Breast augmentation with implants

After some unsuccessful attempts at the beginning of the last century, the real story of breast implants began in the 1960s, spurred on by two American surgeons Frank Gerow and Thomas Cronin. In 1962 they developed an implant formed of an envelope and filled with a silicone gel. This new implant had a clear and rapid success. After a period of optimism, it had to be admitted though that the result was often very disappointing; the breast often had a fixed, unnatural shape, it was too firm and sometimes even frankly distorted. Additionally, a real shell formed around the implant. During the 1970s and 80s, the consistency and texture of breast implants was regularly changed and the shell problem seemed to be resolved, or at least in part. A controversy broke out in the 1990s, calling into question the use of silicone. Cases of autoimmune diseases were attributed (wrongly) to breast implants, which led to the ban on silicone implants in 1994. This ban was lifted in 2001. From 1994 to 2001, however, the only authorized implants were filled not with silicone but saline.

Any reference to breast implants unfortunately brings to mind the famous PIP breast implant scandal. What should you know about it?

Poly Implant Prosthesis (PIP) was a company founded in the 1990s by Jean Claude Mas in the south of France and which had been manufacturing breast implants since the 2000s. The company went into liquidation in 2010. At the time of the peak of its glory, the company was 3rd in the world in the production of breast implants. It exported 80% of its production outside France (especially to developing countries in South America or Eastern Europe). 300,000 women are said to have had PIP implants fitted. The first complaints from patients and surgeons date from 2005 and began to be regular from 2008. It was, however, necessary to wait until 2010 for the French Health Products Safety Agency (AFSSAPS) to sound the alarm and for Jean Claude Mas to be summoned to court.

He was sentenced to 4 years in prison in 2013 and given a 75,000 euro fine for fraud and aggravated deception as well a lifetime ban on exercising a professional activity related to health. At the start of 2014, 30,000 implants had already been removed with a total risk of failure estimated at 25% and more than 2,000 women had filed complaints in France. The failure of the implants was due to the presence inside some of them of an artisanal silicone gel that did not comply with traditional health standards and was strictly prohibited in a medical device. This gel was inserted inside the implants in a concealed manner, presumably for financial reasons (the artisanal gel being cheaper than the gel conforming to sanitary standards). This artisanal gel present in some of the PIP implants (but not all) caused a progressive degradation of the implant’s shell, leading to its rupture. It was introduced fraudulently inside the implants in a more or less random manner.

A CE certification marking fraud was also clearly established, the data being masked and falsified by PIP. The implants appeared to be standard because they were CE marked and the selling price of the PIP implants was paradoxically identical, or even more expensive, than other brands of breast implants.

The main risk of the PIP implants came from the possibility of the silicone shell rupturing, which lead to the release into the body of the gel whose exact ingredients were not clearly established (it was variable from one implant to another). From asymptomatic rupture to more severe inflammatory reactions, everything could be seen. Even cases of suspected breast cancer (about 8 to 20 out of 1,200 PIP implants) have been described, although it is difficult to link the PIP gel directly given the high prevalence of breast cancer in the general population (one in 9 women).

The AFSSAPS currently recommends that all women with a PIP implant benefit from a clinical and radiological examination, that any suspected rupture or proven rupture of the breast implant be managed surgically, and that preventive explantation (without signs of rupture) is discussed. The health insurance system covers all the costs (removal and replacement of the implants) in the case of initial reconstructive surgery (breast reconstruction after cancer, etc.) and the costs of removing implants as part of cosmetic surgery (breast augmentation for aesthetic reasons). On the other hand, the fitting of new implants is the responsibility of the patient, being an aesthetic procedure.

These are the types of breast implants currently available :

• round or anatomical or asymmetrical or made to measure (shape)
• smooth, microtextured, textured or macrotextured (shell)
• filled with silicone gel, saline, hydrogel or polyurethane (filling)
• low profile (or projection), intermediate or medium, high, extra high (volume and size)
• cohesive, flexible, firm, double gel (touch)
• from different brands (Allergan, Sebbin, Cereplast, Eurosilicone, Perouse, Arion, Mentor, Mac Ghan, etc.)

