Treatment for breast asymmetry

 
All patients have a degree of breast asymmetry to a greater or lesser extent and when performing a breast reduction or a breast augmentation it is often possible to correct minor degrees of asymmetry, but we always warn people that there will be some residual asymmetries as it is quite natural to have differences between the two halves of our body.

It is cases of severe breast asymmetry that can pose a challenge and often require a little more thought and planning.

The first question to ask if you have a breast asymmetry, is whether you are happy with one of your breasts.

If you are happy with one of your breasts then it might be possible to just operate on one side to try and make that breast look like your ‘good’ breast.
If you are unhappy with both your breasts, then you may need surgery on both sides.

The next question is whether it is the size or the shape, or both the size and the shape that you are unhappy with.

If it is just the size that you are unhappy with and both breasts are of an acceptable shape, then it will be possible to make the big one smaller by doing a breast reduction or the small one bigger by using breast implants and sometimes and combination of these is required.

Breast implants are very effective at increasing the size of the breasts and although they come in a variety of different shapes and profiles, they do not have a dramatic effect on the shape of the breast.
If it is the shape that you are unhappy with, then your best option would be a breast lift (or a breast reduction if you wanted your breasts to be smaller).

As you can see, surgery for breast asymmetry can often be complex involving a variety of techniques including breast implants which often have to be of different shapes and profiles to give different effects to each breast, breast lifts, and breast reductions.

Whenever different surgery is done to each breast there is a risk that as you age, the breasts will settle differently.

If one breast is smaller and has an implant in, but the other side does not have an implant, then it is likely to be more pert and have a fuller look than the opposite side which is made up of breast tissue, because breast tissue will naturally droop or sag as the years pass.

This is where conversations come in where some patients might want a reduction of a bigger breast to match the volume of the smaller one and then to have the same size implants put into both so that they age in a similar way.

However, this then does bring in the complications associated with implants into a breast that may not have needed them.  It is swings and roundabouts.

Plastic surgery is really an art more than a science

and so there is often no easy answers in these situations and it requires a full and frank discussion with your surgeon.

You need to spend time exploring all of your options and will often have to accept that there will be a degree of asymmetry whatever surgery you have.

The aim of surgery is usually to restore symmetry as best as possible to make you balanced while wearing clothes and sometimes out of clothes you will still see some asymmetries and these are often magnified because you have lived with a more significant symmetry in the past.

I think it is important to realise at the beginning that all patients have a breast asymmetry to some degree, so it is usually a case of bringing it back into normal limits rather than achieving perfect symmetry.
We look at the consultation as a partnership between us and you and while we will help and guide you through the process, we will always aim to come to a mutual decision as to what might be the best option for you.

Don’t worry if this does not come in the first consultation.

It often takes two, three, or more consultations before you come up with a clear plan and that is why we only charge for the initial consultation because we want you to feel that you can come back as often as you need to go over things and make sure that you are happy with the plan.

As ever, it is always important to wait until your breasts have stopped developing so ideally you should wait until you are at least 18 before having surgery for breast asymmetry and you should also be happy and stable with your weight before having your breast asymmetry corrected.
You will need to be aware that as time goes on, particularly if you put on weight or have children, your breasts can change and so we always offer all our patients unlimited follow ups in the future because we know that life can be unpredictable.

For more information please download one of my guides and if you would like to arrange a consultation with us, the only plastic surgery clinic in the UK that specialises in breast surgery, call us now to arrange a consultation so that we can go over all of the possible options.

Dual Plane Breast Augmentation

One part of the consultation for patients considering breast augmentation is whether to have the implant on top of or underneath the muscle.

Unfortunately there is an awful lot of hype around cosmetic surgery

…particularly breast implants and I will often hear patients say to me they have heard that on top of the muscle is better or that under the muscle is more natural.

It is not really possible to make these sweeping comments, because the fact of the matter is there are good things and bad things about both.
You need to weigh up the pros and cons and take into account your body type and physique and your lifestyle and hobbies, so that you can come to a balanced and informed decision as to what might be right for you.

Sometimes patients will come to the clinic torn between whether to have them on top of or behind the muscle and they are delighted when they hear about the dual plane technique, but surely this is a compromise between the two with all of the benefits of both.

If someone tells you that one way is the best way to do something or if one type of implant is the best implant, when there are lots of other options available I would advise caution in listening to that advice, because if one was the best, then surely there would be no need for all of the others.

I understand that sometimes it is easier to explain things in terms of what we might recommend, but we should really be giving patients all of the available options to empower them to make the decision as to what might be right.

Broadly speaking, implants can either go on top of the muscle or under the muscle.

There are nuances with both planes, but I do not think the average patient needs to get too worried about the specifics. When they go on top of the muscle they can in either be in a subglandular or a subfascial plane and under the muscle can be a dual plane type I, II, or III.

When I teach and lecture plastic surgeons it is not uncommon for trainees to stand up and be unsure about the exact differences between dual plane type I, II, and III, so it is not something I would expect the average patient to know much about.

