Hello there, it's James Southwell-Keely from Woollahra Health and Beauty, we're the big blue building on Edgecliff Road just down the hill from [inaudible 00:00:19] Junction, train station, bus stop, et cetera. Love to see you. Today, we're talking about breast augmentation surgery, it's a hot topic, it always is. It is, in fact, the most common plastic surgery, cosmetic plastic surgery procedure performed in Australia and around the world.

Now it's actually a very hot topic at the moment, more so than usual because of the recent discovery of atypical large cell lymphoma, which is a type of tumor that can be found in the capsule, the scar tissue that forms around the impact but we'll touch up on that later in this discussion. Now, we're talking about the breast in this series. We're going to do a series of talks about different aspects of cosmetic breast recon surgery as well as reconstructive breast surgery.
As a small addendum here, plastic surgery covers both cosmetic and reconstructive elements to the surgical pathway. We'll be leaning more towards the cosmetic in this series of talks but we'll definitely be touching upon the reconstructive aspects of breast surgery as well. Why do patients have breast surgery? It's a really interesting question. Obviously, there's the necessary breast surgery we have for obstructed ducts, cancers, lumps and bumps, et cetera, but there's the cosmetic as well.

The reasons that patients have cosmetic surgery are many and varied. We'll kick through those right away but first of all, what different types of surgery do I perform and what different types of cosmetic breast surgery exists out there? We have straight out augmentation which increases the size, the volume, and improves the shape of breast. Then there's reduction surgery where you have large breasts and wish to be smaller. Following on from that is a breast lift operation where it's more about the shape, improving the shape and lifting the nipple areola complexes back more towards the position they once occupied in your youth.

There's a mixture of an augmentation and a breast lift where you need a combination of increased volume as well as an elevation of the nipple areola complex. There are, of course, combinations of all of the above for breast asymmetries, maybe one side of your chest wall is over-developed relative to the other or maybe you have an underlying asymmetry in your chest wall so the rib cage is receded on one side and overly projecting on the other, for instance. Definitely, asymmetry is a big reason to do, undertake reconstructive and/or cosmetic breast surgery.

Finally and equally importantly, is reconstructive breast, so surgery for patients who've had mastectomies and wish to restore their normal physiology so that they fit back into their clothes the way they once did and feel whole again and good about themselves. That's really, really important and an incredibly satisfying part of my work, I must admit.

Let's talk then about the different motivations that patients will undertake augmentation breast surgery, so that's to increase the volume and improve the shape of one's breast. These are listed in no apparent order and come from person observation and discussion with patients but also looking on the internet and just seeing what different patients are asking. There's an incredible consistency in these questions that are asked.

The first is, and probably most importantly, self-esteem. Patients feel that they are some way deficient and the augmentation surgery makes them feel more whole, more comfortable in their own skin. There are lots of different reasons for that motivation but it's a very successful operation in terms of addressing that issue.

Next is asymmetry, we've touched upon that in the introduction that sometimes one breast will develop into a D cup size and the other breast will develop into a B cup size. This makes purchasing clothing very difficult, patients are very self-conscious about this down at the beach or in the gym change room and it can really hamper one's social development and people feel very stigmatized in this situation.

Following on from that, there are different congenital problems where patients are born with an under-developed breast or tubular breast or constricted breast. They're all similar conditions and all the same condition, different names but there are variations on that asymmetry, with increasing levels of asymmetry or difference in size and shape between right and left breast. Attending to these and making them look as close as possible to one another can be very challenging surgery but, once again, incredibly satisfying, where for me, surgeon, and for the patient.

Next is a reduction in size of one's breast. This is another reason patients come to surgeons requesting breast [inaudible 00:05:07] surgery. There's a phone in the background, it's probably a patient now inquiring about some of these procedures we're talking about now. Here we go, a reduction in size, how does this happen? It could happen with significant weight loss, just as you've lost weight from your waist and your hips so too you lose weight from the breast. 50-70% of your breast volume is made up of fat and tissue and it's metabolically active. As you lose weight from this part of your body so too do you lose weight from the breast.

With this loss of weight you lose volume, like a deflated tire or a balloon that's losing its air and they become saggy. Accompanying that reduction in volume, you have a redundancy or an excess of skin and the nipple areola complex or the nipple [inaudible 00:05:52] of that starts drooping down towards the ground. To restore the shape and volume of one's breast, breast augmentation in and of itself is sometimes enough, and sometimes we need to combine that with a lift operation.

