Treating the Breast

Mr Taimur Shoaib introduces the modern approaches to breast augmentation surgery

Knowledge of surgical procedures is an important part of the skillset of all aesthetic practitioners, whether they are primarily surgical or non-surgical professionals. In an audit performed at my clinic, La Belle Forme in Glasgow, we reported that 22% of our patients who attended initially for a non-surgical treatment subsequently underwent a surgical procedure at our clinic. On average, the patient would wait 18 months after their first encounter at the clinic to undergo surgery. Patients often ask their non-surgical practitioner for advice on which plastic surgeon they recommend for surgical treatments. Non-surgical practitioners may feel that they are seeing a patient who wants a result that cannot be obtained non-surgically will need to refer the patient to a surgical practitioner instead to achieve optimum results. This article will provide non-surgical practitioners with an introduction and understanding of what surgeons are currently doing to maintain patient safety and excellent treatment outcomes for breast augmentation procedures.

Manufacturing breast implants A breast implant consists of a shell and filler material, which can be either silicone or saline. All implants, however, have a silicone shell. Breast implants are made through a mould, or mandrel, which shapes the liquid silicone. The mandrel has a mildly rough texture to hold onto the liquid silicone and this is heated to change its structure to solid silicone. This action is repeated, creating a few layers in the implant. The layering structure prevents leakage of the filler material from the implant to the breast, and the implant shell is then filled with silicone.

Nowadays, the majority of medical-grade silicone in the world is produced by Dow Corning, and is always cohesive gel silicone. Therefore, the silicone cannot leak out of the implant into the surrounding breast tissue, if the implant shell ruptures. The shell of a breast implant is given a roughened texture, and this is performed to reduce the likelihood of the long-term complication of capsular contracture (capcon), where the implant feels hard and distorts the shape of the breast.1,2 Any implant inserted into the body will elicit a reaction in which the body surrounds the implant with scar tissue. This scar tissue is completely normal but may thicken and harden over the years. It is believed that 1% of women every year will develop significant capsular contracture – after five years 5% of women, after 10 years 10% of women, and so on.1

Breast implants and ALCL Until a few years ago, many plastic surgeons were using highly textured implants, until these became associated with anaplastic large cell lymphoma (ALCL). This refers to a very rare form of cancer that occurs in the breast lining but does not occur in the breast tissue. The reported risk was very low (1:24,000)3 and the disease was not aggressive in most women, with cures discovered from simply removing the thickened capsule.4 ALCL in association with breast implants was first diagnosed at around the beginning of the centurybut has gained increased attention among plastic surgeons in the past few years.5-7 The association with ALCL was seen with scepticism and surgeons were unsure of the relevance of the association. Practitioners did not know whether the disease and implant were linked; however, over the past few years, studies have shown that these links are correct.8 Implants associated with ALCL have textured surfaces, whilst implants that do not have this association are smooth with no texture.8 Smooth implants, however, have higher rates of capcon.3 This created a problem for surgeons as the decision to use smooth implants and risk capcon rates meant a high proportion of women would need to pay several thousands of pounds for surgery every time they suffer from capcon, or use highly textured implants and run the risk of ALCL. In the past few years, however, a new texture of implant has arisen – the nanotextured implant. The US Food and Drug Administration (FDA) and the International Standards Organisation (ISO) considers this texture pattern to be completely smooth.9 The texture depth, when studied under a scanning electron microscope, is around 16 nanometres or less, but compared with completely smooth implants, the surface areas of comparable implants are the same.9 The nanotextured pattern is made by turning the implant inside out once it comes off the mandrel. The slight roughness of the mandrel creates a pattern on the implant and is used to create the nanotexture. Currently, Nagor and Motiva are two breast implant manufacturers producing minimallytextured implants, which are considered to be smooth walled by the US FDA. The additional advantage of nanotextured implants is the low rates of capcon reported with the Motiva range, which has been out for long enough for reasonable data to be gathered.10-13

Modern techniques In my clinical experience, high quality and long-term outcomes are closely linked to modern techniques in performing breast implant surgery. We understand that implants with bacteria on them will more likely cause long-term problems. Accordingly, myself and many other surgeons now use methods

to reduce the bacterial load on an implant and reduce tissue trauma associated with surgery. These techniques include using intravenous antibiotics (an antiseptic solution to soak the implant), using nipple shields to prevent bacterial seeding from the nipple to the implant, changing gloves before handling implants, using a funnel to slide the implant into the pocket thereby preventing implant contact with skin, using meticulous dissection to create a precisely fitted pocket without blood clots, and using precise closure methods once the procedure is completed. Whilst some of these surgical methods are not new, in my experience, the combination of using all or most of them allows the surgeon to use the best techniques to give the best outcomes. In my view, the combined use of these methods has arguably led to a better, safer, and higher quality of care we can offer our patients.