The important thing is that all submuscular breast implants are in a dual plane

So in terms of cosmetic breast surgery you can use the term submuscular interchangeably with a dual plane technique.

When the implants are placed under the muscle, it is the pectoralis muscle that is used, but this just covers the upper inner part of the implant. The lower outer part of the implant is only ever covered by breast tissue and so there is always a dual plane.

It is possible to put an implant in a total submuscular plane, but this is only used in breast reconstruction when there is no breast tissue to cover the implant, and so other muscles surrounding the pectoralis major muscle are raised and used to get complete muscle coverage, but this is not a technique that is ever used in cosmetic breast surgery.

The dual plane technique and the different types of dual plane are very useful to the plastic surgeon and the types I, II, and III refer to the amount of subglandular dissection that is performed.

For instance, a type III technique involves making a plane on top of the pectoralis major muscle and freeing the breast off the muscle.
This allows it to hang and sit with the implant in cases where patients have a droop or a sag to their breasts, and the dual plane type III is often the most challenging group of patients. A dual plane type I has got only a limited dissection of the breast tissue off the muscle and is what would be referred to as the classical submuscular plane. Whereas dual plane type II is in between the two.

Therefore, I am sorry to say that dual plane is not a compromise between submuscular and subglandular, it is simply submuscular but called by another name. I am not for a moment suggesting that the dual plane technique is a marketing gimmick because it is a very useful technique and is very well established.

However, I do sometimes hear it being used as if it is somehow better than submuscular because it is in ‘a dual plane’ which somehow sounds better.

Alas it is simply the use of terminology and it remains for you to weigh up the pros and cons of the dual plane or submuscular pocket compared to the subfascial or subglandular pocket.
By all means do your research and ask as many questions as you can think of to help you make a decision about whether you should have your implants on top of or behind the muscle, but do not be blinded or seduced by terminology or a slick sales technique that suggests that one is somehow better than the other.

If you have any questions I am on Facebook live every Tuesday at 7 pm but you can comment on the blog below, or e-mail us.

If you would like a guide on frequently asked questions about breast implants, you can download one below.

Our phone number is 0121 454 3680 and we would always love to hear from you.

BREAST IMPLANTS – YOUR QUESTIONS ANSWERED

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Do I Need A Mastopexy?

A mastopexy is a great way to reshape the breasts but when it comes to achieving a good outcome, it is important for us to communicate what might be possible so that we can align our goals.
Over time the shape of the breasts can change and these changes can be accelerated by having children or losing weight, resulting in a droopy or saggy appearance to the breasts.
Many patients want to achieve a more perky appearance to rejuvenate the breast contour.
The reasons that breasts lose their perkiness is because the skin gradually stretches.
This happens over time in all of us because of the effect of gravity.

The Alternative To Mastopexy

It is not possible to give elasticity back into the skin, and so there are two options to combat the problem.

1.  To remove the extra skin and tighten the breast.
2. To add volume to the breast to fill the skin envelope and tighten the skin.

So for this reason, patients often wonder whether it is a mastopexy they need or breast implants; with a mastopexy doing the former, and implants the latter.

 

The main difference is the size of the resulting breasts and that will be about the same size after a mastopexy, but bigger after implants.

So it depends on how big you want your breasts to be.

If you want the breasts to be the same size as they are or smaller, then it is a mastopexy or a breast reduction that would restore the perkiness, but if you wanted them to be bigger, then implants might be all that is required.
However, if the breasts have sagged significantly, implants might not be able to fill the skin envelope enough and you may need to combine it with a mastopexy.  You can read more about a mastopexy combined with implants here.
Often if restoring the breasts to a more perky shape is the primary goal, then a mastopexy on its own is the best option. 

The Limitation Of Mastopexy

You will need to be prepared for the sort of shape that you can achieve with a mastopexy.
We always stress that gravity will continue to operate on the breast and so it tends to settle to a more natural shape without the round and full look that is associated with breast implants.
The problem comes when people want the rounded look and do not want to be bigger, because sometimes you may consider having implants just to achieve this look.
This is an option, but does carry with it the potential complications and limitations associated with implants.
This is why an in-depth consultation is always advisory, so that you can discuss your aims and objectives with your surgeon to see if a mastopexy would be suitable for you.
We can discuss whether the shape you could achieve, which can often be quite transformational to the breast, will be in line with what your goals are.
When you have a mastopexy, there will be a full and rounded look in the upper part of your breast to start off with, but over time they will settle to a more natural shape.

Our primary goal is to have a happy patient and a happy patient is one who knows what to expect and can make an informed decision as to what might be the right operation for them.
We will not dictate to you what surgery you should have, and we will always inform you of what likely outcome you can reasonably achieve.
There is never any obligation to proceed.
If you have any concerns or doubts, then it is always best to go away and think about things and consider what surgery might be the best for you.
If you would like to come to the clinic for a chat, you can email or call us on 0121 454 3680.

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Do I need a scan to check my breast implants?