It can therefore be complicated to find your way around all this various information and so I will explain what all these different types of implants correspond to.

Round breast prostheses are the most used in the world in cosmetic surgery and represent more than 80% of the market. In most cases they give excellent aesthetic results. Indeed, thanks to the new relatively flexible cohesive silicone gel, the round prosthesis, once in the vertical position, does not remain round but takes the shape of a pear (but less than with an anatomical implant) with a lower segment more rounded than the upper segment. This was not the case with the older generations of round implants. In patients with a breast outline with a small glandular volume or a larger base volume, these implants give very good results. Unlike anatomical implants, they do not present any risk of rotation.

Anatomical implants are the first line choice in cases of breast reconstruction after mastectomy (removal of the breast due to cancer). The breast volume being zero, only a pear-shaped implant, called an anatomical implant, can help restore a natural breast appearance. In cosmetic surgery, anatomical implants are only used in 20% of cases on average, but their place is becoming more and more important from year to year in patients with very little breast base. Anatomical breast implants have a natural shape, reproducing the shape of a normal, pear-shaped breast (more than with a round implant). The upper part of the implant is gently sloping so as not to create a too bulging and artificial appearance of the bust and the lower part of the breast implant is more projected. The silicone inside the prosthesis has a shape “memory”. The main risk of anatomical breast implants is rotation of the implant. Since the anaplastic large-cell lymphoma (ALCL) scandal, anatomical implants, which are mostly macrotextured to avoid rotation, have hardly been used any more.

Asymmetrical prostheses (in height or width) are not used in cosmetic surgery. I only use them in certain complex cases of breast reconstruction or rare chest malformations where it is not possible to use conventional round or anatomical breast implants.

Finally, custom breast implants are rigid silicone prostheses whose exact dimensions are calculated using a 3-dimensional scanner. Given the wide range of implants from different manufacturers, they are of no interest today in cosmetic surgery and are only used in cases of thoracic reconstruction (Poland syndrome, pectus excavatum, pectus carinatum) with significant associated dysmorphism of the bone structure (ribs, sternum). Their price is very high (several thousand euros) and their texture is unnatural.

For round breast implants, two elements must be taken into account: the base of the implant (its diameter) which will define the width and height of the breast and its projection (profile). The base of the implant averages 10 to 14 cm. The profile of a breast implant defines its projection, i.e. its thickness. There are low, medium or intermediate profiles, as well as high and extra high. The larger the profile, the more the breast will be projected forward and the neckline plunging. Choosing a high or extra high profile implant automatically leads to a voluminous and unnatural appearance of the breast that most patients do not want. A breast augmentation should remain natural. To obtain a natural result and benefit from the effect of the round implant which, under the effects of gravity, takes the form of a pear in the vertical position, it is better to choose a low or intermediate profile.

The volume of breast implant is given in cc and deducted from these 2 measurements: base and projection. Often patients only talk about the volume of their prosthesis (260 cc, 300 cc, 410 cc etc.) but you should know that for a surgeon this volume does not correspond to much, it is necessary to just carry out the following calculation to understand why:

• a large prosthesis of 12.1 cm base and 3.8 cm projection (intermediate profile) makes a volume of 300 cc
• a large prosthesis of 10.5 cm base and 5.5 cm projection (high profile) has a volume of 300 cc

The volume of the 2 breast implants is identical (300cc) yet the shape is completely different. In the first case, the breast will be large and not very projected, with a natural aspect and in the second case the breasts will be very wide apart and very projected, giving the appearance of very artificial breast growth. The notion of volume is therefore relative. You should know that a volume of 200 cc corresponds to approximately an increase of one size of bra cup. This gives a useful estimate of the gain obtained.

