Breast Augmentation – Mastopexy

A scar has to be placed all the way around the nipple and areola to achieve a breast lift. In general the scars can be of three different types as listed below.

Peri-areolar

• This scar is just around the nipple and areola
• It allows the areola to be reduced in size and while also providing access to place an implant under the breast.

This scar has the advantage of:

• avoiding the vertical or horizontal scars
• good for patients who need minimal lift of the nipple
• in tuberous breast (or snoopy/constricted breast) deformity allows good access to the breast gland to reshape and redrape over the new implant

However this scar has some disadvantages

• The nipple and areola can expand over time as tension is increased under the breast with the implant
• The implant has to be inserted through an incision next to the nipple which increases the risk of contamination of the implant

Lollipop (Vertical Breast Lift Scar)

• This incision is placed around the nipple and areola, as well as vertically down from the areola to the fold of the breast
• This is the most common incision used by Dr Aggarwal for augmentation-mastopexy

The advantage of this scar are:

• Allows excellent shaping of the breast, with the vertical scar allowing removal of excess skin on the breast, and allowing the breast to become more ‘perky’
• Allows resizing the areola to a more appropriate size
• Provides good access to create the pocket for the breast implant without risking contamination of the breast implant
• The vertical scar takes tension off the nipple and areola reducing the chances of it widening over time due to the underlying implant

The disadvantages are few but include:

• An extra scar compared to the periareolar. In general, we find that this scar heals very well becoming inconspicuous over time.
• There can also be some redundant loose skin left at the inferior part of the breast – this takes up over the first few months and rarely needs a small revision. If it needs to be excised the scar is often shorter than it would have been had it been removed at the time of the original operation.

Anchor scar (Wise pattern Breast Lift Scar)

• This incision is placed around the nipple and areola, as well as vertically down from the areola to the fold of the breast, and a horizontal incision in the fold of the breast.
• This is also commonly used by Dr Aggarwal for augmentation-mastopexy

The advantage of this scar are:

• Allows excellent shaping of the breast, with the vertical and horizontal scars allowing removal of excess skin on the breast, and allowing the breast to become more ‘perky’
• Allows resizing the areola to a more appropriate size
• Provides good access to create the pocket for the breast implant without risking contamination of the breast implant
• The vertical scar takes tension off the nipple and areola reducing the chances of it widening over time due to the underlying implant

The disadvantages are few but mainly that there are extra scars compared to the periareolar and lollipop approaches. In general, we find that these scars heal well become more inconspicuous over time. Due to the T shaped scar, sometimes there is slower healing at the T junction.

• Breast implants in augmentation-mastopexy may be placed in a subglandular or submuscular pocket.

• Subglandular
  • This is where the implant is placed above the muscle but under the breast gland
  • This pocket is less commonly used as it offers less coverage of the implant by soft tissues and therefore the implant may be more visible
  • However in certain patients it has several advantages such as:
    • Better cleavage in patients with good soft tissue cover, and already reasonable breast size
    • Less risk of lateral displacement of the implant
    • reduced animation (i.e. movement of the implant with muscle contraction)
    • faster recovery
    • improved shape and better control of gland reshaping in patients with tuberous breast (also known as snoopy or constricted breast)
•  Submuscular
  • This is where the implant is placed under the muscle and the breast gland
  • Submuscular or subpectoral pocket placement allows the following advantages:
    • additional coverage of the implant imparting a more natural look to the result especially the upper pole
    • offers reduced rates of capsular contracture long term
    • less risk of the implant migrating downward (or inferiorly) as the pectoralis major and pectoralis minor muscles sandwich the implant, maintaining its position as they contract during routine muscle activity.
    • easier to image the breast tissue using mammography
• Dual Plane Technique

• Dr Aggarwal routinely employs this technique as it offers the best of both submuscular and subglandular placement
• This is where the muscle is partially divided so that the upper part of the implant is under the muscle (therefore imparting a more natural look to the upper pole of the breast) and the inferior part of the implant is in direct contact with the gland (and therefore imparting greater shape to the rest of the breast).
• In some women dual plane technique along with slightly larger anatomical implants can avoid the need for a breast lift. This is usually only possible when the nipple is at or above the fold of the breast. If the nipple lies below the fold a breast lift will be required.

