I want to be a DD and nothing else will do!

When talking to patients considering breast surgery, I always ask what bra cup size they would like to achieve “ some patients have a very clear view ‘I’d like to be a DD and nothing else will do!’, while others are not so specific ‘I’d like to look natural, be comfortable and in keeping with my frame’.

I always ask the question because cup size is the way that we talk about breast size but I then always say that I cannot guarantee the final cup size.

The bra size is made up of two measurements, there is the chest size, 32, 34, etc., and the cup size, A, B, C, etc.  The chest size should not change following breast surgery (there may be a temporary increase due to swelling) and it is the cup size that is likely to be affected.  However, the precise change in the cup size is difficult to predict for several reasons:

  • bra size is relative.  The bra size is measured by measuring the circumference of your chest (this is the chest size), then the circumference around your bust.  The difference between the chest circumference and the circumference around your bust gives the cup size.  1 inch difference is an A cup, 2 inches is a B cup, 3 inches a C cup and so on.  Because the cup size is the difference between your chest and your bust circumference, it is not an absolute measurement, an A cup will be different for a person with a wide chest compared to someone with a narrow chest.  Therefore, I cannot show you a photograph of a pair of breasts and tell you the cup size, because the same sized breasts on you may be a different cup size if your chest circumference is different to the person in the photograph.
  • bra size varies between manufacturers.  I often have patients tell me that they wear a C cup in one make of bra or a D cup in another make
  • people often wear the wrong bra.   Most people could probably fit in to one cup size bigger or one cup size smaller than they normally wear if they were to adjust the strap size.  It may well be that someone who is a 34D could wear a 36C or a 32DD.

Having said all that, bra size is all we have got to go on, so I always ask what cup size you would like to be.  Just don’t be surprised when I say that I can’t guarantee that I will achieve it!

Watch My Webinar To Learn More About How To Choose The Right Breast Implants 

Only The Best Breast Implants

I often get asked ‘what are the best breast implants?’. Like most things, there is no one answer to this question otherwise we would all use those implants. Most plastic surgeons will only use the best quality breast implants from the top manufacturers like Allergan, Nagor, Polytech and Mentor, which is why very few of us ever used PIP implants.

Most of these carry a lifetime guarantee and have a proven track record in terms of capsular contracture and implant failure rate.

Nagor

Nagor implants are manufactured in the UK and their premium round implants are the Impleo range. They also have the CoGel range, which is their anatomical (or teardrop) implants. They have dense texturing with a double shell and come with a lifetime warranty.  The warranty covers capsular contracture as well as shell failure, however it is important to be clear about exactly what the warranty covers:

  • they will provide a replacement implant as well as an implant for the other side
  • they will allow a size change above and below the replacement implant
  • they will not cover any of the other costs associated with surgery

Polytech

Polytech is a German company who manufacture polyurethane foam coated implants.  They also have a range of silicone implants, however, it is their range of polyurethane foam coated implants that I use mostly.  Polyurethane foam implants have always been known to have a significantly lower rate of capsular contracture when compared with silicone implants and this makes them particularly appealing.  However, there was a study done that suggested that some products of the foam could cause cancer in rats in an experimental setting and this led to their use being greatly reduced in this country.

They have continued to use them in Brazil and there is a large experience of their use in Australia and there is no evidence to suggest that they cause cancer in humans.  Nevertheless, this is something that you should discuss with your surgeon and do your own research on, because you must weigh up the pros and cons of having them.

I think that they are good implants but have an open and honest discussion with patients and give them the information to allow them to make an informed decision.  You can read more about them here.
Polytech polyurethane implants also come with a lifetime warranty which includes:

  • exchange of implant in case of shell rupture for lifetime of the patient
  • free of charge exchange of the implant in case of capsular contracture Baker grade III or IV up to 10 years after implantation
  • free of charge exchange of implant in case of implant rotation or dislocation for up to 10 years after implantation
  • the original implant can be exchanged for an implant of the same type and the size may be chosen freely
  • the hospital costs associated with exchange of implants will not be covered, however there is an additional insurance policy provided with Polytech implants which provides up to £1500 per implant to go towards the cost of revision surgery required within 2 years of implantation.

 

These are the manufacturers that I use most often and I am happy to recommend them to my patients.

