Mr Patrick Tansley MD FRCS (Plast) is a UK registered Specialist Plastic and Reconstructive Surgeon, trained, qualified and experienced in all aspects of cosmetic surgery. A former Hunterian Professor of the Royal College of Surgeons of England he is one of the founders of NorthEast Plastic Surgery (Melbourne and Brisbane) along with Dr Sugitha Seneviratne FRACS (Plast). With a special interest in breast and facial plastic and cosmetic surgical procedures, Mr Tansley was kind enough to answer some of our more common breast implant questions.
Are Breast Implants better under or over the muscle, or does it depend on the individual patient as to what will suit better? When would you choose one or the other?
Implant placement must be carefully considered both in context of a woman’s natural breast and chest wall morphology and also to achieve her desired appearance. Key factors to be taken into account include the amount of natural soft tissue cover along with the type of implant to be used, a consideration which can introduce many subtleties. Implants can be placed on top of the muscle, underneath the muscle or ‘dual-plane’, which is a combination of both and can include a variety of subtypes.
As part of the consultation process I show patients de-identified photographs of previous breast augmentations, representing each of these planes of implant placement and as closely representative as possible to a patient’s own morphology and desired appearance. For this purpose, it is important to ensure that patients understand that only photographs which show uncovered breasts are useful. They allow a proper assessment of key factors including shape, symmetry, volume and nipple position. Patients should beware surgeons and websites that are only prepared to display clothed work – photographs of patients in bras or bikinis should be considered with great caution – such clothing can disguise a multitude of problems and create unrealistic expectations.
It is vital that the surgeon selected to perform a breast augmentation is sufficiently expert not only to be able to measure and assess the patient correctly preoperatively, but also to understand the pros and cons of the surgical techniques for plane of implant placement and when or when not to use each. Only then can a safe and effective operative plan be made. Accordingly, I spend a great deal of time counselling my patients to ensure the decision about the operative plan will achieve a woman’s desired outcome in all the circumstances.
One of the most common things people ask is about breastfeeding and implants. So, once and for all, can you breastfeed after implants, and when and how might things go wrong? Are you better to wait until after having children to have breast implants?
Breast implants do not interfere with breastfeeding and should a woman so wish, she can breastfeed after having breast augmentation.
The more pertinent issue for most women relates to the breast changes consequential from pregnancy that occur above a breast implant. Breast size naturally increases during pregnancy and reduces thereafter as the breast gland ‘involutes’ during weaning. This can have a profound effect on the appearance of augmented breasts as the breast gland volume and overlying skin envelope changes, often resulting in ptosis (‘sagging’ of the breasts) which can lead to a ‘double bubble’ or ‘waterfall’ effect where the soft tissue of the breast appears to be ‘falling off’ the underlying implant. This can be addressed surgically, but again requires expert knowledge, assessment, surgical ability and experience.
It is difficult to be too proscriptive about a recommended interval between having breast augmentation and having children, but in general terms I consider it acceptable for a patient to undergo breast augmentation as long as they are not considering expanding their family within approximately 12 months of breast augmentation surgery.
Many patients are concerned about choosing the right sized implants. How do you help guide women to get the right size for them, and how often do you have patients come back for revisions?
Size and shape of breast implant choice is a key consideration in getting breast augmentation surgery right. It is not only critical that the surgeon is expert and experienced in breast augmentation surgery but also that they are prepared to devote the time and effort to talking, and most importantly actually ‘listening’ to what a patient desires before surgery is contemplated. This process ought not be delegated, as is commonly the case within practices who deploy ‘nurse consultations’. Skilled and accurate operative assessment for surgery ought only be undertaken by the responsible surgeon. Imaging techniques are also popular but I avoid their use as in my view they can be highly misleading and create unrealistic expectations for patients. I undertake all patient assessments myself, using solid reliable techniques that have stood the test of time.
It is reputed that the commonest complaint for women following breast augmentation surgery is to regret the size of implant they have chosen, typically wishing they had ‘gone a bit bigger’. This can be avoided by choosing an experienced, expert surgeon who can not only assess a patient properly but also counsel them wisely according to the wishes they have expressed in context of their natural morphology. Not every patient can expect to have ‘perfect breasts’ and it is important to be realistic about what can be achieved within the constraints of the many variables that exist. This is the very reason that I undertake all patient assessments myself.
At least a second consultation several weeks after the first is also important. Amongst a range of other considerations, patients should be given the chance to consider their size selection carefully at home and offered the opportunity to come back and discuss it further. I instruct a range of techniques that can be tried after the consultation regarding the size of augmentation under consideration. Selecting the correct size of augmentation is such an important decision, it must not be decided improperly or in haste.
