Mum's the Word

Created on 15th January 2012

Pregnancy and breast feeding can have a profound effect on a woman's body and, in particular, her breasts. Professor Frame of Springfield Hospital looks at the options available to surgeons

Breast augmentation is the commonest cosmetic surgery procedure in the world. Different age groups are involved ranging from the young under-developed or mal-developed breast, to the post-partum or weight-loss breast, where the supporting fat and ligamentous structure to the breast has been altered to cause a loose and ptotic appearance. The degree of ‘slide' down the chest wall in the erect posture, and whether the nipple remains at or above the level of the submammary fold, will dictate as to whether augmentation or mastopexy (uplift), with or without augmentation, is the better option.

Professional women with careers that often demand a larger bust, such as models and dancers, tend to be the exception, in that often the starting point would be considered to be normal breast size.

Assessment
Assuming the woman is a good candidate for this type of surgery, it is essential that psychological profiling and, if necessary, counselling are carried out to avoid the potential disasters awaited by operating on people with dysmorphism. Suicide is well recognised as a consequence of inappropriate surgery. The visits to the surgeon, pre-admission clinic and a GP's past medical history type referral are advised to avoid the psychiatric disaster. The patient must understand her anatomy, variance from other women and asymmetry, to have the correct expectation from surgery.

Techniques
Silicone breast implants
In the UK silicone breast implants are virtually always used (Fig. 1). They may be round, dome shaped, with varying degrees of projection, or they are ‘anatomically' shaped (teardrop).

I have found that the latter usually do not augment most women in the upper pole to a satisfactory cleavage or outcome. They often slide laterally, leaving a fairly ugly central gap, particularly on thin women. With ‘loose' empty breasts after lactation, or massive weight loss, they will rotate and misshape.

Implants can be placed behind the pectoralis major muscle but inappropriate contraction of the muscle will again cause misshape of the breast.

The biggest variable to the result though is the starting skeletal asymmetry. No woman has symmetrical breasts and too large an augmentation can worsen the asymmetry. The lower profile, round implants give a more natural and least misshapen result. In the more mature post-partum woman this is usually the best option.

The best implants on the market have been approved for use in the USA by their regulatory authority (FDA). The UK safety regulatory authority do not control product utilisation as carefully and this can be reflected in poor long-term outcomes with some less reputable prostheses. The better implants will probably last the woman's lifetime, provided they are inserted properly and appropriately. I use the Allergan/ McGhan range of silicone gel implants.

Autologous fat transfer
Lipo harvesting of fat from the flanks, thighs and abdomen to augment breasts, that have lost their fat volume after lactation, is becoming very popular, particularly in women who do not want the ‘implanted' look. At the Anglia Ruskin University we are researching fat survival and possible relevance to breast cancer. At the moment the science is supporting the safety of this technique. Small puncture scars and judicious liposuction are obvious benefits to this procedure. Fat survival rates are variable; the fat has to be seeded rather than pooled and not inserted under tension if the best outcome is to be achieved.

Hyaluronic acid augmentation
A recent vogue is to augment the breasts with ‘fillers' that last for five months to over one year. This is totally unresearched on safety and efficacy standards and not advised at present.

Suction augmentation and other devices
For a few years now a group from Florida has made a commercial effort to encourage women to use suction caps on each breast overnight. True, the volume of tissue increases but this is very temporary and the potential trauma with this needs more in the way of safety and efficacy studies.

Summary
The changes in the shape of a woman's breast after lactation can be distressing. If this persists for over a year after cessation of breast feeding then a breast augmentation can be considered. Patient selection is vital and it is very much a woman/woman type requirement
because the vast majority of men, particularly husbands, do not feel that this is a necessary procedure. Outcome measures clearly show the benefits of the procedure in the correctly identified patient. CSMUK