Contemporary plastic surgery Creating beautiful breasts

Today we are producing an interview done with Dr. Shashanka Rathnayake, Consultant Plastic and Reconstruction Surgeon attached to the Teaching Hospital, Kandy, with regard to contemporary plastic surgery.  

Excerpts:

QWhat are the types of plastic surgeries done for the breasts?

The breasts are considered as the most beautiful sexual organ in females. Since It is an integral part of the beauty of a woman, aesthetic improvement of breast appearance definitely enhances the beauty of a woman. 

When considering the beauty of the breast we need to consider the size, symmetry, nipple position, nipple size and the shape of the breast. Although big breast may be appreciated as beautiful or attractive, from an aesthetic perspective the size of the breasts should be in proportion to the body configuration. On the other hand, in our country the number of women requesting breast size reduction by surgery would be more than the number requesting breast size augmentation or increase in size. 

Q How do you talk about breast size in females?

When we discuss about the breast size it is important to mention about the bra cup size rather than the total chest circumference. Although the total chest circumference is a representation of the size of the breast it is difficult to have an objective idea about the breast and what size we are going to achieve after surgery. Therefore, the client should have an understanding about the cup size of the breast to agree on a size augmentation or a reduction. 

Plastic surgeons can change the cup size of the breast up or down depending on the client’s requirement and clinical requirement. As I mentioned it is very important to understand the concept of relative body proportions. The ideal body aesthetics will be manifested only when this concept is respected. Sometimes it is a bit hard to convince the concept of appropriate size of the breast to some clients as they expect unrealistic and unacceptable size change.

QHow can you increase the size of the breast?

Breast augmentation is a commonly requested surgery in the west. It is usually done by inserting appropriate size implant under the breast. In addition, there is increasing enthusiasm in breast size increase with fat grafting. However, the fat grafting is in the process of establishing as a modality of breast augmentation since results are not very predictable. The proportion of the fat injected to the breast will remain in the breast to a variable degree but promises can’t be made. 

In our country woman are a little slow to think about breast augmentation or increase in size by a surgical procedure when it is highly required. It may be due to several reasons. Mostly, it may be the cost as breast implants are very costly. One implant would cost about LKR 60,000 to 95,000. However, cost is lesser in Sri Lanka compared to the other countries. In addition, the woman in our country are not really updated about the subject. They may think that the breast implants would cause much problems and are cancer producing.  They may also think that it gives an unnatural consistency and artificial look. 

Actually, there had been problems with saline implants and silicone implants. However, the modern technology and research has been able to overcome the past problems in relation to the breast implants and the new implants are serving the purpose for past 10 years without any problem. In addition, the reputed companies manufacturing the breast implants are giving a warranty on the breast implants and if there is a technical failure for some reason they would replace the breast implant and an insurance scheme would cover the hospital charges of implant exchange. 

The breast implants would increase the volume of the breast and the size would be given in milliliters. There are two main types of breast implants, round implants and anatomical implants. The round implants would inflate the size of the breast uniformly. It would not cause any problem even though the implants rotate due to handling. However, aesthetically superior outcome can be achieved by the anatomical implants although there is a rare risk of distortion of breast shape due to rotation of the implant. 

QHow do you insert these implants under the breast? Does the procedure leave a big scar?

The surgical procedure of inserting the implant is done in two main ways. One is through a small incision under the breast and axilla. Second is sub-mammary or under the breast incision which is commonly performed and is hardly visible. Most of the plastic surgeons like this incision as the outcome of the surgery is predictable and technically easy. However, the axillary incision is more popular and literally there is no scar after sometime. However, it is technically demanding.

Q How do you reduce the size of the breast?

Frequently ladies come and request breast reduction surgery. Sometimes they have become patients of neck pain and backache due to heavy breasts. The enlargement of breast to a disproportionate size could happen after pregnancy. It also could happen to the young females also without a pregnancy due to hormonal imbalances. There are surgical procedures to reduce the size of the breast by removing a part of the breast and reshaping it. It is not only reducing and reshaping but also repositioning the nipple position. 