For anatomical breast implants, three elements must be taken into account: the base (or width), the height and the projection. Breast augmentation can be compared to made-to-measure tailoring because the range of anatomical breast implants available is so high and it is essential to have recourse to a surgeon who is used to placing them because the technique of installation is more delicate than with round implants; the slightest malposition of the implant can be seen and the risk of rotation is not negligible. The rest is comparable to round implants (low, medium, high profiles).

Anatomical breast implants have the following advantages: very natural results, a pear-shaped breast, slightly rounded upper pole, well-curved lower pole, gently sloping neckline, choice of almost “made-to-measure” prosthesis, firm gel, rare folds, natural appearance to the touch, and shape memory gel.

As regards the drawbacks, mention should be made of the risk of rotation, the macrotextured nature with a risk of ALCL and the absence of significant volume in the bust (no plunging neckline).

Round breast implants have the following advantages: natural results with the new flexible gels and low or medium profiles if a sufficient volume of breast is present at the base, a flexible breast to the touch, a plump cleavage if desired, and no risk of rotation.

The disadvantages are as follows: the risk of a less natural result in the event of very high projection and low breast volume at the base.

For the aesthetic indications it is necessary to remember for the anatomical prostheses:

• thin patient with very small breast volume
• significant increase in volume without a too bulging neckline

For round implants :

• almost all other cases

Wishes of the patient :

• pear shape, natural: anatomical or round, low or intermediate profile
• plunging neckline: round intermediate or high profile
• no breast at all, small breast augmentation desired: anatomical
• low breast volume, light or medium augmentation: round low or intermediate profile, sometimes anatomical.
• significant increase, domed bust: round intermediate or high profile
• significant augmentation, barely visible neckline: anatomical or intermediate round.

In all cases, only your surgeon will be able to say whether, depending on your morphology (gland thickness, width of the thorax, quality of the skin, position of the areolas, visibility of the ribs, muscle strength, possible asymmetry, etc.) if round breast implants will allow a natural result, or if it is necessary to opt for an anatomical breast implant (not less given the problem of the texturing of anatomical prostheses). As always, it is the relationship of trust between patient and doctor, which will allow choosing the right method to get as close as possible to the desired result. I commonly use the 2 types of implants, round or anatomical, depending on the case and the patient’s wishes.

The vast majority of serious and international scientific studies agree on one point: microtextured implants pose less of a shell risk than other implants. With the exception of implants placed in a strict retropectoral position (behind the pectoralis major muscle) where a smooth prosthesis seems suitable but presents a risk of ascent to be taken into account. Macrotextured implants could be associated with a theoretical (although extremely rare) risk of anaplastic large-cell lymphoma (ALCL) and, due to this theoretical risk, it has not been recommended to use them since 2019. They have now been largely withdrawn from the market and therefore only smooth or nanotextured implants are used in France.

The cohesive silicone gel breast implant always has a firm appearance when used as an anatomical implant. For round implants the gel can be flexible or firm. Soft gel has the following advantages: very natural palpation, and pear shape in an upright position. The firmer the gel, the more the breast is bulged at the neckline and the bust firm on palpation. Generally a soft gel cohesive silicone implant is preferred for its natural feel.

Breast implants in saline solution (salt water, inert in the body) are almost no longer used today, except in rare special cases or when patients specifically ask for it. From 1994 to 2001, silicone was banned in France (due to the fear of autoimmune diseases, which is currently refuted) and only the saline implants were authorized. Since 2001, few cosmetic surgeons still use them (less than 5%). In practice, Dr. Masson does not use saline implants except in exceptional cases.

There are three advantages to implants filled with saline solution which can be described.

First advantage, in the case of the breast implant rupturing, there is no leakage of silicone from the shell. This was especially true when the implants were filled with liquid silicone. Since breast implants are now filled with cohesive silicone gel, this is no longer the case. In addition, paradoxically, the implant shell for saline implants most often contains silicone …

Second advantage, the saline implants are placed when empty and inflated in situ by the surgeon. The scar is thus smaller. With the new techniques for placing silicone implants and flexible silicone, this is also less true than in the past.