There are other manufacturers out there, such as Allergan and Mentor, who are major, reputable companies and produce good quality implants.  They all have slight differences and I have samples of all of the implants that I use in the clinic to allow patients to see and feel them.

Ever since the PIP scandal, patients are becoming more aware of the implant manufacturers and this can only be a good thing.  Most reputable surgeons should be happy to talk about the companies that produce the implants they are using and you should feel free to ask questions, after all, you will be paying for them.

For more information head over to our Breast Enlargement page.




How do I choose the perfect size breast implant for me?

When you are first thinking about having a breast enlargement, this might seem like any easy question.  You may know someone who has had breast implants, so you ask them what implants she had and she says she had 390cc implants, so you think, her’s look great, so I’ll  have 390cc implants too please.

Size is Not Important

Unfortunately, like most things in life “ it is not that simple!  The volume of the implant (in this case, 390cc) is only one factor when choosing which implant to have.  In fact, when I am deciding on which breast implant to use on a patient, it is probably the last thing that I consider.

Watch my webinar where I talk about some of the difficulties in choosing breast implants

Width is Important

The first thing that I think about is the base diameter of your chest as this will dictate how wide an implant that I can use.  This is crucial.  If the implant is too wide for your chest, then you may get a web between your breasts (known as symmastia or synmastia), or there may be too much of the implant to the sides of your breasts and your arm will hit your breasts which will be uncomfortable.  If the implant is too narrow it is not so bad, but it will not fill the footprint of your breast and so it is more difficult to give a nice shape to the cleavage.

You Cannot Compare Implants without Knowing More than the Volume

There are many different breast implants that have 390cc volume because implants come in different shapes and projections.  The different shapes of implant are round, teardrop (also known as anatomical or shaped implants) and conical (the conical shape is only available in polyurethane foam implants).
There is also a variety of projections for each shape “ low, medium, high and extra high.

This means that a 390cc low projection implant will look different to a 390cc extra high projection implant.  In fact, the low projection implant will have a wider base diameter than the extra high profile implant.  This brings us back to the base diameter, which is the key when deciding on a breast implant.

How I Choose a Breast Implant

When choosing a breast implant, the first thing that I do is to measure the base diameter of your chest.  This is a fixed measurement and will dictate the size of implant that you can have.
The next step is to try on some sizers.  I have a sizing kit in the clinic, which has sizing bras and vests and allows you to ‘try on’ different volumes in your bra to get an idea of the sort of size increase that you would like.

Cup sizes are unreliable and whilst I always ask patients if they have an idea of the cup size that they would like to be, I always stress that I am unable to guarantee a particular cup size.  The sizing kit is more accurate and will give a good idea of what is achievable with the different volumes.

Finally, we go through some of my before and after photographs of patients with different shapes and different projections of implant to see what sort of ‘look’ you are after.  Everybody is different and your final result will depend on the size and the shape of your breast before you start, but you can get an idea of what the different shapes and projections look like.

It is then a case of putting these pieces of information together to come up with a final cup size:

  • Base Diameter of your breast as established by my measurements
  • Volume of Implant as established by the sizers in sizing kit
  • Shape and Projection of implant as established by the ‘look’ you desire based on photographs

Sometimes, everything fits together nicely and it is relatively straightforward to come up with the implant that is right for you, but at other times, a compromise may be needed.

You May Need to Compromise on Size or Shape

The base diameter of your chest is set and you cannot change it and this will narrow down the range of implants that I can use in your case.  Sometimes patients choose a certain volume of implant and then chose a certain shape, but it may not be possible to use an implant of that shape and volume in their breast.

The common situation when this occurs is when patients choose quite a large volume and may have a narrow chest.  They may then go on to say that they don’t want too much fullness in the upper part of the breast and want a more natural look.  It may be that in order to use an implant of the volume that they like, they will have to have an extra high projection, which will give a lot of fullness in the upper part of the breast.  Alternatively, if they wanted a more natural look with a lower profile or anatomical implant, then they would have to accept a smaller volume of implant. We can have a discussion about this and you may want to go away and think about things.

I am very happy to see you again and again to go over things to make sure that we are confident that we have chosen the best implant for you.