• Dr Aggarwal will place waterproof dressings over the incisions. You will also be placed in a surgical bra that you must wear for the first 6 weeks. This helps to reduce swelling, pain and discomfort as well as controlling the position of the implants in the early post-operative period as the area heals.
• You will be able to get the area wet after 48 hours and go back into the surgical bra after your shower. You will not be allowed to swim in a pool or beach for at least 2 weeks after surgery. This could be a little longer is there are wounds that are slower to heal.
• You will be given a script for antibiotics by Dr Aggarwal which you must continue until the box runs out
• You will also be given pain relief medications although most patients only report minor amounts of post-operative pain that is responsive to simple oral analgesia.
• You will not be allowed to go back home on your own – you must have someone accompany you home, and it is best to have someone look after you for the first few days as you recover. You should not drive for at least 24 hours after having an anaesthetic nor operate heavy machinery.
• While most sedentary activities can be resumed in the first week, you must not do any exercise for the first few days after surgery that could raise your blood pressure. You will also not be allowed to do any heavy lifting or upper body exercises for the first 6 weeks.
• Dr Aggarwal will see you a week after your procedure to inspect how the wound is healing. You will be given instructions how to look after the wound as it continues to heal. You will be able to ask questions about what you can and cannot do. Generally we will see you at 1 week, 3 weeks, 6 weeks, 3 month, 6 months and 1 year post surgery.

Round Implants

• These are used in women who:
  • have reasonable tissue thickness
  • Desire a more enhanced look, or greater upper pole fullness
  • There is a concern that the implant could rotate
• These implants are available in less firmer gels and can therefore feel softer to touch. However due to the softer gel, they can be more prone to rippling which can be visible and palpable in patients with thin overlying tissues.
• Round implants come in smooth and textured varieties, and in different projections.
• Dr Aggarwal uses round implants from Mentor and Motiva.

Anatomical Implants

• Anatomical or ‘tear drop’ implants are fuller at the bottom than the top resembling the shape of a native breast
• These are useful in women who:
  • Have less thickness to their tissues and therefore less likely to hide the underlying implant shape
  • Desire a more natural looking result
  • Have a shape to their chest requiring difference in width and height of the implant (as anatomical implants come in different widths and heights)
  • Have tuberous breasts, or significant breast asymmetry
  • Have a degree of droop (ptosis) to their breast and want to avoid a breast lift
• Anatomical implants are always textured though the degree of texturing varies between different implant manufacturers.

Smooth Implants

• In Dr Aggarwal’s practice smooth implants are less commonly used as they have less stability of position and are more prone to implant malposition especially down and out when placed in a subpectoral/submuscular position
• However their benefits can include
  • Lowest Risk of ALCL (see tab on ALCL)
  • May be possible to insert these via a smaller incision

Textured Implants

• Textured devices are more commonly used because as the tissue heals around the implant it produces a Velcro effect with the implant surface adding to maintenance of implant position.
• Benefits of textured implants include
  • Better maintenance of implant position
  • Lower capsular contracture rate especially in the subglandular position
  • Option to use anatomical implants with firmer gel consistency offering better maintenance of long term shape, and less rippling
• The degree of texturing of implants varies and can be described as:
  • Macrotexturing: this is a very coarse texture imparted to the device during manufacturing. It was thought that texturing was a big reason why textured implants had reduced capsular contracture rates (see capsular contracture in complications) in breast augmentation. However this has lost favour recently whereby macrotextured implants from multiple manufacturers have been associated with higher rates of ALCL (see ALCL tab).
  • Microtexturing: this is degree of texturing that is much finer than macrotexturing. We regularly use implants from Mentor which offer microtexturing. Mentor implants are available in smooth and round, and we employ them for both reconstructive and cosmetic breast surgery. Microtextured implants have a much lower rate of ALCL (see ALCL tab).
  • Nanotexturing: with increased innovation and research around ALCL, a new category of texturing has been recently developed. This texturing is so fine that the implant almost resembles a smooth implant whilst still offering the benefits of texturing. It is thought that given the reduced association of microtexturing with ALCL that these implants will have an even lower risk of such issues. Dr Aggarwal uses implants from Motiva which feature nanotexturing.

