following a double mastectomy improve a patient’s psychological health? And, should the NHS fund this surgery?
Looking at Figure 1, would surgery for the patient with breast asymmetry improve her psychological health? Should the NHS fund surgery to reduce the size of larger breasts causing back and shoulder symptoms (Figure 2)? Why in most regions is breast reconstruction after mastectomy funded by the NHS but surgery for breast asymmetry, tuberous breast deformities (Figure 3) and debilitating large breasts often not funded? In my opinion there is a strong argument for selected cases being performed within the national health system. As a plastic surgeon I specialise in corrective breast surgery and almost every day I witness first-hand how this type of surgery improves the psychological and often physical health of my patients. This improvement has also been reported in scientific studies.2
Firstly, although breast reconstruction is essentially a cosmetic procedure it is classified as reconstructive rather than cosmetic so will be excluded from this discussion.
The main procedures are: breast enlargement, breast reduction, breast uplift, breast uplift with enlargement, removal of breast implants, removal of breast implants with an uplift, exchange of breast implants, areolar reduction, inverted nipple correction, nipple reduction and correction of the male breast (gynaecomastia). These operations occupy more than 80% of my working hours.
The most common procedure is breast enlargement with more than 30,000 cases per year in the UK.6 In the US it is estimated that 4% of women have breast implants.3 In the UK there is no official data but an estimated 600,000 women have had breast implant surgery. This an estimate figure,11 which assumes 30,000 UK women have had implants each year for the past 30 years. This puts the UK at number nine in the list of countries with the most breast implants per capita.4
Surgery has become more refined; recovery time is quicker and the latest sixth generation silicone implants are available in a wide variety of shapes and sizes to suit all physiques. In most cases surgery is performed as a day procedure and patients are back to work within a week. 3D scanning is an exciting recent development that allows people to see how they would look with a variety of implants following surgery. In my practice all patients undergo a 3D scan. This measures and assesses their chest wall and breast tissue and suggests an optimum implant for them. They can then see their chest in 3D with various sizes and shapes of implants (Figure 4).
Our patients then try the implants in specially designed bras under their own clothing to help them determine the ideal implant for their physique and lifestyle. Following surgery patients can exercise normally, breastfeed, have mammograms and in the majority of cases do not lose nipple sensitivity. The ability to breastfeed is preserved because the implants are placed behind the breast tissue and the connection between the breast glands, which produce milk, and the nipple is preserved.
Nipple sensation is reduced in approximately 5% of women following breast enlargement.12 Loss of sensation depends on the route the nerves (that supply sensation to the nipple) travel, from the chest wall, and this cannot be predicted. During the operation I will often see these nerves and make every effort to preserve them.
This operation is one of the most satisfying procedures for both patient and surgeon and few patients regret having it performed. Symptoms from a large bust include: back and neck ache, poor posture, intertrigo (skin infection where the breast lies against the upper abdomen), difficulty in finding clothes that fit, and exercise difficulty.
In my practice, surgery is performed as a day case or with an overnight stay, with the use of absorbable stiches that do not need to be removed. Some patients prefer to stay overnight in an hospital environment and this can be arranged.
Modern surgical techniques involve much less blood loss and bruising than they did previously. This means that it is very unusual to have any bruising following surgery.
This operation is similar to a breast reduction in that the nipples are lifted and reduced in size and the breast skin tightened. In a reduction, breast tissue is removed whereas in an uplift only skin is removed and the breast tissue preserved and re-shaped.
This is one of the most challenging procedures for a breast surgeon and the one with most litigation associated with it. Why? The problem is that the surgeon is both trying to reduce and tighten the breast tissue and skin whilst stretching it with an implant.
It can be performed as either a one or two stage procedure. The benefits of a one stage procedure are a single operation and recovery; the down sides are limited size of implants, a higher revision rate, an increased risk of complications and arguably a worse cosmetic result. For this reason many surgeons prefer to perform a two stage procedure with the uplift performed first followed by an implant three to four months later.
Within the region of 600,000 women in the UK who have breast implants, each implant has an average lifespan of 15 years, so removal of the implants is becoming more of an issue.
Whilst implants do not need to be removed at 15 years, many manufacturers recommend that they are. In addition, most women develop more natural breast tissue as they age and this combined with implants can make them feel too busty and matronly. For this reason many women decide to have their implants removed.
The good news is that the breast skin shows a remarkable ability to retract naturally when the implants are removed. Skin, by its nature, is stretchy and expands as we grow and put on weight and contracts as less stretch is put on it.
In most cases, when breast implants are removed, the breasts return, within months, to a similar appearance as prior to surgery. In some cases there is excess skin and a low nipple position, thus a breast uplift is needed at the time of the breast implant removal.
As many implants are now reaching recommended time for removal, many women are electing to have their implants exchanged. This reached a peak in 2012 with the PIP crisis.7
The crisis occurred when inspections revealed that the implants, created by French company Poly Implant Prothese (PIP), were composed of sub-standard, often non-medical grade industrial components. It is not known exactly how many women in the UK received these implants, as at that stage, there was no compulsory implant registry.
I personally operated on more than 350 women following the crisis, removing a wide variety of defective implants. Many of the women had systemic symptoms from the ruptured implants. On the Aurora clinics YouTube channel we have videos showing how the implants looked on removal. Many UK women are still unaware they have PIP implants or have decided not to have them exchanged.
The areolar is the brown area around the nipple. The average diameter of a normal areolar is 4-4.5cm.8 Many women feel their areolas are too wide, too low or of an abnormal shape.
In most cases surgery is performed under a local anesthetic with patients awake. In some cases a permanent stich is inserted to hold the areolar in its narrowed size and shape following surgery.
Approximately 10% of women in the UK have inverted nipples.5 This can be embarrassing and cause difficulty breast-feeding. The condition can also affect men. In most cases nipple inversion develops in puberty as the breast develops and remains throughout adult life. If nipple inversion occurs later in life it can be a sign of underlying breast pathology and possible cancer. If this occurs, it is important to exclude cancer and we would advise the patient to visit their GP before any further action is taken.
We have developed a procedure performed under local anesthetic to reliably and permanently correct inverted nipples. In the majority of cases nipple sensation is preserved but the ability to breastfeed is not; this is because the milk ducts are divided during the operation. Tight, shortened milk ducts are the cause of inverted nipples as they tether the nipple inwards.
Enlarged protuberant nipples can cause embarrassment for women and men alike. Typically, people with this condition will avoid activities in which they show their chest and tight clothing. Correction is again performed under local anaesthetic with minimal downtime.
This is a common disorder of the endocrine system and affects up to 70% of adolescent boys.9 Fortunately 75% of cases resolve within two years of development without treatment.10 I do not specialise in the treatment of gynaecomastia but several surgeons within our group do. For mild cases without significant skin excess Vaser liposuction has proved extremely effective.
For more severe cases with skin excess as well as breast enlargement surgical excision is often required. Unlike Vaser liposuction this has the down-side of involving some scarring on the chest skin.
In my career I have focused on bowel, hand, burn and cancer surgery, but I can honestly say that breast surgery has proved the most rewarding. For a surgeon, it combines artistry with technical ability; for a patient it can make real and longstanding improvements to their mental and physical health. In addition, technical advances in surgical technique, implant quality, and patient education systems such as the 3D scanner, continue to push the speciality forwards. I would like the take home message from this article to be that breast surgery treats real functional and psychological problems. It provides a long-term solution to these and is a rewarding speciality for surgeon and patient alike.
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