I USED TO JOKE TO AN ORTHOPAEDIC COLLEAGUE THAT THE NICE THING ABOUT HIS JOB WAS WHEN HE WANTED TO DO A KNEE REPLACEMENT NO ONE TOLD HIM WHAT SIZE PROSTHESIS TO USE.

The wide range of implants available today combined with the evolution of breast augmentation surgery means that it is well worthwhile to obtain a careful assessment by a plastic surgeon who is experienced in cosmetic breast surgery prior to undertaking this operation.

Prospective breast augmentation patients often come burdened with well-meaning advice from friends or relatives with regards to what shape and size implant they should use. The common advice is “go a size bigger”. This may seem like sound advice but with the multiple implants available a size bigger is such a marginal change that it is practically imperceptible to the human eye.
In addition excessively large breast implants are not without their problems. If the implant exceeds the natural breast dimensions it will tend to be easy to see and may create an unnatural appearance to the breast.

Fortunately use of the Vectra 3D imaging system combined with a sizer kit means that patients can now get a very accurate idea of their likely breast size with any given implant prior to undergoing the operation.

The next common myth I hear is that teardrop implants make the breasts look saggy. The real situation is actually the observe. Teardrop implants are often used in patients who have a degree of breast deflation and mild sag as they tend to provide a shape that masks breast sag by making the nipple tilt up a little. This is through virtue of their greater projection at the lower pole of the breast which helps the breast achieve a less sagged appearance.

It would also seem that a widely held myth is that putting the implant in front of the muscle makes it look larger. This has actually been researched quite carefully and the true situation is actually the opposite.

Breast implants are not inert devices. Particularly if they are larger they exert some pressure on the overlying breast tissue and the fat surrounding the breast. This pressure has the effect of making those tissues thin out to some extent. When an implant is placed behind the muscle the soft tissues at least in the upper two thirds of the breast are protected from this pressure effect. Thus studies have shown that implants in front of the muscle will in time result in a smaller augmentation result than those behind the muscle.

Another myth I encounter is that breast sag can be fixed if you simply use an implant that’s large enough. Unfortunately this is not the case as we would all prefer to do an augmentation rather than a lift as the scarring is much less extensive.

Breast sag needs to be differentiated from breast deflation. In breast deflation the breast tissue has simply “melted away” as one commonly see’s with major weight loss or simply with the hormonal “shut down” when breast feeding stops.

Breast sag however is when the nipple sits low compared to the fold below the breast. The fold below the breast is a relatively fixed point and cannot be moved to a limitless degree. As such it will usually inhibit how low on the chest wall the lower border of the implant can sit. Now this may seem attractive as women commonly like the fullness in the upper pole of the breast.

However breast implants only look good when they sit directly behind the breast. Extensive research has been done on this by Dr Patrick Malluci, a London based plastic surgeon. He surveyed people’s opinions on multiple photographs of breasts and discovered that regardless of age, gender or country of origin they all felt that breasts look better when 50-55% of the breasts volume was in the lower half of the breast. This gives that natural breast shape that is attractive to the eye.

While the very full upper pole may look attractive in low cut clothing, if a breast has the predominance of volume in the upper part then without clothing it tends to look quite bizarre with the nipple pointing at the ground. Basically it has a very upside-down appearance. It is important to remember that this very full appearance in the upper half of the breast is very much a bra look and a breast is not meant to look that way without clothing.

If there is true breast sag to a significant degree the presence of the fold below the breast will inhibit how low on the chest wall the implant can sit. Strangely enough when the implant sits low it makes the breast tilt up and look a bit less sagged. Conversely when the breast implant sits high- too high for the breast – then it tends to make the breast look saggy as it tilts the nipple in a downward direction and the point of the maximum curvature and projection of the breast is in an unnatural upper position, making the breast look quite sagged.
One can’t overcome this by increasing implant size. Apart from the drawbacks of excessively large implants alone, the larger breast implant will tend to create more and more of a fuller effect in the upper pole of the breast and this makes the sag appear worse.

A breast lift is designed to shift the nipple-areola to a situation on the breast curve where it achieves the most attractive appearance. Unfortunately this involves more scarring than a breast augmentation but where sag is present to a significant degree than augmentation alone will result in an unattractive breast appearance and the scarring of a breast lift is generally a better trade off if a more attractive breast shape is provided.

Where breast sag is borderline much discussion and assessment needs to be had before deciding on the appropriate course of action. It may be worthwhile trying implants alone to see if this will provide an appearance that is attractive enough with minimal scarring. Generally at 6 months the patient herself can judge whether or not that has been a good trade off or whether the extra scarring of a breast lift will be worthwhile if it provides a better breast shape.

Something of a preview of the likely outcome can again be obtained with the Vectra 3D imaging system. This device cannot only provide a predicted image of the effect of breast augmentation but also of a breast lift. Thus one can compare prior to surgery to get some idea of what breast augmentation alone would look like versus the effect of combining augmentation and a breast lift.

The wide range of implants available today combined with the evolution of breast augmentation surgery means that it is well worthwhile to obtain a careful assessment by a plastic surgeon who is experienced in cosmetic breast surgery prior to undertaking this operation. The consultation is very much a two way street with assessment of your breast shape combined with the implications of your preferred outcome in choosing the best course of action to help you to arrive at that result.