• Saline implants were popular overseas especially in North America as that continent went through a period of not using silicone implants.
• In Australia these are rarely used as they carry a higher risk of rupture and rippling. If they rupture they lead to complete loss of breast shape.
• The touted benefits of saline implants are thin capsule formation around the implant and if it was to rupture the content being saline which is simply absorbed by the body.
• However with modern generation silicone implants being of extremely high quality the benefits of these silicone implants clearly outweigh those of saline implants.

• Mentor is probably the biggest implant manufacturer in the world with the longest safety track record of any manufacturer.
• At Mode Plastic surgery we routinely use Mentor implants for both our reconstructive and cosmetic surgery patients.
• Available in both round and anatomical device shapes, smooth and textured, we are able to select the best device for a particular patient.
• Furthermore their microtexturing offers lower risk of ALCL than other manufacturers that employ macrotexturing to their devices (see ALCL tab).
• Mentor implants come with a lifetime warranty.

• The newest manufacturer on the block is Motiva however their implants are backed by years of research and extensive experience overseas.
• Motiva implants also offer other benefits not seen before in other implant manufacturers’ devices, which is why we at Mode have employed their use:
  • Microchip technology – which can be scanned externally by a Q-reader. This allows instant detection of serial number, size and type of implant to be detected allowing for safer record keeping. If a patient was to ever see a surgeon decades down the track this information can be essential, and particularly if there was ever an issue with the implant device.
  • Nanotextured technology – delivers the benefits of textured devices with safety profile of smooth implants.
  • Ergonomix implant technology – a special category of ‘round’ implants that have a softer gel imparting a natural feel to the breast, and also behaving like ‘anatomical’ implants with the effect of gravity.

• MonoBloc construction – the outer shell and inner content are not two separate things but the implant is constructed as one unit.
• Offer of 5 year extended warranty period (for surgical fees) and lifetime implant protection – Like Mentor Motiva offer a lifetime guarantee for their implants. This means should the implant ever become faulty the company will replace them free of charge. However patients can still be faced with surgical, anaesthetic and hospital fees for an operation in the event of device failure – Motiva offers the option to purchase extended warranty for 5 years during which period they will also contribute towards the cost of other fees associated with the operation, offering a complete peace of mind.

• Motiva implants are slightly more expensive than the Mentor implants, with Motiva Ergonomix implants being comparatively priced to Mentor anatomical devices.
• Motiva implants are currently only available to our cosmetic surgery patients.

• Modern generation silicone implants are of very high quality but as with all foreign bodies they have a lifespan and must eventually be replaced.
• Currently we state that the implants will last 10-15 years. However this does not mean that you will definitely need to sign up for surgery at the 10 year mark.
• Dr Aggarwal will examine you every year following breast implant surgery. This is to ensure there are no changes in the breast shape as well as integrity of the implant.
• If there is any suspicion of implant integrity or the implants are over a decade it may be worthwhile obtaining imaging at that stage. If imaging detects a problem with the implants or there are other reasons for surgery (e.g. scar revision, breast lift, etc) you will be offered surgery for exchange of implants.

• Implant palpability – it is possible to usually feel the implant at the lower, outer part of the breast in thin persons as this is where the coverage is the least. However in very thin individuals or those with small breasts or little soft tissue cover it may be possible to feel or see the implant elsewhere.
• Rippling – softer gel implants are more prone to rippling than higher cohesive gels. Patients with thinner tissues are more likely to experience this where it can be possible to both see and feel the rippling of the implant. Rippling can occasionally be masked by fat grafting or by change to a firmer gel implant.
• Rupture – rupture rates of modern day silicone gel implants are very rare. If they do occur they are picked up incidentally on imaging as the form stable implants maintain their shape despite the rupture. However given implants are foreign bodies they will lose integrity over time and will eventually need to be replaced.
• Rotation – this is only an issue for anatomical (or tear drop) implants. To prevent this an exact size of pocket is created to match the size of an implant. If there is a concern regarding rotation, round devices obviate this risk.
• Capsular Contracture – The body reacts to a foreign body such as a silicone implant by forming a layer called the capsule around it. In 5-8 % of patients this capsule can become hard over time changing how the implant feels, and sometimes how it looks. It can also become painful in extreme cases.
  • Most of these cases occur in the first year after insertion of breast implants
  • Most manufacturers cover this complication as part of their lifetime guarantee.
  • Studies indicate that capsular contracture is lower with textured implants (especially when placed in subglandular plane or just below the breast and above the muscle), and lower with submuscular placement of implants
  • More recent literature indicates that this may be related to contamination of the implants during insertion with a chronic response of the body to a ‘biofilm’ of bacteria on the implant surface causing the capsule to become hard.
  • The treatment for capsular contracture involves removal of the implant, removal of the capsule and insertion of a new implant with care taken to prevent capsular contracture. However in some patients who have had recurrent capsules the only solution is to permanently remove the implants.
• ALCL – see tab on ALCL

