Breast augmentation is a procedure in which patients get silicon implants inserted in order to enhance the size of their breasts. After the number of breast augmentation surgeries we are in fourth place in Europe, since we have done more than 2500 such procedures. Aesthestic and reconstructive breast augmentation is a complex medical and phycological field, which evokes several questions and doubts. The key and the most frequent questions are listed and considered in the answeres below.

What are the most common public misconceptions concerning breast enlargement?
In public opinion the theory often prevails (especially in the male world) that breast augmentation means an increase from normal size breasts to that of a “sex bomb”. The truth is really quite different!
In reality the majority of our patients are practically without breasts. The operation allows them to achieve a normal breast size, proportional to their body size. Overall, the size of the breasts are 3(C) and never larger than a 4(D).

What objectives does breast surgery try to achieve?
In the majority of cases we try to satisfy two desires at the same time:
Natural breasts that have natural lines, symmetry and soft to the touch with no visible scars and no visible signs of the implants are desired for the naked body. These requirements are important for the patient’s intimate life. And a natural breast shape takes precedence over size. The correct size of breasts, depending on correct proportions (hip size, waist, chest, overall size measurements), creates a female figure for normal life when dressed as 90% of our life is experienced with our clothes on.

The crucial decision: whether we want to have “nude” or “dressed” breasts?
The majority of Slovene and Italian women want to achieve both objectives, but they have to decide which is more important: a natural-looking breast when nude, or the size of the breast when dressed. For example: A woman who does not have enough skin (gland cover) to make a sufficiently large enough natural breast required by her body’s proportions has to decide either to make small, natural breasts for “show”, which are also too small for her figure, or to insert larger implants to meet her physical proportions, and, at the same time, risk the fact that part of the prosthesis will be visible when she is nude. Often a compromise has to be made.

What are the physical and mental benefits of breast implants?
Above all the benefits are psychological. Women with small breasts significantly alter their self-esteem to feel more positive, complete, and more female. Women who have had a breast removed due to cancer overcome their feeling of being a cancer patient and their feeling of disability. A similar result is achieved in women with extremely small breasts, which are in the majority. Also young mothers with “breast shrinkage” desire to have their breasts to return to as they were before pregnancy.

How many women who already have implants are really satisfied?
Many studies have been carried out in this field which show that up to 80-90% of women are satisfied with the results of the operation. These women would also be operated on again if need be. This is the strongest argument for satisfaction. Often the reasons behind dissatisfaction, despite the extensive information available to women, are unrealistic expectations.

What are ideal breasts?
They are proportionate in relation to the figure, natural in form, without visible scars, without a visible edge of the prosthesis, symmetrical and naturally soft to the touch. At the same time it is difficult to achieve all of these things, which we explain to the patient prior to surgery depending on her case.

What about when there is no hope of promising an ideal breast? 
Expectations must be lowered to the level of the realistic result. Thus the patient has a higher potential for satisfaction. If the patient cannot accept this, then it is better to decline performing the surgery.

Who decides most often for breast enlargement?
The first and largest group are adult women who are practically without breasts (who look like males in the chest area) and can only achieve a normal female symbol with surgery.
Others are young mothers after childbirth with wrinkled and sagging boobs. After childbirth and breast-feeding the body can be re-sculptured with a healthy lifestyle (diet and exercise), while breasts require the help of a plastic surgeon.

What kind of prostheses are available and what are they filled with? 
We can distinguish between two types of implant, both of which are made of silicone bags where silicone is in contact with body tissue. With fixed implants, the size of the prosthesis is determined at the factory and is already filled with silicone gel or an isotonic solution.
The other type of implant is such that we can fill them once they are fitted in place in an operation. Usually they are filled with physiological solution, which is sterile water containing 0.9% dissolved salt and is easily accepted by the body if the implant should burst.
Other liquids are also on trial (such as soy solution) as implant filler, but it will still take some years of testing before these substances are proven safe and useable.
Implants have either a smooth or a rough surface. In our experience, those with rougher surfaces are adopted more easily by the body and there is less chance of the body making a hard cover around the implant or the prosthesis moving later on.
The advantage of an implant filled with silicone is that it is more similar to breast tissue and therefore feels more natural to the touch and more natural to women.
The advantage of an implant filled with physiological saline is that it is not dangerous to the body should there be a leakage through the wall of the prosthesis. A disadvantage is that the water is less similar to breast tissue, the patient feels the implant more and it is more noticeable to the touch.
Water may also pass through the wall of the implant into the body and as such, the prosthesis, and therefore the breast itself, can be significantly reduced. However, water-filled implants have been in use for too short a period of time to be able to say how much the reduction is, for instance over a period of ten years! At our clinic 99% of patients opt for silicone implants.