Finally, the third advantage is that the volume of saline added to each prosthesis is controlled directly by the surgeon. In the event of any asymmetry, therefore, it is theoretically easy to overinflate one side more than the other in order to correct it. In practice, given the huge choice of sizes of silicone gel breast implants available on the market, this is no longer relevant.

Regarding the drawbacks, we should mention an aspect of being very unnatural to the touch (like a balloon filled with water), the significant firmness of the implant, the presence of waves and inevitable folds over the years – especially in a forward leaning position on small-starting breasts, a gradual deflation of the implants which can sometimes even be brutal (in just a few days, which can cause big problems in the event of a unilateral rupture!), rupture and leaks concerning the inflation valve and, finally, the lifespan of the implant which rarely exceeds 10 years (although rare cases with more than 25 years of follow-up have been described). The disadvantages are therefore not negligible.

The only indication of breast augmentation by saline breast implants which could still be relevant today are implants being placed in the retromuscular position in patients who already had a significant volume of breast before the intervention and also in those who categorically refuse silicone gel implants.

Breast implants pre-filled with cohesive silicone gel today concern the vast majority of patients. The palpation of the silicone gel implant offers a natural effect which is pleasant to the touch. Silicone gel does not contraindicate pregnancy or subsequent breastfeeding. It is not the cause of autoimmune diseases, cancer or rheumatic disease. Finally, the lifespan of these breast implants is greater than that of saline implants.

For these reasons, most plastic surgeons today use breast implants filled with silicone gel and not saline for breast augmentation surgery.

Hydrogel-filled breast implants are used very little, if at all. They have existed since 1996 and only one type has been approved in France since 2005. Carboxymethylcellulose hydrogel (CMC) is an aqueous, viscoelastic and biodegradable gel. The consistency of these implants is close to that of silicone gel breast implants and the product contained in them is biodegradable. They are therefore an attractive prospect, at least on paper. Their average lifespan is a little less than 10 years (like saline implants and a little less than silicone). A significant inflammatory response to the rupture of these hydrogel implants has been described in several cases. Due to the very low number of patients undergoing breast augmentation by hydrogel prostheses (and this despite the age of the product), it is difficult to conduct scientific studies with a high level of evidence, unlike silicone gel or saline breast implants. For these reasons, the vast majority of cosmetic surgeons do not use this type of implant, whether in France, Europe or around the world.

The first polyurethane breast implants were manufactured in the 1960s. They were used a lot from the beginning of the 2000s, then with the ALCL risk stories in 2019 they were almost no longer used anywhere and were completely withdrawn from the market in many countries. These are breast implants made of a cohesive silicone gel that is covered with an outer shell of polyurethane foam. There are round, anatomical and conical shapes. The polyurethane layer triggers the formation of multiple microcapsules around the breast implant rather than a smooth membrane as with other implants.

The advantages of this type of implant are the very low risk of periprosthetic shell (less than 1%), the almost zero risk of rotation in the case of an anatomically shaped implant, the possibility of treating light ptosis without any scar other than that of the implants with forms of conical implants and a velcro effect which prevents secondary ptosis of the breast (breast sagging over the years).

The peculiarities are the firmness of the breasts in the first year, the ideally submammary scar to place the implant, the almost prerequisite premuscular position of the implant and the much higher price.

Numerous scientific studies confirm the advantages of these polyurethane breast implants in case of shell issues. However, most of these implants have been withdrawn from the French market since 2019 due to the rare but possible risk of ALCL.