• Widening of the nipple-areola complex – this is the most common problem with a periareolar approach to augmentation-mastopexy. Sometimes a special suture made from Gore-Tex is used to prevent stretching but this is also not completely effective. The most effective way of preventing this complication is to place a vertical scar in addition to the scar around the nipple (lollipop) which takes the tension off the nipple and areola.
• Asymmetrical scars – due to additional scars on the breast, and native asymmetry there can be a difference in how each breast behaves to the underlying implant, and can produce an asymmetry to the scars, albeit the aim is to get them as symmetrical as possible.
• Asymmetrical nipple position and shape – due to additional scars on the breast, and native asymmetry of every woman’s breasts there can be a difference in how each breast behaves to the underlying implant, and this can produce an asymmetry to the nipple size and shape, albeit the aim is to get them as symmetrical as possible.
• Nipples too high or too low – in general at the end of an augmentation-mastopexy procedure the aim will always be to have the nipples sit a little low. This is because as the muscle relaxes, the skin stretches and the implant settles the nipples will move up. The aim is to avoid the nipples looking too high as this can be an extremely difficult problem to correct. If long term nipples are too low this can be easily addressed though a crescenteric lift, which can be performed under local in rooms.
• Unusual breast shape – it is common for the initial shape of the breast to be unusual as the tight pectoralis muscles with a subpectoral implant take time to relax and for the implant to settle due to gravity. This can take approximately 6 weeks to 3 months. However occasional problems can occur including:
  • Malposition
    • Implant moves either centrally, laterally (down the side), up or down, needing revision surgery for correction
  • Double bubble
    • Can occur in patents with tuberous breast deformity where the fold of the breast needs to be lowered.
    • The old fold gives the appearance of a fold on the breast as well as the new fold where the implant sits. This can be camouflaged with fat grafting
    • Occasionally this is due to an inferior malposition of the implant (implant moving too far down) which needs to be corrected surgically.
  • Asymmetry
    • Most women’s breasts are asymmetrical
    • Where the asymmetry is significant there are two options – to either place different size implants, or when performing the lift to perform a small reduction on the larger size followed by identical implants.
    • This process is not entirely predictable and there can be small asymmetries in the final breast shape.
  • Waterfall deformity
    • This occurs when the implant sits too high and the breast appears to have fallen off the front of the implant
    • This tends to only occur when a patient was trying to avoid a breast lift and the implant failed to adequately sufficiently lift the nipple.
    • By performing a breast lift this deformity is avoided.
  • Atrophy of tissues – a foreign object like silicone pushing against the normal breast causes it to thin. The bigger and heavier the implant the greater the degree to which this will occur. As the tissues thin implant visibility, palpability and rippling become more pronounced and the risk of implant malposition become higher. We therefore caution against selection of large implants and Dr Aggarwal will usually guide you as to what size will suit your frame whilst trying to minimise this risk.
  • Change in nipple sensation – this can occur in up to 15% of patients but is usually short lived and returns to normal after a few weeks to months.
  • Animation deformity – this is movement of the implant with muscle activation. This occurs in all patients having submuscular placement and for this reason for the first 6 weeks the pectoralis muscles should not be heavily used to avoid movement of the implant. Long term extreme use of the pectoralis muscles (such as heavy bench pressing) should probably be avoided to avoid long term implant malposition. Some degree of implant movement with pectoralis muscles will occur in all patients and should be expected rather than seen as a complication.

