Here at The STAIANO Clinic we have developed the ’10 Step Process For Choosing Your Ideal Breast Implant’ because there are a vast array of techniques, types of implants and opinions about breast implants and we see a lot of confusion out there.
The operative time is shorter than the other methods of breast reconstruction and there are no extra scars.
However, there are drawbacks. If the implant becomes exposed or infected, then it will need to be removed, although it may be replaced later.
If capsular contracture occurs, then you may choose to have the capsule removed and the implant exchanged. If there has been radiotherapy to the chest wall, then the formation of the capsule is accelerated and so implant only reconstructions are not recommended if radiotherapy has been given or is planned.
There is a limitation to the size of implant that can be used based on the diameter of the chest wall and so implant reconstructions are best suited to patients with small breasts.
One of the other drawbacks of implant reconstruction is the lack of ptosis or droop. This means that there may be some asymmetries when out of a bra, with the reconstructed breast not moving and the other breast having a natural flow. For this reason, a patient with small breasts needing a bilateral breast reconstruction is an ideal candidate for implants.
When reconstructing the breast with an implant, the implant is placed underneath the pectoralis major muscle so that it has some extra soft tissue covering it.
This space may be tight and so an expandable implant may be used. These have an injection port that can be gradually inflated in the outpatient department on a weekly basis for 3-6 weeks.
While you can find plenty of information on the internet, it is not filtered or verified, so it can be hard to know what to believe.
There is no substitute for an in-person consultation with a Consultant Plastic Surgeon who can measure your frame, assess your current breast size and shape and work with you to ensure that you choose the implant that will achieve your goals.
Having specialised in breast augmentation since 2007, I have developed a pathway that will guide you through the complexities and simplify the process to ensure that you choose the ideal breast implants for you.
STEP 1: DOWNLOAD OUR FREE GUIDE WITH INFORMATION AND PRICES
If you are in the research phase, then the first step is to get our guide with information about pricing and finance plans as well as frequently asked questions and tips about what you should be looking out for when choosing a plastic surgeon.
If you have any specific questions or concerns, then I do a Live Q&A every Tuesday on our Facebook, Instagram and YouTube channels, so you can either send me a question beforehand or ask me live on the night.
STEP 2: ARRANGE A 15 MINUTE CHAT WITH ONE OF OUR SURGEONS (optional)
If you don’t feel ready to commit to coming for a full consultation, you can arrange a 15 minute call with one of our surgeons to go over all of your questions and talk about any concerns you may have. We offer ‘virtual consultations’ that can be held by video call or phone and can be booked online. There is a £35 charge for these calls, however, if you would prefer to go straight to a full consultation, then you can purchase a ‘clinic passport’ and get unlimited access to the clinic.
STEP 3: GET A CLINIC PASSPORT AND COME FOR A CONSULTATION
Your ‘Clinic Passport’ is a unique system that we have developed that allows you unlimited access to the clinic to go over your proposed treatment with your surgeon as often as you need. In fact, we encourage you to come back for at least one more consultation after the initial one because it is always helpful to go over things.
You will also be able to email us or call us if you have any questions and we have a Private Facebook Group open to anyone who has been to the clinic where you can share your hopes and fears and ask a question without fear of the whole word seeing it.
STEP 4: OVER OR UNDER THE MUSCLE
In the old days patients would not really be aware whether the implant was put under or over the muscle but these days you are much more informed and likely to be involved in this decision.
As with anything in life, any time there are different ways of doing things there will always be pros and cons of each.
When talking about putting the implant under or over the muscle we are referring to the pectoralis major muscle (your pec) which is a large fan shaped muscle that has a narrow insertion up by your shoulder and then fans out across your chest to have a wide attachment along your breast bone and lower ribs.
The benefit of putting the implant on top of the muscle is that it is less painful because the muscle is not divided and it does not bleed as much so the recovery is quicker.
Also the implant sits with the breast which is preferable.
The opposite is true when the implant is placed under the muscle because when the muscle is divided, it hurts when you move and there is more risk of bleeding and so recovery is slower.
Furthermore the muscle can sometimes hold the implant high and can sometimes pull the implants wide to give an abnormally wide cleavage. There is also a risk of ‘animation deformity’ which means if you exercise your arms and your pec muscles, your breast might move as the implant moves underneath the muscle.
The benefit of putting the implant underneath the muscle is that the muscle will cover the implant in the upper part which means there is less risk that you may be able to feel the edges of the implant and less risk that you will be able to see visible rippling of the implant. You should note that even when the implants are placed under the muscle, they are not covered by muscle in the lower part or to the side and so there is still a risk of rippling or being able to feel the edge in these areas.