There are 5 possibilities:

• submammary scar
• scar under the areola
• scar across the areola
• scar in the armpit
• scar in the navel

The submammary scar is the most widely practiced scar in the world. It is located in the submammary groove, is horizontal, and measures 3 to 5 cm depending on the size of the implants. It is located in a natural fold and a shadow area, especially in the case of a sagging breast (ptosis), and is most often very discreet. Its advantages are as follows: less shell, less hematoma, less infection, better visibility for the surgeon, possibility of placing implants of any volume, including large and dual plane, breastfeeding possible, and no sensory disturbance of the areola. There is also no technical difficulty for the subsequent implant change. Among the disadvantages, we should mention: a potentially visible scar if the submammary groove is not well marked, associated ptosis difficult to correct if significant, the scar is potentially visible in broad daylight when lying down.

The subareolar scar is the most practiced in France although increasingly less and less today. It is located just under the areola and represents half of a circle (lower periareolar scar). In cases where the areola is pigmented and well rounded, it is almost invisible. Its advantages are as follows: the scar is normally very discreet, there is the possibility of correcting a relatively large associated ptosis by carrying out, in addition, a scar all around the areola (Round Block) and also the possibility of using the dual plane technique. Among the disadvantages are: sensory disturbances in the area of the areola (but which disappear in a few months), a risk of infection and raised shell according to some studies, breastfeeding impossible in some (rare) cases, and no possibility of posing large breast implants if the areolas are too small.

The transareolar route (through the areola) has the same advantages and disadvantages as the subareolar route and gives very comparable aesthetic results.

The axillary route (under the arm, in the armpit). The scar is located in a fold under the arm, where the hair is. It does requires prior hair removal. The advantages are as follows: speed of the intervention, a possibility of endoscopic control, no scar on the breast and a very discreet scar under the arm, no sensory disorder in the areola. Disadvantages: sometimes the scar is visible in a tank top or swimsuit, at least for the first few months, difficulties in using the same scar during a subsequent change of implant, difficulties in placing implants of large volume, a theoretically increased risk of infection (from sweating), risk of larger hematoma, possibility of ascension or displacement of the implant, risk of rotation in the case of anatomical implants, the implants can only be in the retro-muscular position and there are potential difficulties in interpreting scintigraphy analysis of the sentinel node in the event of breast cancer . In practice, you should know that this scar for placing breast implants is no longer used much in 2019.

The umbilical route (through the navel). Nicknamed TUBA (trans-umbilical breast augmentation). This is in fact an anecdotal technique and very little used. Only saline implants can be used and introduced using an endoscopic system. The interest is as follows: an absence of any scar on the breasts and only in the navel. In practice though, given the usual discretion of breast augmentation scars, whether under the breast, at the areola or under the arm, the interest seems less given the list of drawbacks associated with this approach. The disadvantages include: length of the intervention, specific equipment needed, it is an extremely rare procedure which is performed very little and surgeons are therefore not familiar with it, the implant has to be saline, it is almost impossible to control bleeding during the surgery, there is a risk of perforation of certain vital organs on the way between the navel and the breasts (heart, spleen, liver, lungs), an eventual change of implant using the same scar is almost impossible, no correction of associated ptosis is possible, there are very few cases performed and therefore very few scientific studies on this technique, and finally there is a theoretically significant risk of infection (the navel is a known area for carrying staphylococci).

In practice, the first three ways to remember are as follows: the submammary route, i.e. in the groove under the breast (the most used approach in the world), the areolar route, whether under the areola or in transverse (the most used approach in France) and the axillary route (under the arm in the armpit).

The choice of the position of the scar depends on your morphology and the breast implant chosen and can only be done in consultation with your surgeon.

The size of the implants is decided in consultation. It is difficult to get an idea of ​​volume by looking at photos because each case is unique. The base of the breast can be more or less wide, the height of the breasts also, the thickness of the tissues (skin, fat, mammary gland, muscle) is also not the same from one patient to another. Likewise, an implant of equivalent volume can be very wide and not very projected (low profile) or not very wide and very projected (high profile). The volume is the same but the results completely different.

In consultation, it is important to spend time trying out the different sizes of breast implants in front of a mirror in order to get an idea of ​​the volume and the shape you want. Your surgeon is there to advise you.