Insertion above or below the muscle?
Implants can be inserted under the breast tissue or under the pectoral muscle. The insertion is recommended under the muscle in cases where the patient has little gland tissue and very thin subcutaneous tissue so that the edge of the prosthesis is less visible or noticeable to the touch, as insertion below the muscle indicates a thicker cover above the implant.
In this case there is also a lesser chance of a hard capsule forming around the implant.
Negative aspects of insertion under the muscle are: it is much more painful for several days after the operation, limited physical and sporting activity as the pectoral muscle may permanently move the implant (during first few weeks after the operation), later only temporarily.

When above the muscle?
If there is sufficient gland and subcutaneous skin cover for a natural covering of the prosthesis, especially in sagging breasts.
Drawbacks: a greater possibility of the formation of a hard capsule, and, if the patient subsequently loses weight, the edge of the implant may become visible.
Advantages: Less painful post-operative surgery and physical activity is not interrupted.

Breast implants are ‘foreign’ to the body.
Every breast implant is “foreign” to the body, where the body reacts by forming a capsule around it. In some patients (approximately 5%) this is thicker and can, depending on the shape of the breast, be more hard and round. Otherwise, the capsule is not a threat to health and can be removed with an operation if the patient is bothered by it. Unfortunately we cannot predict in which patients it will happen. In ten years of operations the percentage of patients forming this type of capsule is 15-20%.

What can we do to prevent a prominent capsule forming?
We carry out a special massage (often as long as one year), after the operation, or ultrasonic treatment. If we are unsuccessful (1% patients) we repeat the operation inserting the same implant under the muscle where there is a significantly reduced chance of a capsule reforming.

Post-operative scars
Every breast augmentation with implants also means a scar. The size and the visibility of scars depend on the approach and technique used. Today’s methods require the insertion of the implant through the fold under the breast, due to fewer traumas and less manipulation of the implant, and in doing so, fewer complications.

Breast augmentation via the navel
This kind of insertion is dangerous and is an inaccurate method which we do not perform.

Will the patient need another operation in her lifetime?
The patient receives a lifetime guarantee in the event of a burst implant. One of the studies claim that 85% of patients are satisfied with the results; 15% of patients were re-operated due to several reasons (due to a hardened capsule, the desire for a larger size implant, due to the implant moving, …).

Thickness of the subcutaneous tissue and skin cover
The thickness of the subcutaneous breast tissue and skin cover has a decisive influence on the selection and method of a breast implant’s insertion. Patients with a subcutaneous skin thickness less than 1 cm (if you take the skin above the breast between your thumb and forefinger and the thickness is 2cm or less), then the implant must be inserted under the pectoral muscle and not directly under the gland tissue. Even anatomically shaped implants will give a more natural breast shape and the prosthesis’ edges will be less visible.

Anatomically-shaped or rounded implants
The advantages of anatomically-shaped implants over round implants are substantial. The most important factor is that anatomic implants allow us to create a natural breast shape in most patients. Rounded implants enable us to create a natural shape in only certain breast forms (breasts which have more gland tissue or when an insertion is made under the pectoral muscle).

The size of breast tissue and the method of insertion 
The size of the inserted implant in women who have previously given birth is determined by the size of the breasts during pregnancy. After pregnancy, the subcutaneous tissue and skin remains stretched requiring an implant of a certain size to correct sagging and breast volume. If the patient does not wish to have such large breasts as they did during pregnancy, it is necessary to cut away some of the tissue, which usually means additional scars. If the distance between the nipple and the fold under the breast is 7cm or more, then the breast sags down too much to be able to repair it using only suitable implants. In this case a breast lift will also be required.