It may all seem daunting, but don’t worry, it usually comes down to some pretty simple choices.

It is important not to get too bogged down in deciding between the exact volume of implant.  The result depends on many factors and the actual implant volume is only one factor.  Whilst it is impossible to guarantee a cup size, breast augmentation delivers predictable and life-changing results and has a very high patient satisfaction rate.

Download my guide on ‘Breast Implants – Your Questions Answered’ here.






Only the best breast for Angelina Jolie

There has been tremendous publicity surrounding Angelina Jolie’s decision to go public with her decision to have a double mastectomy.  It has helped to increase the profile of breast cancer and the BRCA gene and has empowered women around the world.  So what sort of reconstruction has Angelina Jolie opted to go for?  You would have thought that the likes of Angelina Jolie would have had the very best reconstruction available, wouldn’t you?  I frequently get people in the clinic saying that they want the best reconstruction please, but in fact there is no ‘best’ reconstruction.

What is the ‘best’ breast reconstruction?

The best breast reconstruction is different for different people.  It depends on your age, your medical history, your body shape, your breast shape, your job, your expectations and your social circumstances.  The fact is that everyone wants the best breast reconstruction.  It is the job of you and your surgeon to have a full and frank discussion (and often more than one discussion) to go through your goals and expectations and the options available to discover what is best for you.  There are many ways of reconstructing the breast and if there was one best way, we would all just do that one.

So what breast reconstruction has Angelina Jolie had?

Angelina Jolie has had a bilateral breast reconstruction using implants and allograft.  Allograft is a sheet of material derived from another animal (usually pig or cow), used to cover the implant.  This is probably the shortest operation of all of the bilateral reconstructions, although it is often done as a staged procedure so may need more than one operation.  It has the benefit of not leaving any scars anywhere else other than the breast and so complications are potentially less because there is no ‘donor site’ associated with reconstructions that use your own tissue (flaps).  When people think of breast implants, they think of well known celebrities who have had breast enlargement, this is not the same as when implants are used for breast reconstruction.  Breast enlargement involves enhancing the natural breast, whereas, when implants are used for reconstruction there is no breast to enhance, so the shape comes completely from the implant.  For this reason, I always use teardrop implants for reconstruction as the shape of the breast following an implant reconstruction is the shape of the implant.  The results are often good in a bra, but the breast lacks the natural movement of breast tissue and can often feel quite firm and high, however it is ideal for women with small, pert breasts and for women having a bilateral reconstruction (both sides), like Angelina Jolie. The benefits are that the surgery is shorter, the recovery is quicker and there are no scars elsewhere on the body, other than the breast.  Perhaps this is why Angelina Jolie has chosen it, as it is probably the best option if you want minimum downtime and need to get back on your feet to look after children or work.

Bilateral implants with Allograft

This lady is shown 5 months following double mastectomy and reconstruction with implants and allograft.

The ‘Jolie Effect’ “ You can still be beautiful and feminine after mastectomy

Angelina Jolie has announced today that she has undergone an elective double mastectomy to reduce her risk of developing breast cancer.  We are becoming better and better at diagnosing and treating breast cancer to the extent that we can now look at various risk factors, in particular family history and genetic testing, to identify individuals who are at high risk of developing cancer, and treat them before the disease has had a chance to develop.  This may sound like something out of science fiction, but in fact it is something that is increasingly done and widely available on the NHS.  The news today that Angelina Jolie has undergone a double mastectomy for this reason will increase public awareness and help patients who are undergoing mastectomy or who have had mastectomy to realise that it is still possible to be beautiful and feminine after mastectomy.  One can only imagine how difficult a decision this can be for any woman, and Angelina Jolie is to be commended for making these personal details public.
Double mastectomy and reconstruction
Breast cancer is the most common cancer in the UK and Angelina Jolie is one of a list of high profile celebrities who have been affected by it including Kylie Minogue and Sharon Osbourne.  It can affect women as well as men and there are a variety of treatments including surgery, radiotherapy and medical treatments.  Outcomes can be very good with a move towards less radical surgery and better reconstruction techniques, which means that women can lead normal lives following a diagnosis of breast cancer.