Another benefit of putting the implant under the muscle is that capsular contracture ,which is when the implant becomes hard, is felt later on because the muscle gives a layer of padding over the top of the implant.
We make the decision based on a balance of the risks:
Under – pros: less rippling*, less capsular contracture, less feeling the edge*
Cons – more post op discomfort, increased risk of bleeding (haematoma), implants may sit high or wide, risk of animation deformity
Over – pros: quicker recovery, implants sit with the breast and less likely to sit high or wide
Cons – more likely to feel edges and more likely to see rippling in slimmer patients, capsular contracture appears sooner
*the muscle covers the implant in the upper medial part in the cleavage area (you may still be able to feel the edge or see rippling in the lower outer part)
STEP 5: CHOOSE THE IMPLANT THAT FITS YOUR DIMENSIONS – THE TRIDENT APPROACH
This is often the focus of most patients who are considering breast implants – which implant do I choose?
Over the years of putting in countless breast implants, I have developed a way to ensure that you choose the implant that will suit your frame and match your expectations.
…and one thing that I have learned is that it is not all about the size!
THE TRIDENT APPROACH allows us to help you to choose an implant based on the dimensions of your frame and the look that you are trying to achieve, rather than making you pick a volume of implant based on your best friend’s experience or someone you saw on the internet.
The Trident Approach, takes a 3 Prong strategy and involves:
The base diameter of your breasts is the single most important dimension when deciding on an implant. It is a set measurement and one that you cannot change and it will dictate the size and shape of implant that you can have that will ‘fit’ your frame.
Many patients will spend a long time agonising of what size they would like, when in fact the decision is not only about the size and the aim of using the sizers is to get a ballpark estimate of the sort of volume that you are trying to achieve.
We always ask ‘what cup size would you like to be?’ but will then be quick to point out that we cannot guarantee any particular cup size as cup sizes are not a precise science.
The sizers will give you a better idea of what the different volumes can achieve in terms of an increase of the volume in your bra, but they will not give you that much of an idea of what sort of shape you can hope to achieve.
Implants come in two shapes – round and teardrop
…and in different profiles – low, moderate, high and extra high (these names vary between makes)
The before and after photos will give you an idea of what sort of ‘look’ you are trying to achieve.
It is important to remember that you have to add the implant to your current breast shape and so it is not as simple as saying that round implants give a fake look and teardrop implants give a natural look.
It depends on how much breast tissue that you have before you start and it depends on the profile of the implant that you choose.
It is possible to get a natural result with a round implant.
When you have an idea of the shape and profile of implant that you would like and we have measured the base width of your breast, then you will usually have the choice of only a handful of implants.
Using The Trident Approach, it often boils down to quite a narrow choice of implants and it is not as daunting as it may seem at first.
We encourage patients to come back for at least a second consultation and maybe even a third and fourth because it is important to be comfortable with your implant selection.
We don’t want you to feel pressured in to making a decision, which is why, once you have purchased your ‘Clinic Passport’, you will be welcome back to the clinic as often as you need so that you can be sure that you are making the right choice about the size, shape and profile of implant that is right for you.
STEP 6: CHOOSE THE TYPE OF IMPLANT
There are a variety of different types of implants on the market and they all have their strengths and weaknesses.
Everybody wants to have the ‘best’ implant but the fact is that there are pros and cons of all of them, otherwise we would all be using one type.
Unlike many clinics, we are not tied to any particular make or manufacturer of breast implant and so we are free to use any type of implant as long as the hospital is able to get hold of it.
A breast implant is made up of a shell and contents and the different types of implants that are available are as follows:
Saline – saline implants are filled with salt water rather than silicone gel and saline implants are not commonly used in the UK.
Pros – some patients feel that they do not want to have any silicone implanted in their body (although saline implants still have a silicone shell).
if the implant leaks it is just salt water that leaks out, which is easily absorbed by the body.
they can be inserted empty and filled during the operation allowing a smaller scar (can even be placed through a small scar in the belly button – TUBA or transumbilical breast augmentation)
Cons – more likely to ‘deflate’ over time
more likely to have visible rippling and so usually need to be placed under the muscle
not available in the teardrop shape
Silicone – the majority of breast implants that we use in the UK are filled with silicone gel.
Pros – silicone gel is made to feel similar to the consistency of natural breast tissue and can give a better ‘feel’
the gel is called ‘cohesive gel’ and has a firm consistency known as ‘form stable’ or ‘gummy bear’, which means that it does not leak liquid silicone if the shell ruptures and will keep its shape. It is safer in the event of implant rupture, although the implants can feel a bit firmer than the older, more liquid silicone implants
Cons – some patients feel that having silicone in their body makes them feel ill (known as breast implant illness), although in these cases, it may be best to avoid breast implants all together.
