Breast Augmentation Choices

Breast Augmentation in Sydney – Choices

What are my choices in breast augmentation in Sydney?

You’ve decided on consulting a fully qualified plastic surgeon to discuss breast augmentation in Sydney. You will still have several decisions to make about your process. It is the opinion of Dr Gavin Sandercoe, Specialist Plastic Surgeon in Sydney,  that all patients should understand the process of any procedure, particularly elective ones, and be involved in the decision making process. This allows patients to understand the advantages and disadvantages of each decision point and be happy with the inherent risks in each decision.

The following opinions apply to primary (first time) breast augmentation for women with breasts that do not have obvious abnormalities in shape – the ladies out there that just always had small breasts during development, or those that lost volume/shape after breast feeding or with age. Women that were born with breasts that are asymmetrical or abnormal in shape or appearance require a different set of rules to be applied to achieving a great result.

It should be noted that these are the opinions of Dr Gavin Sandercoe, and other surgeons may have different opinions that are equally reasonable and valid. When performing a breast augmentation in Sydney, Dr Gavin Sandercoe aims to create breasts that appear natural, and are always within the confines of ‘normal’ breasts.

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During a consultation with Dr Gavin Sandercoe, you will discuss all of these points, and he will tailor a solution that is right for your needs. The key decision points are:-

1.    Incision

2.    Pocket

3.    Implant fill

4.    Implant shape

5.    Implant shell

6.    Implant texture

7.    Implant volume

Dimensions and volumes of suggested implants are a completely individual fitting (much like a shoe) and cannot be generalised upon without a formal consultation with your plastic surgeon. To help you determine which implants you would like for your breast augmentation in Sydney, your surgeon needs to examine you and discuss your medical history and goals.

All of these options are to be taken in the context of the plastic surgeon’s clinical assessment of the patient. Important factors to be considered are:-

•    Patient factors such as age, breastfeeding history and future pregnancy plans
•    Breast factors including current dimensions and shape
•    Skin and soft tissue thickness and quality
•    Nipple position on the breast
•    Chest wall shape
•    Existing asymmetries
•    Need to avoid interrupting the pectoral muscles for work or athletic pursuits
•    Desired volume and shape

1.    Incision

There are three common incision sites for breast augmentation  – the inframammary fold (IMF), around the nipple (periareolar) and through the armpit (trans-axillary). In the USA, where saline breast implants are more common, some surgeons use an approach that leaves a scar in the umbilicus (belly button).

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a)    Inframammary fold.
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It is Dr Gavin Sandercoe’s opinion that the inframammary fold (IMF) incision is the most versatile and controllable approach for breast augmentation in Sydney. Almost all revisionary surgery is performed through this incision, as it provides direct access to the IMF, implant and gland for precise manipulation of breast shape. A normal incision is 4-6cm long, depending on the desired implant’s dimensions. It is generally an imperceptible scar, hidden in an inconspicuous fold on the body, hidden even under small bikinis. It may sometimes ride up onto the underside of the breast or pucker slightly during healing. Patients that are concerned about scars or have a history of poor scarring may elect to avoid this incision.

b)    Periareolar.
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This incision runs along the lower half of the circumference of the areola, and can be virtually invisible in ideal circumstances for a breast augmentation in Sydney. However, it can only be used if the implant can be physically fit through an incision that long (i.e. there needs to be a correlation between the areolar circumference and the implant size). Generally speaking, breasts need an areola with a diameter of at least 40-45 mm to be considered. Implants can drop a little more via this approach. In patients with darker skin types, it can be a useful method to reduce scarring. As evidence continues to mount that capsular contracture is related to low grade infection, the periareolar approach may become less popular.