• The risk in the literature varies widely from 1/3,000,000 to 1/50,000.
• However a recent study conducted in Australia (Wilkinson et al PRS 2017) documented the risk as
  • Biocell or macrotextured implants (Allergan, Inamed, McGhan) = 1/3817. These implants are not used at Mode Plastic Surgery.
  • Polyurethane implants (Silimed) = 1/7788. These implants are not used at Mode Plastic Surgery.
  • Siltex or microtextured implants (Mentor) = 1/60,631. We commonly use these implants carrying the lowest risk of ALCL of all textured devices.

• At this stage this is currently being investigated and new research is ongoing.
• It is unlikely that the implants directly create the disease and there is good support for an infective theory – i.e. that minor contamination of the implant produces a ‘biofilm’ on the implant surface which then causes ongoing inflammation that reaches a critical point to cause the disease.
• A study by Adams et al PRS 2017, demonstrates that with defined steps to minimise bacterial contamination there were no documented cases of BIA-ALCL in even macrotextured implants.
• At Mode Plastic Surgery, Dr Aggarwal employs the 14 point plan to prevent contamination of breast implants.

• This is a plan developed in consensus by plastic surgeons across the globe but especially from Australia and USA to reduce bacterial contamination of implants thought to cause not only BIA-ALCL but also capsular contracture
• This plan, employed by Dr Aggarwal in all his implant surgeries includes:

1. Use of antibiotics via a drip at the time of anaesthetic induction (when the patient goes off to sleep)
2. Avoid peri-areolar incisions (Dr Aggarwal favours the inframammary fold incision for this reason)
3. Use of nipple shields to prevent spillage of bacteria
4. Perform meticulous dissection of the breast implant pocket
5. Performing careful control of any bleeding
6. Avoiding dissection into the breast tissue (where bacteria live).
7. Using a dual plane pocket if required (Dr Aggarwal uses this routinely)
8. Cleaning the breast implant pocket with betadine or antibiotic irrigation solution
9. Minimising skin-implant contamination
10. Minimising the time of implant opening, reposition and replacement of implant
11. Changing surgical gloves prior to handling the implant. We also use clean or new instruments that were not used in the pocket dissection
12. We avoid using a drainage tube, where possible
13. Closing the wound in layers
14. Recommending our patients use antibiotic prophylaxis to cover subsequent dental or surgical procedures that produce bacteraemia, and at Mode Plastic Surgery we provide lifelong follow-up

• Given the rare occurrence of the disease, we do not recommend removal of breast implants.
• Thousands of women have breast implants in Australia each year and have done so for many years without issue.
• This disease affects a very small minority – it is therefore important to be aware of it, consider it before committing to surgery and knowing what to look for.

• If you develop a late swelling of the breast following breast implant you should inform us immediately.
• Dr Aggarwal will refer you for an ultrasound and at the same time a fluid sample will be collected which will be sent off for a special marker of the disease (CD30)
• You will not be required to undergo special imaging unless the marker returns positive from the ultrasound guided aspiration.

• Given the rarity of the disease, regular screening is not yet recommended by the TGA
• At Mode Plastic Surgery, we offer lifetime yearly checks of your implants and if, as with any procedure, you have any issues or concerns you should notify us to see Dr Aggarwal.

• BIA-ALCL has occurred in women who have had breast implants for both cosmetic and reconstructive reasons
• However currently there are no reports in Australia of BIA-ALCL occurring in women who have only ever had smooth implants.
• At the time of preoperative consultation you should discuss this with Dr Aggarwal.

• Most cases are cured by removal of the implant and capsule surrounding the implant.
• If a patient was to develop BIA-ALCL on one side we would generally recommend removing the implants and capsules on both sides.
• All cases are discussed in a multidisciplinary setting with involvement of a haematologist with experience in lymphoma. Occasionally chemotherapy or radiotherapy is needed – usually when there is a solid lump (not just fluid filled).
• Over the last 10 years, three Australian women have died from breast implant-associated ALCL.

• You can see us at our main practice at Gordon, or at our other locations at Hornsby, Hunters Hill or Camperdown.
• Please scroll to the bottom of the page to find out more information about these locations.

