Botulinum toxin is a powerful chemical agent and its use and administration is restricted to prescription by a doctor on a named-patient basis. There are 5 known types of Botulinum toxin, and we use type A. It should only ever be administered after careful medical examination of the patient. Essentially, Botulinum toxin and fillers are used for the cosmetic treatment of facial lines, and the rejuvenation of skin and underlying tissues. However, from a purely functional perspective, Botulinum toxin can be used to control muscle spasm, pain and excessive sweatiness, and in these cases may be available to patients on the NHS. In its more common cosmetic usage, Botulinum toxin works by stopping the transmission of nerve impulses to the facial muscles that contract and cause wrinkles, such as frown-lines between the eyebrows and crows’ feet around the eyes. Unable to frown or perform other basic muscle contractions, patients find that about a week after a Botulinum toxin injection their facial wrinkles smooth out, giving them a more relaxed and youthful look. This effect begins to wear off after two-to-three months, at which point the facial muscles start to work again. This is usually the time when most patients come back for a top-up. Fillers work by bulking up facial tissue, and can be used to fill in lines and contour dips in the face. Most fillers are temporary, lasting between six months and two years. You should be very careful if considering permanent fillers because they often have undesirable late complications which are very difficult to treat.
2. Where should I go for more information and support?
BAPRAS’ cosmetic surgery checklist Department of Health – Cosmetic surgery BAAPS – British Association of Aesthetic Plastic Surgeons
In the last decade there has been a shift in the understanding of breast enlargement surgery. While this type of surgery has always been a volume operation (in other words making breasts bigger), it is now also regarded as a reshaping operation, where the size and shape of the breast needs to sit naturally with the build and dimensions of the patient. This approach aims to achieve a more natural looking breast that does not exceed or damage the boundary of the breast.
2. What surgery is available, and what techniques are involved?
Breast enlargement involves the placement of an implant under the patient’s breast tissue to enhance the size and shape of the breast. In the UK, the vast majority of implants are made of silicone, although saline is also an option. Implants can be placed either directly behind the breast (known as subglandular placement), or behind the breast and chest wall/muscle (known as submuscular placement). The implants are usually inserted using an incision under the breast at the crease , but can be put in via an incision in the armpit or around the nipple
Behind the breast
The insertion of implants behind the breast is considered to be the simplest of the available enlargement procedures, and the least likely to cause discomfort. This route is also the most effective for patients with slightly drooping breasts, resulting in fuller volume and better uplift.
Behind the muscle
The insertion of implants behind the breast muscle provides more padding, which is a key consideration for slender patients and those with very little breast tissue where the edge of an implant may be detectable through the skin. The muscle provides extra cover and helps to hide the upper portion of the implant, and so is strongly recommended for those whose ribs are visible.
Dual plane operation
When slender women with slightly drooping breasts seek enlargement surgery, surgeons often combine these two routes, placing the implants partly behind the breast and partly behind the muscle. Through this combined approach surgeons try to give patients the benefits of both techniques.
Implants can either be round or tear-shaped. Round implants provide a bigger volume at the top of the breast, along with a deeper cleavage. Tear-shaped implants, meanwhile, can look more natural. With either of these options, there are varying degrees of projection, depending on whether patients want their augmented breasts to look subtle or more noticeably pert. Temporary implants, placed inside a bra, can help patients assess their options and make decisions about which implants will help them achieve the augmentation they desire.
3. Is this surgery available on the NHS?
Cosmetic breast augmentation is generally not available on the NHS so you will have to consult a plastic surgeon as a private patient and pay for the operation yourself. There are some exceptions to this rule. In some parts of the country the local Primary Care Trust (PCT) will allow consultations and operations for small breasts in certain circumstances. These exceptional circumstances vary from region to region. In general, patients with absent breast tissue, very little breast tissue or marked asymmetry might be considered exceptional. Your GP or PCT in your area will be able to tell you about the local rules that apply for where you live. BAPRAS is unhappy that this type of postcode rationing occurs and has worked with the Department of Health in drawing up guidelines for commissioning cosmetic procedures on the NHS. However, at present it is the local PCT that decides what is available for their population.
4. Who will I see as a patient?
We would strongly advise that you consult your GP if you are considering breast augmentation. They will be able to refer you to a local plastic surgeon to discuss your options. Some patients will choose to approach a private hospital or clinic themselves. If you do this you should ensure that your initial consultation will be with the surgeon who will be doing the operation. You should expect to pay for this consultation. You should check in advance that the surgeon is on the specialist register of the GMC in plastic surgery. You can check here to see if they are a full member of BAPRAS. At your first consultation you will be asked what is bothering you about your breasts and about your expected outcome from the surgery. You will be examined and some discussion will follow about implant shapes and possible sizes. If you are considered suitable you will be told about the operation, the expected outcome and possible risks and complications. You should be given a ‘cooling-off” period before booking surgery, and will usually have a second consultation. You will be sent a quote regarding the cost. You should avoid any deal in which you are asked to pay any form of non-returnable deposit. Most hospitals will offer a package price that covers the cost of treating any complications arising in the initial weeks after the operation.
5. What should I expect in terms of treatment, procedures and outcomes?
Breast enlargement surgery takes between one and one-and-a-half hours, and is done under general anaesthetic. The operation itself involves accessing and creating the pocket into which the implant will be placed, using one of the insertion routes mentioned above: breast- crease, armpit or nipple.
Once the pocket has been created, the implant is inserted and the incision wounds are stitched. You may be able to go home the same day, but many patients will spend one night in hospital. Post-operative pain in these procedures is easily controlled. Patients will be mobile from day one and should be back to full exercise within six weeks. Patients are recommended to take around two weeks off work immediately after the operation in order to ensure they recuperate fully.
The nature of the scars will depend on the technique that has been used. Scars tend to be quite red in the first six weeks, changing to purple over next three months and then fading to white. Most patients will form good quality scars over time.
6. What complications can occur?
All breast enlargement procedures carry the risk of bleeding or infection. These risks are both less than 1%, but if they do occur will result in reoperation. A degree of altered sensation in the breast area is very common after breast enlargement. This usually gradually gets better, but there is a slight risk of losing nipple sensation completely. Hardening, or encapsulation, around the implant is also a potential risk, and up to 10% of women over a ten year period will experience this problem. The breast shape is likely to gradually change as time goes by. In the case of most women this will not trouble them, but sometimes the shape is not as good as it was and further surgery might be considered. Some patients can feel or see the edges of their breast implants under the skin. Sometimes visible folds and ripples become evident. Implants are made to be very tough, but the envelope can gradually fail and a leak can occur. This is not usually a serious event, but once detected will necessitate removal and exchange of the implant.
There is no universally agreed replacement schedule for breast implants, and it is rare for there to be a need to exchange breast implants before ten years. However, you may develop one of the problems described above and may need or choose to have revision surgery at some time in the future. For this reason anyone having breast enlargement should be prepared both personally and financially to have a further operation at some time.
7. Where should I go for more information and support?
BAPRAS’ cosmetic surgery checklist; Department of Health – Cosmetic surgery; GMC plastic surgery specialist register