c)    Transaxillary.
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Transaxillary (through the armpit) approach is mostly utilised by patients that are concerned about a scar on the breast, and is a technique propagated in the Asian market. Placement of smooth shelled gel, or saline filled implants, can be performed reliably through this incision. Due to the distance from the nipple and inframammary fold (two key components in breast augmentation), this technique is more difficult to precisely manage these two factors and the shape of the breast between them (the lower pole). It is common to have implants that are placed too widely apart when using this method. Anatomical or teardrop shaped implants are difficult to place precisely. Passing the implants through the armpit places the patient at increased risk of infection and capsular contracture. There are multiple problems with using this approach for a breast augmentation in Sydney.

d)    Transumbilical.
Placing an implant through an incision in the belly button is an idea that sounds better than the reality check. An endoscopic approach to underneath the breast has multiple problems. The most important point about this approach is that it is only suitable for saline implants, where the plastic surgeon can place an uninflated implant down a very small hole and inflate it later. Manipulation of the inframammary fold and lower pole is very difficult. In Dr Sandercoe’s expert opinion, this approach is not recommended for a breast augmentation in Sydney.

2.    Pocket

There are two broad categories of implant pocket (subpectoral and subglandular) with many variations of both. For simplicity, just the two major categories will be discussed. Based on your needs and amount of body fat, the most appropriate pocket will be suggested to you for your breast augmentation in Sydney by Dr Gavin Sandercoe.

The position of the implant in relationship to the breast gland, the pectoral muscle and the rib cage is probably the most important decision in planning a breast enhancement.

a)    Subpectoral
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This is also called sub muscular (or under the muscle). It is the most common and most versatile of the positions to place the implant.

Advantages of the subpectoral pocket include:-

• Reduced risk of capsular contracture
• The extra thickness of the muscle helps hide the implant edges, especially in thinner patients
• Reduced risk of skin wrinkling and rippling
• Easier screening for breast cancer

The major disadvantage of this implant position is the extra discomfort in the first few days after the operation. By the end of the first week, there is no difference between the discomfort that patients feel. Competitive athletes may lose a little chest strength, and there is a small risk of implant movement on pectoral (chest) contraction.

b)    Subglandular
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Placing an implant between the breast gland and the muscle has the advantage of not disrupting the pectoral muscles. It is useful when performing a breast augmentation in Sydney in athletes, and in patients that wish for increased manipulation of their breast shape and nipple position. When creating a natural shaped breast, this pocket is limited to smaller implants that are within the breast confines, or to use in slightly heavier set patients whom have enough body fat to disguise the implant edges.

However, this is offset by the increased risk of capsular contracture and increased visibility of implant edges.

3.    Implant fill

Modern implants used for breast augmentation in Sydney are only filled with either saline or cohesive gel. There have been attempts in the past at filling implants with other materials, but they have been unsuccessful at creating & maintaining history of safety and reliability. In the Australian market, almost 99% of breast implants used are silicone gel filled.

Modern ‘silicone’ implants are filled with a cohesive silicone gel. Most manufacturers supply implants in both a soft and firm gel. New generations of silicone cohesive gel do not leak the way that older silicone gels did. The current gels have a texture similar to Turkish Delight – even the softer ones!  In November 2006, the US FDA approved the use of cohesive silicone gel implants and this type of implants now occupies 90% of the world wide breast implant market.

Saline has been the fill of choice in the USA in past decades, and receives more awareness due to the popularity of American television programs on plastic surgery. Saline is very uncommon in Australia, as a saline implant will always feel like a bag of water under a breast. Saline implants only come in round shapes and have a very high rate of ‘rippling’. The only advantage of saline filled implants is the ability to introduce them through smaller incisions, and then fill them up once they are in place. For the majority of patients, Dr Gavin Sandercoe recommends silicone gel implants for patients having a breast augmentation in Sydney.

4.    Implant Shape

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This is probably the greatest operative decision that the patient has control over. Incision and pocket tend to be decided by surgeon preference and body shape considerations. Once a patient understands the pros and cons of each implant shape, it becomes fairly easy to decide which implant the patient prefers for her breast augmentation in Sydney.