The main difference between breast implants is the shell of the implant and it relates to how rough it is. They range from a completely smooth shell (smooth implants) to a very rough shell (polyurethane foam implants) with micro and macrotextured implants in between.
Smooth Implants – this is how implants were first made back in the 1960’s and these have a glassy smooth surface. They were found to have a risk of rippling and of going hard (capsular contracture) and it was found that by making the surface of the implant rough, it would break up the scar tissue that forms around the implant and make it less likely to contract and go hard. However, more recently, there has been a very rare cancer associated with breast implants called Breast Implant Associated – Anaplastic Large Cell Lymphoma (BIA-ALCL) and this seems to be related to the roughness of the implants and so does not occur with smooth implants.
Pros – less risk of BIA-ALCL
Cons – increased risk of rippling
increased risk of capsular contracture
no teardrop shape – there is no adherence between the implant and the pocket which means that there is no teardrop shape available for smooth implants (although they do tend to settle in to a teardrop shape when in the body)
Microtextured implants – these are relatively new implants and fill the gap between traditional macrotextured silicone implants and smooth implants. The surface is gently roughened. In the classification of implants, they are classified as smooth but they have a slightly roughened surface in order to give some of the benefits of the textured surface while still being classified as ‘smooth’
Pros – slight roughness to the surface may reduce the risk of capsular contracture
may be seen as a compromise between completely smooth and traditional (macro)textured implants
Cons – relatively new on the market
no teardrop shape (although come in a less cohesive type which is more likely to settle in to a teardrop shape when in the body)
Macrotextured Implants – these have probably been the most common type of breast implant used in the UK. They have a roughened (textured) surface which helps the implant to adhere to the surrounding breast tissue and reduces the risk of capsular contracture. However, it is this roughened surface that has been implicated in the development of the cancer, BIA-ALCL
Pros – textured surface offers better adherence
less chance of capsular contracture (compared with smooth or microtextured)
Cons – increased risk of BIA-ALCL
more chance of capsular contracture (compared with polyurethane foam implants)
Polyurethane Foam Implants – these implants have been around since the 1960s but have had a controversial history. They have the lowest rate of capsular contracture of all implants and integrate with the breast tissue securely and so are less likely to migrate or rotate.
However, a by-product of the polyurethane (2,4 TDA) was found to cause cancer in rats and so these implants were not used in the UK for a long time. However, they continued to be used in other parts of the world and this cancer has never been found in humans.
More recently, polyurethane foam implants have been implicated in BIA-ALCL as it seems that this rare cancer which occurs in the capsule around the breast implants (it is not breast cancer) seems to more common in implicated in implants with a rougher surface and polyurethane implants have the roughest surface of them all.
Pros – low risk of capsular contracture
low risk of migration or rotation
Cons – increased risk of BIA-ALCL
theoretical risk of cancer caused in rats
| Rippling | Capsular Contracture | ALCL | |
| Smooth Implants | ++++ | ++++ | + |
| Microtextured Silicone Implants | +++ | +++ | ++ |
| Macrotextured Silicone Implants | ++ | ++ | +++ |
| Polyurethane Foam Implants | + | + | ++++ |
STEP 7: GA OR TWILIGHT?
There is a choice of the type of anaesthetic that you have for your breast augmentation.
Traditionally, it would be done under a general anaesthetic (GA) but more recently, the use of Twilight anaesthetic has become more popular.
GA
General anaesthetic involves being put to sleep. It requires the involvement of an experienced anaesthetist and the use of an anaesthetic machine.
You will not be aware of anything during your procedure and you will ‘wake up’ in the recovery room when it is all over.
During the procedure you will have a tube in your mouth that will be helping you breath and this may occasionally leave you with a sore throat.
When you wake up, you sometimes feel groggy and disorientated and you may feel nauseated. This feeling can last some hours and occasionally may last for days.
Surgery is usually done as a day case, but if you have a General Anaesthetic, you may prefer to stay in hospital overnight and go home the next day.
Twilight
Surgery can be done under local anaesthetic with sedation which is also known as Twilight Anaesthetic. This has the benefit of a quicker recovery time and less of a ‘hangover’ feeling. It means that you will be able to go home on the same day as the surgery.
The downside is that you may be more ‘aware’ of the procedure and you may feel some discomfort.
Some people think that because it says local anaesthetic, that they will be awake and responsive during the procedure, however, the sedation is such that you are usually quite drowsy and often lapse into periods of sleep.
STEP 8: COOLING OFF
We believe strongly in giving patients the time and the space that they need to make a decision.
You will never experience any ‘hard sell’ or pressure from us to go ahead with surgery or to make any decisions about your implants.
We realise that this is a major life decision and should not be rushed.
