Exchange of Implants

1. want smaller breasts
2. want larger breasts
3. have capsular contracture affecting one or both breast implants
4. have an implant rupture in one or both breast implants
5. have had larger breasts in the past that have deflated following weight loss &/or pregnancy – sometimes this requires an uplift (Mastopexy)
6. are worried about possible safety notifications regarding the type of implant they currently have inserted (e.g. P.I.P. implant scandal of 2011)
7. want to improve self-image and esteem

Breast implants are either round or anatomical (tear drop) in shape, comprised of an outer silicone shell filled with either silicone gel, Silicone gel and borosilicate microspheres (B-lite) or saline (physiological salty water). Round implants are a good choice if you have sufficient breast tissue to give you a good shape, whereas teardrop (anatomical) implants are a good choice if you have little or no breast tissue and need to create the shape of the breast mound.

Implants can either have a smooth or a textured surface – a textured surface is the most common implant surface used outside the U.S.A. There is currently much discussion over the surface texture of implants and its relation to a blood cancer (Anaplastic Large Cell Lymphoma or BIA-ALCL) – the current data suggests a lower incidence with smooth implants.

Gel filled implants are the most commonly used variety. The silicone gel used in most implants today is cohesive (gel-like) – so should the implant rupture, the silicone doesn’t run out everywhere. Saline filled implants are less commonly used outside of the U.S.A. They do not feel as ‘realistic’ and have a propensity to leak slowly, resulting in deflation and the rippling of the silicone shell with possible wrinkles that can be both felt and visible.

Implants are manufactured to last a lifetime (most come with a lifetime guarantee against rupture) and, unless there are problems with the implant, there is no need to replace them after a fixed period of time. This said, it is recommended that you have imaging (Ultrasound or MRI) roughly every ten years to confirm they haven’t ruptured.

The size of your replacement implants is dependent upon several factors, all of which will be discussed with you during your consultation(s). These include:

• the size of implants you already have in-situ – it is helpful if you bring this information with you to clinic
• The kind of ‘look’ you are after with your new implants
• The dimensions of your chest
• Amount of redundant tissue you have that requires filling – often

In clinic a range of sizes will be recommended based upon the above factors. If you are wanting larger implants you will be asked to perform the ‘rice test’ at home (see separate sheet) – this will provide us with a ball-park figure of how much extra volume you would like adding to your current implant volume.

The ultimate decision is yours – Mr Davis is there to simply advise and guide you.

The implants used by Mr Davis are manufactured by  Motiva and B-lite (up to 30% lighter) but happy to use Mentor – Mr Davis has no affiliation to any of these manufacturers, and those used are subject to change in the future should something not currently known come to light. Mr Davis has never used PIP implants nor implanted Allergan implants.

When you are required to have a mammogram as part of the national breast cancer screening program, or for any other reason, please notify the radiographer that you have implants in place and have had fat grafting (if applicable) – they will then perform a displacement view enabling the breast tissue to be seen. There is no evidence that having a breast implant reduces the ability to detect breast cancer.

The operation is carried out under a General Anaesthetic (you are asleep) and takes roughly one-to-two hours.

Usually your old incision scars are excised and access gained through the resulting wound. It is usual that the pocket your implants are situated in (on top of/under your muscle) will not be changed unless clinically indicated. Implants are inserted using a Keller funnel® (one of many measures employed by Mr Davis to minimise possible contamination of the implant). It is normal that you will be able to go home the same day.

You will be required to wear a non-underwired post-surgical support bra (Mr Davis advocates LipoElastic® garments) for a period of at least six weeks.

You will be encouraged to shower one day after surgery, however you are to dab your breasts dry, let them dry naturally or to use your hairdryer on a cool setting to blow them dry – you are NOT to rub your breasts for one month after surgery.

After two weeks you will be asked to apply moisturiser over your scar on a daily basis for a period of three months.

You will come for a wound check one week after your surgery and return to see Mr Davis in clinic between six and ten weeks after surgery – earlier if required. Further follow-ups will be arranged as necessary.

Bleeding & Haematoma
Bleeding can occur at any time in the first 10 days or so after the surgery so you should therefore avoid any trauma to your breast area and avoid strenuous exercise or anything that is causing your breasts to be moving vigorously in any direction. Where possible, arm movements should be limited in the first week.