• Usually Hunters Hill Private or Castlecrag Private hospitals

• Stop smoking at least 2 weeks before surgery
• Cease fish oil, and other supplements such as Ginkgo, Ginseng.
• Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.

• Yes for a total of 6 weeks.
• You should not wear any bras with an underwire during this period

• You should not do any exercise that raises your blood pressure for at least 72 hours after surgery to avoid the risk of an unexpected bleed
• Heavy upper body exercise that activates the pectoralis major muscle should be avoided for 6 weeks
• Extreme heavy duty upper body exercise such as very heavy bench pressing should perhaps be avoided permanently as this risks displacement of the implant from its ideal pocket location.
• You should note that there will be some movement of the implants with exercise as they are commonly placed under the muscle

• Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.
• For the future you should remember that if you are ever having dental work or other invasive procedures to cover yourself with some oral antibiotics as there is a small risk of bacteria entering the bloodstream with such procedures that can reach the implant cavity.

• Once you have implants, you will require surgery at some stage to exchange them. As they are foreign objects they have a lifespan of roughly 10-15 years.

• Dr Aggarwal will offer to see you yearly and once implants are 10 years old it may be wise to image them to inspect whether there are any issues with their integrity.

• It is safe to undertake air travel after having implants
• However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

• You may swim in a pool or beach after 2 weeks as this is the time it takes for the incision to heal.

• It is best to not drive for several days and up to 1 week after surgery.

• No
• All our breast augmentation-mastopexy surgeries are performed under general anaesthesia given by an accredited anaesthetist
• The surgery is performed in an accredited private hospital
• It is usually a day surgery procedure but you will need someone to pick you up and accompany you home after the procedure

• This is not common but it is possible that there is a reduction in nipple sensation for a period after breast augmentation-mastopexy. In the minority where this happens, in most of those cases the sensation returns to normal weeks to months after the procedure. It can take as long as 12 months. Because incisions are being made in the
• Permanent loss of sensation of the nipple is very rare.
• If this is of significant concern to you, you should not have surgery on your breast.

• Implants should have no impact on your ability to breast feed.
• However with the mastopexy procedures there are incisions are made in the breast skin and tissue which can have an impact on the ducts of the breasts.
• However even in the normal population (women who do not have breast implants) up to a third of women cannot breast feed at all, and a third require additional supplementation for their infant.
• Interestingly these proportions of women are unchanged after a mastopexy procedures but our advice to women is that it may be possible for this procedure to reduce your breast feeding ability, and if this is of significant concern for you, then you should not have this procedure until your family is definitely complete.

• Yes
• This is easier if the implants are placed in a subpectoral or submuscular position.
• Radiographers are used and well accustomed to imaging breasts with implants that need to be displaced temporarily to allow the breast tissue to be imaged.
• It is important for you to participate in regular screening as you would have otherwise done for breast cancer based on your age and family history.

• There is no association between breast implants and breast cancer
• Patients should still however continue their regular screening for breast cancer based on their age and family history
• In Australia it is recommended for women who reach the age of 50 to undergo 2^nd yearly mammography for breast cancer screening in the absence of other significant family history – if you have a strong family history you may be required to start breast cancer screening earlier
• Implants more recently have been associated with a rare lymphoma called ALCL. The risk is extremely low and we still consider implants to be very safe way of augmenting the breast.

• Yes but none are as reliable, or cost effective
• Fat transfer for a natural augmentation does exist but is limited by
  • Areas of fat available for harvest: the skinnier you are the less likely it is that you will have fat deposits elsewhere to harvest
  • Fat grafting is unpredictable and approximately 50% of the fat does not survive the transfer
  • This means that it has to be ‘overdone’ to an extent – but all the fa must be in contact with tissues that provide it with good blood supply, otherwise it dies and can form hard cysts (fat necrosis).
  • The procedure is time consuming and often needs to be repeated.
  • The hours it takes to perform a single procedure and often a second means it is extremely expensive.
• Dr Aggarwal does not offer fat transfer for breast augmentation.
• It is possible to have mastopexy alone, and if you are uncertain about implants this may not be a bad option as it allows you to obtain a better shape than before. You may be happy with this procedure alone, and if implants are required or desired these can be inserted at another procedure.