Clinical assessment for revision breast augmentation surgery is even more complex as breast implants are typically already present on the front of the chest and frequently are of unknown size and sometimes have undergone complicating factors such as rupture. How then does a surgeon properly assess new implant size for such a patient? It can be difficult, so I would suggest choosing an experienced expert who knows how to do it and does it well. A large part of my practice relates to such surgery following operations performed elsewhere, both from outside Australia – for example Thailand, but also increasingly from within Australia. Caveat emptor.
Increasingly I observe on social media platforms photographs of surgeons in the operating theatre surrounded by many boxes of implants, apparently attempting to suggest a thoroughness of approach as a consequence of the sheer number of different sized implants available. Do not be misled – this is more commonly a sign of indecision of an inexperienced, inadequately trained surgeon who may not know how to undertake a correct preoperative assessment. Do not choose a surgeon that uses this approach. A patient should know what size implant she will wake up with following surgery, rather than having to ask for the outcome when she awakes from anaesthetic. Only in exceptional circumstances should implant size be determined ‘on the operating table’. Such circumstances can be advised to a patient beforehand.
To date, I have not had a patient return for revision surgery based on incorrect implant size selection at either primary or revision surgery. See my reviews at https://www.plasticsurgeryhub.com.au/psh-directory/cosmetic-practitioners-clinics/mr-patrick-tansley/#reviews.
We receive many concerned questions about the look of scars after breast surgery. When should a patient be concerned about the appearance of scars after a breast augmentation? What should they look out for and when should they express concern to their surgeon?
It is not possible to cut adult human skin without leaving a scar and this must be explained to the patient and understood by them before they give their consent to undergo breast augmentation surgery. However, an excellent resultant scar relates both to surgical factors and patient factors. A combination of optimum surgical technique and education of the patient by the surgeon and their nursing staff in regard to postoperative wound care is vital to achieve this outcome.
Scars go through phases of healing and maturation which can take many months. It is important for patients to understand that this is a process rather than an event that occurs over a short period. The surgeon and their practice nursing staff should be trained and sufficiently experienced to guide the patient as to what to expect at each stage and how to manage the process. Various adjunctive treatments can be applied and the practice should be able to advise the patient regarding the pros, cons and available evidence of each.
If the patient is counselled well, they should be reassured and know what to expect during the scar healing and maturation process. The surgeon should be informed of anything that arises outside of those expectations so that appropriate management can be instituted if required.
Many women are initially concerned about the positioning of their implants straight after surgery. How long do breast implants take to “settle”? Also, how long until any swelling subsides?
This question is best addressed by an understanding of the various implant types in combination with position of implant placement. As with many things in life, it is assisted by an understanding of history, in this instance related to breast implant manufacture.
Smooth implants (whether filled with saline or silicone) do not ‘grip’ the tissues of the body and therefore usually ‘drop’ or ‘settle’ over time. This is one of their disadvantages, which not only should be expected but is made far worse when such implants are placed under the muscle which acts as a displacing mechanical force upon the implant during each contraction.
Textured implants came into existence as a negative-imprint of PolyUrethane-foam-covered silicone implants (PU foam) in an attempt to mimic the good properties of PU-foam. However, those aims have not really been achieved and in very few cases do textured implants actually adhere and ‘grip’ the tissues as they were supposed to do. As a consequence, they also often ‘drop’ or ‘settle’ like smooth implants and if anatomical (tear-drop) in shape, frequently also rotate which gives a very poor aesthetic appearance. More recently, textured implants have been found to be the type of implant that has been most commonly associated with Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Including for these reasons, I cannot identify a justification for implanting textured implants into patients and do not do so. I speculate they may not be available on the market for much longer due to the safety concerns arising from their use.
PolyUrethane-foam-covered silicone implants are the implants with the longest follow up period, having first been used around 1968. Their overwhelming advantages in comparison to smooth and textured implants relate to the manner in which they ‘grip’ and integrate into the tissues of the body. Not only does this mean they do not ‘drop’ or ‘settle’, but their capsular contracture rate, the commonest complication of breast implants and the major complication about which patients should be concerned, is but a fraction of that of smooth and textured implants. Only one type, Silimed (Brazil) and no longer used, has been shown to have an association with ALCL and that is hypothesised to relate to manufacturing issues. No cases of ALCL have been recorded in the Polytech type (Germany) which I use.
PU foam implants are more demanding to use and as a result require far greater surgical understanding and technical expertise. This appears to be the overwhelming reason why many surgeons do not use them. Whilst it possible for a surgeon to place a smooth or textured implant too high at surgery and expect to ‘get away with it’ in the knowledge that such implants are likely to ‘drop’ or ‘settle’, such an approach is not possible with PU foam covered silicone implants. Such implants must be placed absolutely precisely at surgery as they will stay in that position and will not ‘drop’ or ‘settle’.