Your breast will usually become swollen and tender with a bleed and may develop bruising – if this occurs you should return for review as you may require a return to the operating theatre to explore and stop any bleeding vessel(s)and remove any blood.

Seroma
This is a collection of clear/pale yellow fluid that essentially leaks and collects from the tissues as part of the normal reaction to surgery/injury. This nearly always resorbs over a period of weeks, but is occasionally large enough to warrant it being aspirated with a needle and syringe in clinic.

Infection
Whilst not common, should it occur your breasts may be swollen, red, warm/hot and tender – not to be confused with the inflammation of healing. You may also feel unwell in yourself. This is treated with a 5-to-7 day course of oral antibiotics. Very occasionally an infection can result in part(s) of the wound coming apart – this is managed by a regular change of dressings and showering, and will be allowed to heal by itself over the subsequent four-to-six weeks.

Swelling &/or bruising
Swelling will almost certainly occur naturally and can take months to fully settle down. Bruising can be treated, unless contraindicated, with the use of Arnica or other such products should you wish.

DVT/P.E.
Very occasionally a blood clot may form in one of the deep blood vessels in the leg (Deep Vein Thrombosis). Blood clots have the potential to break bits off that can travel up to the lungs resulting in a pulmonary embolus. As a way of reducing the risk you will be required to wear compression(TED) stockings on your legs from admission on the day of surgery until 2 weeks after surgery. You will also be encouraged to keep as mobile as is possible and to stay well hydrated.

Scars
Scars are by definition permanent, so will always be there. Initially scars can be red and with time should fade through pink to ultimately be pale and flat. Occasionally scars can become hypertrophic or keloid whereby they are raised, red, lumpy, itchy and unsightly or can stretch to become wider.

Altered nipple sensation – numb or over-sensitive
The nerves supplying the nipple areolar complex can be damaged during the surgery resulting in your nipple(s) feeling numb after surgery. This usually recovers with time, however permanent loss of or reduced sensation can happen. Ever so occasionally the nipple can become oversensitive.

Inability to breast feed
It is not uncommon to be unable to breast feed after a breast uplift as the milk ducts and/or nerve supply to them is interfered with when relocating the breast tissue.

Altered breast sensation/numbness
As per the nipple, nerve damage can occur to the nerves supplying the skin over the breast. This is usually temporary but can occasionally be permanent, resulting in numb skin.

Nipple loss – full or partial
Just as the nerves to the nipple can be damaged, so can the blood vessels that supply and keep the nipple areolar complex alive. Damage to these can result in some (partial) or all (full) of the nipple and areolar being lost.

Asymmetry
No two breasts are ever completely symmetrical – they are “sisters not twins”. Despite best efforts to make the breasts as symmetrical as is possible, minor asymmetries will remain after surgery. Very occasionally a notable asymmetry can occur that requires further surgery to adjust volume, shape or nipple position.

Fat necrosis &/or lumpiness
When the breast tissue is mobilised its blood supply can become compromised, as per the nipple, resulting in some fat and breast tissue dying off (necrosing). This presents itself as a firm lump or lumpiness within the breast, and will usually settle by itself over the subsequent months. Very occasionally the old liquid fat can discharge itself through a hole in the scar/wound, requiring regular dressings until it settle sand heals itself. Very occasionally the fat will calcify requiring further surgery to excise it.

Skin necrosis
Very rarely the blood supply to the skin of the breast can be compromised resulting in skin dying – this is most common at the T-junction where the vertical element of the scar meets the horizontal aspect of the scar in your breast crease. This is managed, should it occur, with dressings until healed. Very occasionally the scar requires revising.

Wound breakdown
Very occasionally some of the wound can come apart for a multitude of reasons. This is almost always small enough to manage conservatively with dressings, allowing nature time to heal the area. Should any scar that forms be unsightly or an issue then this can always be revised at a later date, often under a local anaesthetic such as those used by the Dentists if putting your teeth to sleep for a filling etc.

‘Dog ears’
These are little areas of skin and underlying fat/tissue that cause skin at the ends of your scars to sit a little proud. Often these settle with time and massage however occasionally they require removing under a local anaesthetic.