Complications Despite surgeons being able to perform surgeries smoothly, there may be complications which arise that are associated with breast implant surgery. Early complications, such as infection and haematomas are rare and long-term complications can be reduced with some of the modern techniques described. Medium term complications can still occur and with the cost associated with breast implant surgery, it is not unreasonable to expect a certain amount of aftercare associated with cosmetic surgery. Medium term complications include implant movement and displacement, early capsular contracture, and skin stretching resulting from increased weight within the breast itself.14 Many surgeons offer an aftercare package for their patients. However, some surgeons will go as far as stating they will correct any complication they can within a year or so after surgery. Beyond that time, the complications are classed as long-term. These complications include changes with the ageing breast, the post-pregnancy breast and capsular contracture.14 Medium complication rates are low in breast implant surgery, and if a patient suffers through no fault of their own and through no fault of the surgeon, it seems fair to include a no-fault compensation scheme as part of the cost of surgery.15 The compensation would normally cover the cost of performing surgery within a fixed time frame, rather than compensation for other monetary losses. It is worth mentioning that Breast Implant Illness (BII) is a relatively new concern that has been gaining momentum in recent years. Symptoms can include hair loss, tiredness joint pain and headaches but there is debate among the community as to whether this is a genuine medical condition, or whether the symptoms actually relate to other reasons.16,17 There is limited data around the subject and more research is needed to fully understand the potential link between the individual patient and these symptoms. If a patient does experience any of these symptoms it is important that they report them to their surgeon.

Predicting outcomes One of the key questions patients will ask is: what will I look like after surgery? In my view, this is a question that can be answered through the experience of the surgeon, using computer simulation and using external expanders. Surgeon experience is a traditional approach to answering this question. The surgeon will ask the patient what look they are hoping to achieve, the patient is examined, and the surgeon maps a journey from where the patient is, to where the patient wants to be. Almost every patient in my practice, when asked what look they are hoping to achieve, says natural. However, this word has a wide range of acceptability that it is important to explore further by asking the patient what increase in size they want, what they want in the upper pole of the breast and whether an inner cleavage is important to the patient. Computer simulation devices are now available for predicting outcomes. These systems take photographs of the patient, adding volume to the breast so the patient can see what the computer thinks they will look like after surgery. Although they are a useful tool, clearly these systems have their limitations. They fail to consider the inevitable stretching of skin following expansion of the breast and no person or device can predict the effects of an increased volume within the breast and how this relates to time. All breasts will change with weight loss, weight gain, pregnancy, breastfeeding and time. Many manufacturers will provide external expansion devices to help inform the patient on what size they will be after surgery with a particular implant. These expanders are similar to the padding used in bras. The patient attends with fitting clothes, wears a non-padded bra and the external expanders are placed within the bra to give an approximation of the appearance in clothes, after using an implant size that correlates to the size of the expander. Using a combination of some or all three of these allows the patient to have a rough idea of the results they will have after surgery. Predictability of outcomes is steadily improving as technology advances and is, of course, one of the most important aspects of breast augmentation surgery.

Wider relevance Measurement of quality is a fundamental part of every healthcare professional’s practice. The quality of outcomes can be measured in many different ways and for breast implant surgery, some of these measurements include the reduction of complications, improving patient satisfaction and long-term safety. Readers of this article are likely to be non-surgical practitioners, and you may be asking a very relevant question to yourself, which is: ‘Why do I need to know about breast implant surgery when I don’t do any of it myself’? The answer is that many patients I see have discussed surgery with their non-surgical practitioners prior to seeing me. The fact remains that your patients trust you and they want your advice. They will often follow your recommendations for non-surgical treatments, and they will also ask you about surgery. Although the discussion may not go into a high level of detail, your patients will appreciate any help you can give them in helping with decision making.

Disclosure: Mr Shoaib has worked as a consultant for Nagor and Allergan, which manufacture breast implants.

Mr Taimur Shoaib has been a consultant plastic surgeon for 15 years and performed his first cosmetic breast augmentation procedure in 1998 when the NHS used to perform cosmetic surgery for eligible patients. Mr Shoaib works in full time aesthetic private practice, where he has a surgical and non-surgical practice based in London and Glasgow. Mr Shoaib has won several awards including Best Cosmetic Group UK, Best Cosmetic Clinic Scotland and Best Reception Team UK at the Aesthetics Awards. Qual: MB ChB, FRCSEd, DMI(RCSEd), MD, FRCSEd (Plast)

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