Dr. Masson is the first surgeon in 2020 to be equipped with software (EVE 4.0) which allows you to take a 3D capture of your breast, carry out all the volume measurements and present the result of your breast augmentation on a screen using augmented virtual reality.

The size of the implants is decided in consultation. It is difficult to get an idea of ​​volume by looking at photos because each case is unique. The base of the breast can be more or less wide, the height of the breasts also, the thickness of the tissues (skin, fat, mammary gland, muscle) is also not the same from one patient to another. Likewise, an implant of equivalent volume can be very wide and not very projected (low profile) or not very wide and very projected (high profile). The volume is the same but the results completely different.

In consultation, it is important to spend time trying out the different sizes of breast implants in front of a mirror in order to get an idea of ​​the volume and the shape you want. Your surgeon is there to advise you.

The breast is successively composed from the surface towards the interior of:

• Skin
• cell tissue under the skin
• Cooper’s ligaments
• adipoglandular tissue (fat and mammary glands)
• pectoralis major muscle
• pectoralis minor muscle
• ribs that form the rib cage

The breast implant can be placed in 3 different planes:

• In a retroglandular or premuscular location, i.e. in front of the pectoralis major muscle (or behind the mammary glands).
• In a retromuscular location, i.e. behind the pectoralis major muscle.
• Using the dual plane, biplane or double plane technique, i.e. both behind and in front of the muscles.

The retroglandular (premuscular) position:

Benefits :

• A less painful intervention
• less risk of displacement of the breast implant and more natural appearance if the breast is already of a certain volume
• little risk of rotation when using an anatomically-shaped breast implant
• no change in breast shape due to contraction of the pectoral muscles

Disadvantages:

• An unnatural aspect to the bust if round implants are being used because the implant is directly under the skin and the gland; there is a risk of a round appearance to the breast, like a “tennis ball”.
• The contours of the breast implant are sometimes noticeable to the touch, especially if it is of not very cohesive flexible silicone gel .
• A possible fold visibility
• An inevitable breast ptosis (sagging) over the years due to the weight of the implant which relaxes the skin, especially if it is thin or stretched.

The retromuscular position:

Benefits :

• little visible aspect to the implant because it is deeper and hidden behind the muscle (fewer folds)
• less noticeable contours of the implant because it is behind the muscle
• no breast ptosis over time because the implant is held by the muscle
• Statistically less capsular contracture or capsulitis

Disadvantages:

• A risk of displacement of the implant during the first few weeks (contractions of the muscle causing the prosthesis to rise upwards)
• Deformation of the implant under the effect of muscle contractions, especially in sports patients
• A high risk of rotation with anatomical implants
• A risk of breast ptosis on the implant which does not move over the years (implant maintained by the muscle and the breast descends upon it).
• more severe pain in the first few days after surgery

Breast augmentation by dual plane technique

This is a recent technique which combines both the retromuscular position (the top of the implant is hidden behind the muscle) and the premuscular position (the bottom of the breast implant is hidden behind the mammary gland).

The dual plane maintains the advantages of the two techniques and eliminates a large number of the disadvantages.

The results are natural and the evolution of the shape of the breast over the years seems better.

It seems to me that specific training for this specialized technique is necessary.

Advantages of the dual plane:

• less painful recovery than with retromuscular
• Implant camouflaged behind the muscle in the neckline so a more natural appearance
• no descent of the implant downwards over time as with the premuscular route because the implant is held up by the muscle.
• less palpable implant contours and less visible folds
• possibility of using a round or anatomical implant
• less deformation of the breast implant during contraction of the pectoral muscle

In my opinion, this is the modern breast enlargement technique that gives the best results today.

CE marking is compulsory for breast implants to be marketed in Europe. The standards are now very strict and must be applied by all the laboratories manufacturing implants. Many manufacturers today share the European market. I only work with the 2 largest manufacturers of breast implants in the world (each with a world-wide reputation). The costs are slightly higher, but I refuse to use brands of implants that engage in price competition. There should be no low cost options in cosmetic surgery, especially in the field of implantable materials.