We've touched upon mastectomy and restoring a patient's feeling of wholeness after cancer surgery, that's a very important reason for using breast implants. It's not an augmentation, per se. Whilst we use similar techniques, the procedure is actually quite different. The risk profile is quite different and the follow-up is quite different. In essence, we're using the same technologies to effect the same result and that's ultimately patient satisfaction and a feeling of restoration of oneself.

Patients come asking about ... It touches upon their self-confidence and self-esteem issues but they feel that they are inadequate before the eyes of their partner. An indirect effect of the benefit from the breast augmentation surgery is the improvement of one's sex life.

Now, this is a little bit esoteric and obviously has never been proven but it's certainly something that pops up time and time again on the internet forums and patients discuss this with me in my room so it can't be neglected as an obvious motivation for such surgery. On the whole, I think it's more about feeling confident in your own skin and if there's something you've lost or have been born without making you whole again, and so you can live a happy and fulfilled life.

Now, let's go back to what I mentioned right at the introduction and that's this atypical large cell lymphoma. It was on the television last night, Tracy Greenshaw presented on this on A Current Affair. It's been in the newspapers statewide and nationwide recently and it's certainly been in scientific publications quite frequently over the last five to 10 years. It seems to be building a head of steam, we seem to be learning more and more about this condition as the years go by and further research is undertaken. In fact, a lot of that research is coming out of Australia and specifically out of Sydney. We're very proud of that, to be at the forefront of the inquiry and investigation of this rare yet emerging condition.

What we learn today is as follows, it tends to occur in textured implants. Now, the reason that we use textured implants at all is probably historic and it was, the texturization implant was introduced to decrease the rate at which scar tissue formed around implants. We call this capsular contracture, it can cause painful, distorted breasts. Everyone's seen those glossy mag photos of those terribly distorted breasts on celebrities and the sensational headlines associated with that. That often is a reflection, wholly and solely, of a capsular contracture.

The reason for the texturization was well thought out and was good, and that emerged through the eighties. What we've found since then, through the nineties, the early 2000s, and now into the next decade, that there is a degree of irritation that's caused to the body's tissues through this texturization. That coupled possibly with bacterial seeding at the time that the implant was inserted can together couple to produce this atypical large cell lymphoma.

There's been a drift back towards the smooth implants. The smooth implants were the first type of implant produced over 50 years ago. The reason we went away from them in the first place was that they caused a high degree of scar formation and this capsule formation, this capsular contracture. Placing the smooth implant beneath the muscle, the pectoralis major muscle on the chest wall, in fact reduces that rate of capsular contracture down to the level achieved using the textured implants so, in fact, it's probably the best bet in this current climate.

There have been no cases reported worldwide of atypical large cell lymphoma using smooth implants today and so I've certainly heavily drifted towards the use of smooth implants for all my patients. There are some patients that still benefit from the textured surface and when I use the textured implants I use the Mentor implants. Once again, to date they have the lowest rate of atypical large cell formation, lymphoma formation. It's something that involves a detailed discussion with patients and then a thorough follow-up before you undertake such a procedure or recommend such an implant, and it really needs to be decided on a case-by-case basis.

By way of a brief prop, there is a smooth implant and here is a textured implant. The smooth implants are universally round, the textured implants will be tear dropped implants which when we see in profile demonstrate an upper polar, it's thinner, versus a lower polar, it's thicker, placed anatomically beneath the skin and into the breast. It was once argued that it created a more natural appearance, that's arguable. You certainly can't see my hands through the textured implant as well as you can through the smooth implant because the light's essentially passing straight through the silastic shell, and hence you can see my fingers beneath that.

In summary, then, smooth implants are never anatomical or teardrop shaped but if you use a soft gel and place it beneath the muscle you can produce a very similar effect. That's probably a discussion topic in and of its own right. We can talk about the history of breast implant surgery and the different controversies and problems that we've had over the years. Personally, I'm very confident to use the smooth, soft, silicone gel implants placed in the submuscular pocket.
That's it for now. This has been our first talk from Woollahra Health and Beauty, myself, Dr. James Southwell-Keely discussing the breast and breast augmentation surgery. This is the first part of the multi-part series about the breast. Remember, we're at Woollahra Health and Beauty, that's a big blue building on Edgecliff Road and I look forward to seeing you soon. Goodbye for now.