As a result of the above considerations, I counsel my patients very carefully as to the thought processes they ought take into account when selecting implant type.
Irrespective of implant type used, swelling will usually take of the order of 6-8 weeks to resolve for the majority. This can be assisted by use of a proper surgical support bra, which I give to all of my patients. Only after that period should a patient be measured for new bras in order to be confident that her new size will not significantly change further.
What are the signs of capsular contraction? What else can go wrong with implants and what are the signs patients should look out for?
The body reacts to placement of a breast implant as a ‘foreign body’ by walling it off through formation of a scar. This scar is known as a capsule, which then separates the body from the implant. It is quite normal and occurs in every instance. However, in a proportion of cases, the capsule subsequently contracts and becomes distorted and thickened. This may be felt by the patient as an uncomfortable hardening around the implant which can ultimately become an unattractive, tennis-ball like structure on the chest wall and require further surgery. This is the commonest complication of breast augmentation and the key to its avoidance is wise selection of breast implant type.
Long term follow up data has shown that smooth and textured implants typically develop capsular contractures at a rate of around 20% (1 in 5). That contrasts with PolyUrethane-foam-covered implants in which the rate is vastly reduced at around 2% (1 in 50). Given that knowledge, when selecting breast implant type, a patient ought consider whether they would be prepared to purchase any other product which had a known 20% (1 in 5) chance of being problematic within a relatively short timeframe and in this instance, that will require further surgery. If the answer is ‘no’, then consideration should be given as to why they would do so for something they are choosing to have implanted into their body? Viewed through that prism, in my opinion, the wise answer becomes self-evident. See http://northeastplasticsurgery.com.au/articles/capsular-contracture-commonest-complication-breast-implants/ for an example of surgery undertaken to deal with capsular contracture following breast augmentation using textured implants.
Whilst current breast implants are considered safe, given that by definition they are all made from material foreign to the body, a multitude of things can go wrong with them. These include but are not limited to capsular contracture (by far the commonest complication – see above) along with infection, rupture, rotation and BIA-ALCL (see below).
What is Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and should patients be concerned?
As current Censor in Chief of the Australasian College of Cosmetic Surgery (ACCS), I am a member of the ACCS’ BIA-ALCL Safety Committee. As such, I was invited to be part of the team from the ACCS that contributed to the meeting of the Expert Advisory Panel of the Therapeutic Goods Administration in Sydney, November 2016. Read the advice published thereafter at https://www.tga.gov.au/alert/breast-implants-and-anaplastic-large-cell-lymphoma.
In addition, read the ACCS’ statement dated 20 December 2016.
Which surgeon should you choose to undertake your breast augmentation surgery?
Patients should only choose their surgeon after having undergone at least two consultations to establish not only a comfortable relationship but also to satisfy themselves regarding their background, training, knowledge, experience and surgical expertise in cosmetic surgery. Plastic surgical training may not necessarily include cosmetic surgical training and patients should always ask their plastic surgeon about their credentials and experience and whether they have undertaken specific training in cosmetic surgery and have appropriate subsequent experience. An honest answer may often surprise.
As a British Specialist Plastic and Reconstructive Surgeon, I undertook specific training in cosmetic surgery at the McIndoe Surgical Centre, on the site of the Queen Victoria Hospital, East Grinstead, one of the founding historic units of plastic surgery dating from the Second World War. I now practice such surgery in Australia – read more at http://northeastplasticsurgery.com.au/melbourne/.
I also undertook specific postgraduate education in cosmetic surgery and as a consequence was awarded in 2013 a Master of Science in Aesthetic Surgery degree with Distinction from the University of London. This is a rare international qualification, to my knowledge not held by any other plastic surgeon in Australia. My thesis in facelift surgery was undertaken with Dr Bryan Mendelson in Melbourne, world renowned facial aesthetic plastic surgeon.
It is also important for patients to establish how their proposed surgeon operates – will they be just ‘a number’ on an operating list of many or does the surgeon operate a bespoke practice that proactively limits the number of operations on any one operating list to ensure the patient receives the best possible surgery from a fresh mind and body? Finally, ask about the degree of aftercare offered and guarantee that you will be looked after should any revisional surgery be necessary.
I practice cosmetic surgery in Melbourne and Brisbane and my special interest and focus is the clinical practice of aesthetic facial and breast surgery. Read more about my background at https://www.plasticsurgeryhub.com.au/dr-patrick-tansley-london-melbourne-brisbane/. I am a Fellow, Councillor and current Censor in Chief (CIC) of the Australasian College of Cosmetic Surgery. In this role, I oversee the training and qualification of Australian trainees in cosmetic surgery. The ACCS is the only surgical College in Australia to offer a dedicated training program in such surgery.
Bespoke reconstructive & aesthetic plastic surgery & MediClinic.