Is shape more important than size?
The majority of patients in Slovenia are eager to know the size of their future breasts. After the operation they deal the most with the shape of their breasts. It is therefore important to already be aware of this fact when planning the operative surgery. It is true however, that the majority of women wish to have a ‘natural’ breast form, which is a very individual and relative concept as “each eye has its own painter”.

Dissymmetry- Skewing
Almost all women have dissymmetrical breasts, which is almost impossible to correct completely. Often the correction of dissymmetry results in extra scarring. Additionally, dissymmetry is often much more natural than perfect asymmetry undersigned with a scar.

Which implants are safer, anatomic or rounded?
From a health point-of-view, both are equally safe.
Round implants are more, suitable in patients where the prosthesis turns and does not change the shape of the breast compared to anatomic, which deforms the breast shape in rotation. When the prosthesis may turn cannot be predicted. We do know, however, that an inflammatory focus in the body (usually dental granulomas) can be the cause of rotation in implants. Hormonal contraception or hormonal disorders can also affect this situation. Piercing can also cause difficulties. Therefore, we recommend that they be removed at least 1 week before the operation.

Is silicone safe for the human body?
Silicone is a biomaterial which is received and tolerated well by the human body. It causes neither allergies nor reactions and is very widely used in medicine. Anyone who has ever taken medicine in the form of a capsule, which has a silicone covering, has come into contact with it. It is present in medicine, in every injection syringe, etc. This means that virtually everyone has at some time been in contact with silicone.
The extensive use of silicone in medicine is the best proof of its harmlessness to the human body.
The phenomenon of silicone in plastic surgery and in medicine is one of the most noted fields used by the media. Even in our media, articles are transcribed and copied from western press journals, especially America, in a search for sensationalism. I think that the theme has been totally misrepresented by our media in this context, where only certain parts of the truth which seem sensational enough to a certain circle of people are shown. In order to be able to justify the silicone problem, the professional and specialist truth should be understood first.

What does the word capsule mean and what are the consequences?
A capsule is an outer cover formed around the implant itself (it is a natural reaction to a foreign body), which the body creates. In some cases this capsule can become hardened, too strongly defined, or it shrinks and changes the form of the breast and wrinkles the outer surface. The wavy-look of the implant due to the capsule, which is impossible to predict, may cause the implant to become visible (to show through) at anytime in life. A loss of body weight, where the gland and breast tissue becomes thinner, may also cause an implant to become visible which previously appeared unnoticeable.

Is this a serious risk to a patient’s health?
As previously stated, the capsule is a flat scar which forms around the implant and is a natural bodily reaction. Similar reactions are found around artificial joints, pacemakers, etc. Why a certain percentage of people have a stronger capsule is still not understood.

How does a woman feel this change?
It can happen even a few months after insertion. The breast becomes harder, rounder and even painful at times. In severe cases it is necessary to release the capsule or even remove it. During this operation it is better to insert the implant under the pectoral muscle if it was previously placed above. It is also good to exchange a smooth implant with a rough surface one. Before the first operation the patient is already informed of all the possibilities in order to select the correct implant.

What can be done if a hardened capsule forms again? 
In the worst case the implants are removed. In almost 25 years we can state that we have never had a case where we have had to remove the implants due to the re-growth of a capsule.

How can you prevent the formation of a hardened capsule? Does massage help?
As already stated, implants with a rough surface inserted under the pectoral muscle reduce the risk. Our experience has shown that properly done, regular massage helps to soften the capsule. With anatomic implants we have to be more careful in the event of a movement. All our implants have a lifetime warranty against splitting.

What are calcium spots, which may occur in the capsule around the implant? Are they harmful to health?
They are made up of calcium residue which occur very rarely and are not harmful to health. They can interfere with X-ray examinations of the breast (mammography), and it is necessary to inform the doctor that you have implants. In this case your doctor will choose another diagnostic method (CT, US, MR, etc.)

Can breast implants affect the sensitivity of the nipples?
In itself the operation may make nipples less sensitive for a few months; in rare cases this can be permanent.

Do women with breast implants need mammogram check-ups?
They need them just as women without implants do. A doctor will decide upon this depending on the patient’s risk factor (incidence of cancer in the family, number of pregnancies, gynaecological disorders, etc). For women above 40 years of age it is recommended, on average, to take a CBD test every 1-2 years – this is imperative before surgery.

