Cosmetic surgery: less and less risk

To increase the volume of breasts , prosthesis is often one of the most stunning acts. But the recent scandal of PIP prostheses has damaged the reputation of this surgical technique: the laboratory that marketed them had slipped a non-medical silicone gel. This fraud will probably remain unique in the history of breast prostheses, especially as the French and European authorities are now in a state of maximum alert. "Health inspections at the manufacturers have been multiplied; Notified bodies that issue the CE marking will be subject to enhanced control and all prostheses implanted with a strict follow-up, "reports Fouad Tarabah, Quality and Regulatory Affairs Director of laboratories Sebbin (fifth largest manufacturer of prostheses).

Today, their safety seems to have been achieved, and we have some perspective on this surgery practiced for fifty years. But breast augmentation remains a surgical procedure with its risks, and prostheses, products that " wear out ". A leakage of the filling material will occur more or less long term (rarely before ten years, the average being greater than ten years). Hence the obligation of regular monitoring by his doctor. The point with the help of Louis Benelli *, plastic surgeon.

Breast prostheses to increase the volume of breasts too small

Why are some breasts big and some small? Question of heredity. Everything is decided at puberty, when the gland comes into contact with female hormones. If your sensitivity to these hormones - genetically determined - is low, you are unlikely to have a generous breast . In other cases, women see their breasts melt after one or more pregnancies. There, it is rather the involution of the mammary gland which is in question. In fact, the older we get, the more its volume tends to decrease.

A wide variety of prostheses exist, depending on the anatomy of the patient and the type of result expected. At the first consultation, before / after photographs of surgeon-performed procedures on women with similar anatomy are shown to help select the appropriate model.

The form: If the Americans are fans of round prostheses, the French prefer anatomical shaped teardrop, whose appearance is closer to the natural form of the real breasts. As for the degree of projection, that is to say the advance of the areola and nipple, it may be more or less pronounced.

The volume: Since the advent of the Wonderbra bras, the caliber of the breasts continues to increase. From 190 to 200 cm3 in the 80s, we have today grown to 250 cm3 or 300 cm3 or more. Either the equivalent of a well-filled C cup or D. In the United States, the average volume is closer to 400 cm3. Cup D or E is the norm.

The contents of the prosthesis: Silicone gel is the most used product currently. It represents approximately 80% of the prostheses. It is a cohesive product that reproduces the natural consistency of real breasts. However, a prosthesis filled with physiological saline (water containing a concentration of salt equivalent to that of blood) or hydrogel (mixture of water and sugar), depending on how it is placed, can give an equally excellent result. . It is therefore case by case that the choice of the implant is decided. The physiological saline prostheses have the disadvantage of being a little more fragile than those of silicone.

However, following the PIP case, they are more and more in demand, as are the hydrogel prostheses. Completely natural, these products offer maximum safety in the event of a leak.

The texture of the envelope: The prostheses can be smooth or textured. Currently, preference is given to the second, where the irregularities of relief reduce the risk of formation of "shells" (a complication occurring in less than 5% of cases, resulting in retraction of tissue around the implant and hardening of the consistency of the breasts).

Access : Prostheses may be introduced through incisions in the armpit fold (axillary approach), on the areola (areolar) or in the inframammary sulcus (sub-mammary approach). Each has its advantages and disadvantages. Some women, for example, will refuse the scar on the areola, even if it is very discreet. For a first intervention, the fold of the armpit is preferred because it preserves the entire breast (it does not cut the skin or the gland). But it is more technical and requires specialized instrumentation.

The position of the prosthesis : The prosthesis can be slipped behind the mammary gland (retro-glandular), behind the aponeurosis of the pectoral muscle (retro-fascial) or behind the pectoral muscle (retro-pectoral or dual-plane). The decision belongs to the surgeon, only to be able to evaluate the best option for his patient. For a nice result, the prosthesis must be well dressed, that is to say covered with a thickness of gland, fat and sufficient skin. In a very thin patient for example, it is avoided to place behind the mammary gland, which certainly reveals the presence of the implant. With the other two techniques, the edges of the prosthesis are less visible.

The procedure : It usually takes place under general anesthesia, in a semi-sitting position. It lasts an hour and a half. The patient enters the clinic in the morning and leaves the next day.

After surgery: We leave the block, the scar covered with a dressing (removed four days later) and the prosthesis held in place thanks to the wearing of a compression bra (kept day and night for a month, the time a capsule of connective tissue is formed around the implant and fixed permanently). Until the next day, the installation of drains avoids the formation of bruises. The breasts look swollen for two to three weeks, with rare bruises. The scar should be cleaned daily with a local antiseptic. As for the pain, it is not systematic. Some are able to do without analgesics. The breast may be insensitive in places, but it is usually temporary. You can resume normal activity after four days, if you keep your arms around your body. With a good bra, we can even resume the sport a few days after the intervention, but the movements of elevation remain painful for a month. At the slightest sensation of embarrassment or pain, we stop. The final result is reached in about two months.

Possible complications: Immediately after the operation, a hematoma may require to return to the block. In the medium term, an infection may require removal of the prosthesis.

In the long term, shells may develop months or years after breast surgery or both. When a silicone leak occurs, especially if it remains unnoticed, it is possible that it migrates and forms siliconomes (inflammatory reactions in the form of hard balls).

Pregnancy and breastfeeding: It is better to wait six months after prostheses. Slipped behind the mammary gland, they do not prevent breastfeeding.

The cost: From 4000 to 8000 €, according to the notoriety of the surgeon.

Prostheses to enhance a sagging chest

The case is common after pregnancy . One has the impression that the breast has "emptied". It is not breastfeeding that is involved, but the involution of the mammary gland. In other cases, the breast keeps a sufficient volume, but it is not so toned anymore.

Prostheses : They are intended for small breasts slightly relaxed, but without displacement of the areola and nipple.

Plasty-prosthesis : It applies to much more relaxed breasts. It is then necessary, in addition to the curve brought by the prostheses, to tighten the skin to raise the areola and the nipple.

The facelift without prosthesis (" round block " technique ): The breasts have kept a sufficient volume but are not so tonic, and the patient refuses the prostheses. The procedure concludes with a simple scar around the areola.

Possible complications : poor healing (hypertrophic or visible scar). To avoid this we prefer to limit the incision to the simple periareolar circle ("round block" technique).

Pregnancy and breastfeeding: Same recommendations as in the case of prostheses.

The cost: From 5,000 to 8,000 €.

Injections of fat in the chest

Technique: More reliable and better controlled, lipofilling is being rehabilitated by doctors. The act is reserved for young women, because of the growth factors present inside the fat that can stimulate a tumor. The fat, taken by liposuction in the thighs, is reinjected in small quantities via multiple tunnels under the skin. One can inject up to 300 cc per breast, knowing that 20 to 50% of the volume resorbs in the following weeks. Several sessions may be necessary.

Risks: Infection, microcalcifications (small white spots that may lend to diagnostic discussions on the radio), the formation of palpable fat cysts. An American system (BRAVA) would optimize lipofilling: wearing a medical suction cup for a month would improve the intake of fat on the breast, but this technique is still not widespread in France.

Price: From 4 000 €.

Injections of hyaluronic acid into the chest

Launched in France in 2008, the product was banned by ASNM (ex-AFSSAPS) at the end of 2011 as a precautionary measure with regard to the risk of disruption of mammary screening tests. However, the technique was not unanimous among doctors who report excessive cost (close to that of prostheses), a short lifespan (8 to 12 months eviron) and the frequent appearance of nodules during the degradation. hyaluronic acid. For now, prostheses do much better but it may change in a few years.