In cases where the breast lacks volume but where the skin is relaxed, and where the breast sags (breast ptosis), it is necessary to use a technique different from the conventional breast augmentation techniques. Otherwise the breast will certainly be larger than before but sagging and therefore unsightly.

In cases of moderate ptosis, the dual plan technique can correct it without an additional scar. In cases of more significant ptosis though, it will be necessary to associate a periareolar scar (round block technique), a vertical (most often) and sometimes an under breast scar (in T). The intervention combines a ptosis correction (breast lift) with breast augmentation (breast implants).

An alternative to fitting a breast prosthesis is to perform lipofilling. Liposuction is performed in places where the fat is in excess. The fat is purified by filtering or centrifugation and then reinjected into the breast. The fat that is taken remains permanently. However, you often need to plan two lipofilling sessions to obtain a volume equivalent to that of a breast implant.

This is a strictly prohibited and illegal practice in France since 2011! The risks are major: infections, granulomas, disturbance of mammograms, obstruction of breast cancer screening, fistulization of the skin etc. No French surgeon should perform this intervention today.

This is a new and very attractive technique. The principle of composite breast augmentation is to combine breast augmentation by implant, which allows a certain curve, volume and hold to the breasts and, in addition, performing lipofilling in order to camouflage the contours and feel of the implant and thus to get an even more natural result. The volume obtained is greater and the breast firmer than with a lipofilling alone.

Two consultations with the cosmetic surgeon are necessary and a consultation with the anesthesiologist. A blood test is needed. A possible Imaging examination (ultrasound, mammography). A compression bra need to be purchased. A week to 15 days off work needs to be planned for after the operation. You will need to stop smoking at least 3 weeks before. No aspirin should be taken for 10 days before (risk of bleeding).

A blood test is often prescribed by the surgeon or anesthesiologist and adapted to your medical history. Often prescribed: CBC (check for anemia), TP / TCA (check for bleeding coagulation disorder), Blood group (in case of hematoma and transfusion), HIV and hepatitis tests (reduces risk contamination).

In practice however you should know that for a young patient with no medical history, theoretically, no blood test is strictly mandatory. That said, as it is cosmetic surgery, and therefore not urgent or essential, it is more reasonable to carry out a blood test.

A mammogram, possibly supplemented by a breast ultrasound is recommended after 35 years of age. In practice, given the high risk of breast cancer in the general population (one in 8 women) even in young patients, I think it is important to carry out systematic screening before cosmetic breast surgery. Each year, out of a hundred breast enlargements, I detect one or two breast cancers in patients under 35 years of age.

In developed countries, anesthesia for breast enhancement surgery has to be general. Some exceptional cases of breast implant changes can be done under local anesthesia with sedation, but this is extremely rare.

The duration of the operation varies from 45 minutes to 2 hours, on average it takes 1 hour.

The hospital stay is short, usually the patient enters the same day for surgery and is discharged the next morning. Some cases can take place in a day clinic or as outpatient surgery (entry in the morning and exit in the evening). This requires that you live close to where you are operated and are not alone the first night.

Pain is very variable from one patient to another. From least painful to most painful are: the premuscular position, the dual plane, and the retromuscular position of the implant. The larger the size of implant, the more painful the recovery. As a rule, pain is intense for the first 2 or 3 days and then gradually decreases over a week to 10 days. Fortunately painkillers are prescribed and are very effective in combating the pain.

Certain cases of agenesis of the mammary glands or severe hypoplasia (complete absence of breast) may, upon the advice of a public health insurance doctor and with prior agreement with the social security system be covered, at least partially.

The breasts are firm and swollen for the first few days, then gradually become more flexible and mobile. Bruises may be present for the first 15 days. The pain is relieved by analgesics and is present for the first 10 days. The compression bra must be worn day and night for 4 to 6 weeks. It is only removed for showering. The dressings have to be redone every day after disinfecting the scar for 10 days then a healing cream must be applied every day for a month or two on the scars. The sutures are absorbable (there is no need to remove them). The carrying of heavy loads is to be avoided for the first 15 days. Time off work of at least a week is advised. Sport can be resumed after 1 to 2 months depending on the activity (one month for running, two months for weight training or contact sports).