Breast Reconstruction can give Natural and Long-Lasting Results

Just as the methods of diagnosing and treating breast cancer are advancing, so are the methods of breast reconstruction.  A breast reconstruction is still a major undertaking and not every patient will be ready for it, but with advances in surgical techniques such as the DIEP flap and fat grafting, we are now able to give natural and long-lasting results.  People often think of breast implants when thinking of breast reconstruction, but this is only one of the methods available.  The majority of my reconstructions use the patient’s own tissues, either from the abdomen (DIEP flap) or the back (extended latissimus dorsi flap).  These operations take longer and are more complex than using implants but once they are finished, the result is often more natural.  Furthermore, even though the operations take longer, they will often allow you to avoid having further operations in the future.

Breast Reconstruction Requires an Investment of Time by both Patient and Surgeon

The way I see it, if you are considering having a breast reconstruction, you will probably need a certain amount of time in theatre and you can choose how you break up that time.
Option 1: you have a DIEP flap, which takes 8 -10 hours in theatre and is a big undertaking, but once it is done, you will probably only need minor procedures such as dog ear removal or nipple reconstruction.  This is a way of frontloading all of the time in theatre at the beginning of your treatment.
Right sided mastectomy and reconstruction with DIEP flap followed by nipple reconstruction
Option 2: you have an extended latissimus doris flap (ELD flap).  This takes about 5 hours in theatre and is not as major a procedure as a DIEP flap, but the reconstruction that it provides will be smaller.  Obviously, if your breast is smaller, then it may be enough, however, usually patients with small breasts, have slim backs and so it may still not be quite big enough, and so there are then 2 options:
Extended Latissimus Dorsi Flap
Option 2a: an ELD flap with an implant.  An implant can be placed beneath the extended latissimus dorsi flap to enhance the volume, however implants do carry with them additional potential complications.  Among the complications of implants is a condition called capsular contracture.  This is hardening of the implant and can happen to any implant, but occurs more quickly in patients who have had or are having radiotherapy.  If the implant develops capsular contracture, then it may need to be changed and this can happen after around 5-10 years, or sooner in the presence of radiotherapy.  When the implant is changed, then there is a risk of capsular contracture occurring in the next implant and it can come more quickly second time around.  This means that, although the operation is quicker, there is the potential for further surgery every 5 or 10 years afterwards and so the total time in theatre over the lifetime of the reconstruction will even out.
Extended latissimus dorsi flap and implant
Option 2b: an ELD flap followed by fat grafting.  If the ELD flap is too small and you do not want the potential problems associated with implants, then you can accept that it will be small to start with and then build it up with fat grafting at a later date.  I like to wait at least 3 months between operations, but fat grafting can give a useful increase in volume to the reconstruction and can also be tailored to fill in contour irregularities or deficiencies.  It may only be a modest increase in volume that fat grafting can give and so it may need to be repeated, depending on the size of the breast reconstruction that you require.  So you can see, an ELD flap with implant may require further operations every 5 or 10 years, and an ELD flap followed by fat grafting may require further surgery every 3 months until it is up to the required size.  Once the size is achieved, then a breast reconstruction using ELD flap and fat grafting is a permanent solution, similar to a DIEP flap and should age and mature with you.
Extended latissimus dorsi flap then fat graft
Option 3: breast reconstruction using implants.  A breast reconstruction with implants is usually a two-stage procedure.  The first operation involves using a tissue expander to stretch the skin to allow the definitive implant to be placed.  The second operation takes place a few months after expansion of the implant is achieved and allows the definitive implant to be placed.  An implant reconstruction is the shortest of all of the operations and does not involve any extra scarring outside the breast and so is appealing from that point of view, however it is the least long-lasting of all of the forms of reconstruction.  The resulting reconstruction often feels firm and does to have the natural flow or movement of a natural breast and it can often sit high.  It is particularly good for patients with small breasts without much droop and for patients having a bilateral reconstruction.  If hardening of the implant occurs (capsular contracture), then it is more obvious than an implant covered with an ELD flap and so may need to be exchanged sooner.  As you can see, whilst it is a shorter operation to start with, it is a two-stage procedure and there is the potential for further surgery in the future.
Right implant reconstruction
Jonathan will be talking at the Younger Women’s Forumorganised by Breast Cancer Care on Friday 17th May 2013 in Birmingham.