Patients often come to me to ask ‘do I need a scan to check my breast implants?’.
There are different types of scans that can be done to check on the breast:

Mammogram

This is an x-ray that looks at the density of the tissues and is mainly used for looking at lumps in the breast.
It is not very good at looking for problems with breast implants.
*note: a lot of patients worry about having a mammogram if they have got breast implants in, but there is no need for concern because it is routine to use implants in patients with breast cancer who need regular mammograms. You just need to let the xray doctors know that you have implants in so that they can adjust the way that they do the mammogram.

Ultrasound Scan (USS)

This involves using a handheld probe with gel on the skin to look at the integrity of the implant.
It is the same scan that is used when you are pregnant to get a picture of your baby.
It is often the first test for looking for rupture of breast implants.

Magnetic Resonance Imaging (MRI)

This is a bit more involved than an ultrasound scan.
You lie on a table and a large doughnut passes around you.  The doughnut contains magnets so you must tell the operator if you have any metalwork inside your body.
An MRI scan is more sensitive and specific than an ultrasound scan.  This means that it is more likely to be able to tell if the implant is intact.

Intracapsular Rupture Of Breast Implants

All implants are surrounded by scar tissue, known as a capsule and if the implant ruptures but the capsule stays intact, all of the gel will be held within the capsule.  This is known as an intracapsular rupture and this can happen without you being aware of it, in which case it is known as a ‘silent rupture’.
The cause of this is a constant friction of the implant shell, perhaps because of a fold or knuckle in the implant that might be made worse by some degree of capsular contracture.  Over time there can be a thinning of the silicone shell in areas of wear and this can lead to a gradual break or tear.
It is for this reason that I personally do not advocate routine scanning of patients who have breast implants in.
Scans have a cost, both financially and in terms of your health by exposure to radiation (for X-rays and CT scans) and so should only be performed if they are going to change how you are treated.
While they are very accurate in predicting whether your implant is ruptured or not, no scan is 100% reliable. This means that there is a small chance that the scan could say that your implant was ruptured, yet it might be intact and the scan might say that it is intact and it may be ruptured.
I have seen cases where the scan has been wrong both ways.
My practice is to offer all of my patients a yearly review where they can come back to the clinic for a check-up to see if there are any concerns or questions about your implants.
I would only offer a scan if there was a change in the size or shape of your breast that could indicate a problem with the implants.
If there was a problem with capsular contracture, then this is diagnosed clinically, not with a scan.
We make a decision to perform a capsulectomy and replacement of implants based on how bad the capsular contracture looks and feels, not on the basis of any scan.

Extracapsular Rupture Of Breast Implants

So far I have talked about a ‘silent rupture’ of breast implants, which is usually confined to the within the fibrous capsule around the implants (intracapsular rupture) and you normally do not notice when it happens.
This is different to an extracapsular rupture which is where the silicone shell of the implant ruptures as well as the fibrous capsule around the implant.
This is a different situation to an intracapsular rupture and this is the sort of thing that most people will imagine when thinking about rupture of breast implants.
It takes a significant amount of trauma to forcefully rupture the implant shell and in these circumstances, the capsule may also rupture resulting in a change in the shape of the breast and the presence of free silicone within the breast tissue.
Silicone within the breast tissue can cause lumps and may travel to the lymph nodes in the armpit causing lumps here.
This is something that we saw quite a lot of during the PIP scandal where a French manufacturer was producing poor quality implants with a weak shell and a high rupture rate. These implants were filled with non-medical grade silicone which was irritant to the breast tissue and removal of these breast implants was recommended by the Plastic Surgery Associations.
The situation today is not as desperate as this because modern day implants have a thick shell (we only use premium breast implants which have a double shell).  Also, the gel in implants these days is firmer than it was in the past, this is known as ‘cohesive gel’ and we call the implants ‘form stable’ which means the silicone does not tend to leak like a liquid if the shell ruptures.
It does mean that modern day implants feel firmer than older implants, but they are safer in situations of rupture.
The silicone gel is medical grade and not so irritating to the breast tissue, but nevertheless, if there is an extracapsular rupture with free silicone in the breast, your implants should be changed.
An extracapsular rupture is normally quite obvious.  There will have been some significant trauma, like a road traffic accident with a seat-belt over the implant, and there will have been a change in the shape of the breast.
In these circumstances, a scan would be indicated.
In fact, in any situation where there has been a change in the size or shape of your breast, or if you have noticed a lump, then a scan may we’ll be required to make sure that all is well.

As well as a routine annual appointment, all of our patients have open access to the clinic and can make an appointment to come and see us at any time.

If you have noticed changes in your breast, then you need to get checked out.
This means that you need to see your surgeon, or your GP.  If you have breast implants in, then your surgeon will be able to get an idea by examining you whether you have a problem related to your implants or your breast.
If the problem is related to your breast and your breast tissue, then your surgeon may refer you to your GP to see whether you needed any specialist investigation or referral.
If it is felt that your problem is related to your implant, then a scan can help to delineate this, not only looking to see if the implants are intact but also looking for any suspicious lumps or swelling that could signify something more sinister.
For more information give us a call on 0121 454 3680 or email info@staianoplasticsurgery.co.uk.

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