Can the body refuse the implant?
Rejection of foreign objects is a matter of allergic and immune reactions which the body directs against foreign objects of animal or plant origin. Silicone is a synthetic biomaterial and in this context does not lead to rejection reactions. Only in the case of an infection may it be necessary to temporarily remove the implant, but this cannot be considered as a reaction or rejection.
According to our own statistics, the risk of infection is less than 1%.

How long do breast implants last in the body?
Silicone imports have been used from 1964 onwards. There are still many women wearing implants fitted from that period. Today the quality of the implant is so advanced that U.S. manufacturers give a lifetime guarantee against splitting.

How strong are breast implants?
Implants are all tested at high pressure and against long-term repeated loads. Naturally at very high pressure they can puncture – such as in a car accident for example. During a mammogram it is necessary to carry out special projections. Until now we have no data that an implant has burst during a mammogram. The patient receives a lifetime guarantee in the event of an implant puncture.

Which factors may increase the possibility that the implant bursts? Perhaps physical activity?
All physical and sporting activities are permitted, as until now there has been no evidence of the impact of physical activity on implant durability. The possible movement of implants is due to the breast muscle; therefore exercises must be very carefully selected.

What does a woman feel if the implant bursts? Is this visible in mammography?
Any change in shape, size, and sensitivity of the breast can mean a split in the implant. There are several methods of examination to determine if an implant has split. In 90% of cases, the patient does not feel that the implant has split, but this is found incidentally during an examination.

What happens when an implant bursts?
As stated before, a natural capsule forms around each implant which is the body’s normal reaction towards a foreign object. This capsule prevents the silicone (or other content) from leaking into the breast tissue. Only when there is significant pressure, which causes damage to the capsule, can silicone spill into neighbouring tissue. This can also happen with a granuloma, which needs to be surgically removed but is not harmful to health. The purpose of the study conducted by the US government agency FDA over some years was to prove the harm or innocuousness of silicone, in which microscopic particles (silicone bleeding) pass through the wall of the implant via the puncture hole. Until today there are no known definitive results.

Is there a test designed to determine particles of silicone in the body?
Today there is still no routine test for detecting silicone particles in the body which eventually might have seeped from implants. Silicon is found today in food, medicine, cosmetic articles and is present in everybody. However, if we prove the presence of silicone particles in someone’s body this does not necessarily mean that the particles escaped from breast implants.

Is silicone escaping from punctured breast implants a health hazard?
In certain cases, where implants have been removed due to other reasons, a punctured implant was found, but the silicon was caught inside the capsule surrounding the implant. The patient had no difficulties and did not even realise that she had a punctured implant. Therefore, most punctured implants are not even discovered, they do not create problems and are not a hazard to health.

Is breast feeding from “silicone breasts” dangerous?
Studies have proved, that children who drink cows milk from tetra pack packaging (coated inside with silicone foil) ingest more silicone that children who breastfeed from ‘silicone breasts’.  Moreover, the majority of operations are carried out so that the milk gland in the breast is not damaged.

What happens in the event that an implant is punctured?
In this case the implant is replaced in another operation.

Are silicone implants likely to cause breast cancer?
On 20.11.2006, when the US Government Agency for Food and Drug Administration (FDA) permitted the use of silicone breast implants in the USA, any doubts, concerns and suspicions were overruled by their studies.

What is the opinion of oncologists regarding silicone implants and breast cancer?
Even specialists who deal with breast cancer are of the opinion that breast implants do not cause cancer of the breast.

What are autoimmune diseases?
These are diseases (like rheumatism for instance), where the body reacts to its own cells as if they are foreign objects.

Could breast implant provoke this sort of reaction?
According to scientific research there is no connection between implants and the incidence of these diseases.

Can the body develop an allergic reaction to silicone?
As mentioned above, in more than several decades of using silicone in medicine there have been no scientifically documented cases of an allergy to silicone.

What other types of complications are possible when implants are inserted?
The same difficulties may occur as in any kind of surgery. There may be an infection, bleeding, and slow healing of wounds or even anaesthesiological complications. However, these kinds of complications are much rarer than in operations on the appendix and gall-bladder for instance.