Within each of these broad shape categories, an implant can be selected with differing width, height & projection. Selecting an implant that just fills the available chest wall dimensions and soft tissue stretch ensures that patients achieve a natural look, avoiding the telltale signs of breast augmentation in Sydney.

Anatomical implants are shaped like a breast, so they will help shape an abnormal breast and tend to look natural in most circumstances. The shape advantage is less noticeable (compared to a round implant) when placed under the muscle, especially when the patient is standing upright. With a ‘tall’ enough implant, reasonable cleavage can be created. The main disadvantages of anatomical shaped implants are the risk of rotation and cost. Anatomical implants are always textured, to assist in stabilising the implant in the position that it is placed surgically (reducing rotation risk).

Round implants are the most common shape of implants in Australia. They are cheaper than anatomical shaped implants and cannot rotate. Due to their shape, they provide better ‘cleavage’ than an anatomical shaped implant. They are a good choice for women who wish to increase the volume in breasts that already have a reasonable shape, or patients wishing for more cleavage (upper pole projection or roundness). However, there are some situations in which even well planned round implants are noticeable – for instance lying down. Without gravity/standing up and a little tone of the pectoral muscles, a round implant can show itself as it is.

Round implants come in textured and smooth shelled variants. Texturing assists the body in holding the implant in position, much like Velcro. A smooth implant is free to move around the implant pocket. Smooth shelled implants have some advantages for patients whom are having problems with textured implants.

Once a decision of which implant to use is made for your breast augmentation in Sydney, Dr Gavin Sandercoe will discuss the various implant brands with you and outline what he believes the pros and cons of each brand are.

5.    Implant shell

Almost all implants on the market for breast augmentation have a shell of silicone. Other coatings have come and gone from the market, and have not lived up to the promises of decreasing the capsular contracture rate. Recently, polyurethane coated implants have come under fire for increased rate of rupture, and the improvements in capsular contracture rate have been inconsistent. Most studies on polyurethane implants have been poorly designed and have other flaws, which make it difficult to completely believe any data presented. As a result, Dr Sandercoe finds it hard to recommend using implants made from shells other than the ‘standard’ silicone for primary breast augmentation. Dr Gavin Sandercoe does use Silimed (furry Brazilian) polyurethane implants, but recommends them only under special circumstances for breast augmentation in Sydney.

6.    Implant texture

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The shell of an implant can be produced to be either smooth or textured.

Textured implants have a smaller risk of capsular contracture, and the texturing on the implant helps stick the implant (much like fine velcro) in the position that it is placed. Textured implants may cause some wrinkling in the lower part of the breast in thinner patients (due to less soft tissue coverage).

Smooth implants have a greater rate of capsular contracture, and it is advised that patients massage their implants for at least a year to try to decrease this. The difference in capsular contracture rates between textured and smooth breast implants is less when the implants are placed in a sub-pectoral pocket. Smooth implants can also have a tendency to shift around in the pocket that is created for them during a breast augmentation in Sydney.

7.    Implant volume

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In starting a discussion about volume or size of implants, a few mistruths need to be discussed.  Firstly, implants do not come in cup sizes. Secondly, a 200cc implant that looks great on your friend may be too much or too little for you. The best approach is to be assessed by your plastic surgeon, and they will discuss the dimensions of your breast and the amount of soft tissue stretch that is safe for those dimensions. Then a volume is reached that is a starting point for discussing your desired look.

So with all that information, what does Dr Sandercoe suggest for most patients receiving a breast augmentation in Sydney?

IncisionInframammary fold
PocketSub-pectoral
Fill Silicone Cohesive Gel
Implant shapeDepends on the amount & shape of existing breast tissue
Implant shellSilicone
Implant textureTextured is recommended more often than smooth
Implant volumeDepends on your measurements and your discussion with Dr Sandercoe about over & underfilling the soft tissue envelope

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