The result is visible immediately but will become definite after about 3 months when the swelling subsides, the skin softens and the tissues heal. The scars themselves are definitive after 1 year.

Breast prostheses placed behind the muscle or in dual plane tend to move upwards the first few weeks after the operation, hence the need to wear a bra with a compression band (or a breast wrap) for 4 to 6 weeks afterwards. For breast implants placed in the premuscular position, the bra makes it possible to limit breast movement and therefore limit pain as well.

The bra or breast wrap are to be worn night and day and only removed for a shower.

Among the complications to be aware of, it is important to mention:

• anesthesia accidents
• hematoma the first few hours after surgery (often requiring repeat surgery)
• infection (which can lead to the breast implants being removed)
• scar problems (favored by tobacco use and diabetes)
• sensitivity disorders (often transient)
• phlebitis or pulmonary embolism (rare)
• some rare cases of anaplastic large-cell lymphoma (ALCL) which have been described since 2008 and studied since 2011 (promoting role of macrotextured surfaces? genetic factors? local microbiology?). The risk is estimated to be 1 in 100,000. Annual monitoring is essential.
• lymphatic effusion (seroma) around the implants, early or late
• periprosthetic shell (reaction of the body to the implant where a breast becomes hard and painful with a deformation of the implant in important cases: adhesive capsulitis), often requiring a change of implant and a capsulectomy. Occurring early (weeks afterwards) or late (several years later). Learn more about implant shells.
• implant folds or deformations (skinny patients, flexible prostheses)
• displacement of the implant or rotation (anatomical implants)
• implant rupture
• Information sheet from SOFCPRE (the French society for reconstructive and aesthetic plastic surgery) concerning breast implants (breast augmentation with implants)
• Information for women planning breast augmentation with implants (the Ministry of Health and Solidarity)

Having breast implants in no way disrupts pregnancy and is in no way harmful to the child.

Breastfeeding is not contraindicated for patients with breast implants and is most often possible.

It is advisable to wait at least 6 months after pregnancy or after breastfeeding before considering breast augmentation.

Likewise, it is recommended to wait at least 6 months after placing breast implants before considering a pregnancy. However, be aware that gaining more weight than normal during pregnancy and relatively prolonged breastfeeding can have an impact on the aesthetic results.

No scientific study is in favor of an increase in the rate of breast cancer or autoimmune disease in patients with breast implants, despite decades of experience in practice. The incidence of breast cancer and autoimmune disease is the same for patients with breast implants as it is for the general population. Note a few rare cases of anaplastic large-cell lymphoma (ALCL) described since 2008 and studied since 2011 (promoting role of macrotextured surfaces? Genetic factors? Local microbiology?). Annual monitoring is essential and a consultation is necessary in front of abnormal signs such as enlargement of the breast, redness, and unusual pain. The use of macrotextured implants seems that it should be prohibited and microtextured implants have been withdrawn from the market as a precaution in 2019.

350,000 women are said to have had breast implants in France. According to the ANSM (French National Agency for Medicines and Health Products Safety) in 2014, the rupture rate is very low, ranging from 0.01 to 0.3% depending on the duration of implantation. These complications occur on average 7.6 years after installation. This is why the lifespan of implants is time-limited. On average, the lifespan is ten years. Other incidents described over the long term are hard shell formation, folds, waves, rotation, seromas, silicone perspiration, and breast ptosis. In any case, it should be understood that the lifespan of the implants is not infinite, they will probably one day have to be changed, either because the size will no longer be suitable, the shape of the breast will have changed, the shell will have become visible or because the implant will have ruptured. It is not normally a case of urgency to change the implant but, in any case, it is important to have a checkup with your plastic surgeon every year.