We offer all of our patients at least one follow up appointment before surgery to go over things and sometimes patients will come back several times just to be sure – we encourage this.
In fact, we insist on a ‘cooling off’ period of at least two weeks between your consultation and your surgery so that you can be sure that this is the right thing for you.
One of our founding values is that we will ‘do the right thing’ and this means that we will treat you like a patient, not a customer.
If you are not sure, or need more time to decide, then we will postpone your surgery until you are completely happy, no problem.
STEP 9: OPERATION DAY
On the day of your surgery, you will be admitted to your private en suite room in one of our partner Private Hospitals.
You will have the opportunity to meet with your anaesthetist prior to your procedure and your surgeon will ‘mark you’ with surgical marker and take photographs.
We aim to bring you in to hospital 1-2 hours prior to your procedure so that you can be settled and comfortable in your room before going to theatre in a relaxed and calm way.
You will receive a complimentary ‘STAIANO’ gown and be looked after by your named nurse.
You will be given your postoperative advice sheet with the do’s and don’ts as well as what to expect in the postoperative period. You will also have the contact details of The Clinic for any questions or concerns following your procedure as well as the 24 hour emergency contact details of the hospital for any out of hours problems.
STEP 10: YOUR AFTERCARE
One of the founding principles of The STAIANO Clinic and one of the main reasons that I set The Clinic up in the first place, was that I believe that your aftercare is as important as your surgery.
I will often see patients spend time and energy doing their research but they are usually researching the wrong thing.
The focus is on the surgery and all too often, it is the size of the implant, test this in itself will not have a dramatic effect on your outcome
…it is much more important to think of the shape and dimensions of the implant to make sure that it will fit and compliment your frame and your figure
…in fact, more important than that, is to research your surgeon to make sure that they are fully trained and appropriately qualified to perform your procedure. If your implants are not placed correctly, then you are not going to be happy with your result no matter how much time and energy you have spent in choosing the size and shape.
Finally, it is the aftercare that is often neglected when patients are researching having breast implants.
All too often, I am contacted by people who have recently had surgery elsewhere and the have a problem or a query about their surgery.
My advice is always the same – you should talk to your surgeon as they will be best placed to advise you.
When performing surgery, we have a duty of care to look after you.
A significant portion of our week involves seeing our patients at every stage after their procedure to make sure that everything is on track.
Often there will be niggles, bumps, asymmetries, or scars that are a bit red and raised. These things will almost certainly settle and the result that you get at 6 or 12 months is often unrecognisable from the result that you see at 6 or 12 days!
A large part of the service that we offer is to make you feel listened to and looked after.
This involves giving you access to the clinic for advice and support as often as you need. Our success is built on word of mouth, which means that we pledge to,
‘do everything that we can to ensure you get the best result possible’
The one-stage procedure involves the use of an adjustable implant, which is placed underneath the skin and pectoralis major muscle (the pec). The aim is to get as complete a muscle coverage as possible to minimise the risk of visible or palpable knuckles or ripples (rippling) in the implant.
These implants are composed of silicone gel with a central chamber that can be inflated with saline, usually through a remote port. The port is attached to the implant with a tube and is placed underneath the skin where it can be easily accessed and inflated with a needle and syringe (often in the armpit).
Once the implant has reached the desired volume, the injection port can be removed with a short operation under local anaesthetic.
My preference is to perform the operation in two stages. The first stage involves putting in an tissue expander to stretch the skin and the second stage involves replacing the expander with a fixed volume implant. Expansion of the implant is done through and injection port, which is usually part of the implant itself. You may be given a magnet to bring with you to the outpatient clinic to aid location of the metal port lying underneath the skin. The implant can then be inflated a small needle and syringe.
This has the advantage over the one-stage technique of allowing adjustments to the breast pocket in the second stage, such as repositioning the implant or redefining the inframammary fold. It has the disadvantage of needing two operations.
Strattice® is a material that allows a one stage reconstruction without the need for any tissue expansion. This is because tissue expanders are used, not to expand the skin (there is enough skin available in an immediate reconstruction) but to expand the muscle. When an implant is used for breast reconstruction, it is put underneath the pectoralis major muscle to give an extra layer of protection between the implant and the skin.
When Stattice® is used, the lower edge of the muscle can be divided to allow a larger volume implant of a fixed volume to be placed and a piece of Strattice® is used to cover the exposed lower pole of the implant.
This has the advantage of avoiding repeated visits to clinic to expand the implant and it also avoids the second stage procedure to replace the expander for an implant.
The major stages of the one or two-stage procedure are performed under a general anaesthetic and you will have at least one overnight stay. You may stay for 3-5 days if the reconstruction is done at the same time as mastectomy (immediate reconstruction) and a drain is used.
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