Implant displacement/rotation/extrusion
Despite making a pocket to fit the implant you have chosen, with time the implants can move position, more commonly when under the muscle &/or with smooth implants, thereby changing the distribution of volume and shape of your breast(s). Rotation of the implant is not an issue with round implants however with anatomical (tear drop) implants if the implant should rotate then the volume of the implant will be in the wrong position and result in distortion of the shape and/or volume distribution of your breast(s). Implant extrusion can happen if your wounds come open during the healing phase and a part of the implant becomes exposed. Very rarely this can happen years down the line where the tissues stretch and become weaker, eventually opening up at the scar line. Should this occur you will require a return to theatre to wash the breast pocket and implant out before repairing the open wound.

Implant rippling, folds and palpable edges
Implants are not completely filled with gel otherwise they would become too firm and unnatural. As a result of the slight under-filling the implant shell can form small folds or ripples that can be felt and sometimes seen through the skin and breast tissues. Placing the implants under the muscle can help to cover this, however with time as the breast soft-tissues stretch and become thinner and the muscle becomes thinner as the use of it is less once disturbed by an implant underneath it, this initial benefit becomes less and less. No matter whether you have an implant over or under the muscle, the implant edge +/- rippling is nearly always felt at the inferior margin where the breast crease is. Should palpable edges, rippling and folds in an implant be an issue then fat grafting over the top of the implant can often help cover this over.

Implant rupture
Although manufacturers guarantee their implants for life against rupture, one must accept that just like anything else machine and man-made, a small percentage are going to fail and rupture. Rupture can be as a result of multiple factors. It usually presents with your breast swelling and enlarging and/or the shape of your breast changing. Following clinical examination, you will usually be sent for a scan and if rupture confirmed it is recommended that you have the implant(s) removed or exchanged.

Capsular contracture
The body’s immune system recognises that the implant does not belong to it, however it is too large to be able to destroy it so it does the next best thing and builds a wall around it, encapsulates it, in order to ‘control & contain’ any potential problems the implant could cause the body. We call this wall a ‘Capsule’. For the most part you will not be aware that the capsule is there, however with time the capsule can become firm – this is not an indication to have anything done. The capsule can also start to contract, resulting in a change in shape of the implant and often the overlying breast. It can also cause pain. If you have a change in shape and/or pain these are the indications to have your implant(s) exchanged or removed completely.

BIA-ALCL
Breast Implant Associated – Anaplastic Large Cell Lymphoma is a rare blood type cancer that has become associated with having breast implants in. The theories of why it happens are to do with possible low grade infection and to do with the texturing of the implants – this will all be discussed with you in clinic, but data is always being updated as we learn more about this. Regular updates can be found on www.fda.gov and www.associationofbreastsurgery.org

BIA-ALCL most commonly presents between 8 & 10 years of having implants put in (reports are between 1 & 20 years) and is often represented by a spontaneous, painless swelling of the breast, although lumps, a rash and or pain can be presenting symptoms and signs. If the diagnosis is made, then the treatment is removal of the implant and surrounding capsule – this is often curative. Some patients have required chemotherapy and to date, 9 women have died from this condition.

The current lifetime risk ranges from 1:3000 to 1:30,000 depending upon the range of implants used.

Double-bubble deformity
If you have heavy breasts or the bulk of your breast tissue is located lower down your chest wall, then when an implant is placed the breast tissue will invariably fall off the top of the implant creating a so-called “double-bubble” effect – you have the mound of the breast implant with the breast tissue sagging off the bottom. This more commonly happens when the implants are placed under the muscle, but can occur when placed on-top of the muscle.

Future ptosis & ‘Bottoming out’
If you add weight to your breasts you are giving gravity more to work with so the resulting droop of your breasts will occur quicker than if you had no implants/extra volume and weight in place. The skin and soft tissues of your lower half of your breast can also stretch disproportionately resulting in implants dropping and too much volume being under your nipple-areolar complex – this is known as ‘bottoming out’. Similarly, just as the weight of your breasts combined with the help of gravity may have caused the skin and ligaments supporting your breasts to stretch and droop down or position themselves lower on your chest before a lift &/or reduction, these forces are still at work after your surgery with the remaining breast tissues.

The best way to combat this and prolong your results in all cases is to wear good, strong, well manufactured support bras as much as is possible. I advocate the use of LipoElastic® garments.

Visible veins/stretch marks
Any veins or stretchmarks on your breast can be magnified and thus become more obvious when the breast is stretched over the underlying implant.

Further surgery in the future
This is likely to incur more costs