The change in the nipple position of the female breast is called breast ptosis, which  usually happens in the middle age and with the enlargement of the breast during pregnancy. The repositioning of the nipple to the ideal position is part of the breast reduction surgery and it would improve the aesthetic appearance of the breast. 

The breast is a glandular organ and it is not a fat filled fashionable bag. Therefore, liposuction cannot be used to reduce the size of the breast although lipo-injection could be used to increase the size of the breast.

QWhat are the other types of breast aesthetic surgery done for females?

With the ageing process some women would suffer reduction of the breast volume and severe breast ptosis. The nipple position is way beyond and gives a very old look to the breast. This also happens when a previously obese woman undergoes massive weight reduction due to dietary control or bariatric surgical procedure. 

In some of these patients the appearance of breast could be brought to a pleasing state only by changing the nipple position to a higher level. This is called mammopexy and the existing breast volume should be adequate to get a good outcome. 

In some patients the breast volume is not adequate with the breast ptosis. Therefore, we have to do a mammopexy and augmentation simultaneously. In massive weight loss patients, there is lot of excess skin and loss of breast volume as well. In these patients it would be required to reduce the excessive skin by appropriate excision and augmentation with an appropriate implant. The procedure is called augmentation mammoplasty. 

QCan you help congenital breast deformities through plastic surgery?

Certainly we could! Some women are born with breast asymmetry. The asymmetry could be very severe to mild degree. Sometimes there could be a severe abnormality of the chest wall and its muscles of one side. One of these problems are seen in Poland syndrome where there is unilateral deficiency of development of chest wall muscles and chest wall. These patients could be helped with breast reconstruction procedures. They involve using muscles at the back and swinging them to the front and reconstructing a breast using prosthesis. It is also possible to correct minor deformities of the breast size, shape and nipple inversion. 

QCan you explain the breast reconstruction procedures done for breast cancer patients?

Female breast could become her own enemy and take her life away. There are breast screening programs done via breast clinics to early detect breast cancer. However, in women with strong family history the genetic risk of breast cancer could be assessed by a genetic testing of the gene status of BRCA 1 and BRCA 2 genes. It is available for Sri Lankan also but in the private sector. This nature of health seeking behaviour have not become popular in our country due to unknown reason. However, in the west the women with strong family history definitely undergo genetic screening and if it becomes positive would undergo prophylactic or preventive bilateral mastectomy (Removal of both breasts) and reconstruction of bilateral breasts by swinging a muscle from the back and using an implant. I am sure that these kinds of surgery would be performed frequently in the future. 

What is happening in Sri Lanka at the moment is breast reconstruction as a delayed procedure for early breast cancer patients. This could be done using the patient’s tummy fat pad or using an implant under a muscle flap. Currently, the use of tummy fat pad as a free flap technique (Microvascular surgical technique using the operating microscope) is the gold standard for breast reconstruction. However, most of the breast reconstructions done in Sri Lanka with tummy fat pad is performed as a pedicle flap technique as the involvement of the plastic surgeons is less. I think it is high time to move to standard technique since the expertise is available in all teaching hospitals of Sri Lanka. 

Q Are there surgical treatments for enlarged male breast? 

Males also could suffer from breast problems. The commonest problem of male breast is gynaecomastia or enlargement of male breast which would look like a female breast. It is common among the adolescent age nowadays. It is due to a hormonal imbalance. However, it is difficult to be treated with drugs. Usually there is excessive fat deposition and small amount of glandular enlargement. It is possible to suck out the excessive fat tissue by liposuction and excise the excessive glandular tissue with almost invisible scar. The old technique is to remove enlarged male breast with incision around areola. It is quite obsolete and unacceptable now due to the scar and asymmetry of the male breast after surgery.