With rise of demands of cosmetic surgery procedures in India, many women are coming to various clinics for improvement in contour and appearance in their breasts. This demand is not confined to womenfolk of cities only. Enquiry from those presenting for breast surgeries reveal that awareness is due to you tube, net surfing, social media activities and a small proportion gather information from newspapers.

The usual complaints are 1. Sagging breasts, 2. Loose breasts, 3. Small breasts and 4. Large uncomfortable breasts. There is but only one common goal – the breast must be aesthetically pleasing and lifted. Many of these patients who have breasts of adequate size’ cannot express their problems. They either demand increase in the size thinking that will lift up their breasts or they ask for reducing them to make it more attractive. This group mostly need a breast lift or mastopexy. One word of caution for those who come with the idea of winning back the attraction of their spouse or partner is to take them into confidence rather than decide alone. The author has come across patients who consider their cosmetic surgery failure due to non appreciation postoperatively by their spouse or partner. The following are common presentations for cos metic surgery related to breast:

1. Increase in size of the breast or Breast Augmentation : is usally a demand of younger patients although not exclusively so. They feel psychologically withdrawn and a lack of confidence as breasts are an indicator of feminine beauty. In most cases, operation is straight forward and consists of insertion of a silicone gel implants (preferable to saline) behind the breasts or beneath the muscle layer just behind the breast. The results are immediate and satisfaction index very high. For those whose breasts are small and have also sagged, additional procedure of breast lift will be necessary. This is discussed in detail in subsequent section. All these procedures require cutting with an inevitable resultant scar, something resented by everyone coming for cosmetic surgery with the notion that cosmetic surgery is a scar less procedure. There are three common routes of inserting an implant 1. Inframammary (along the breast fold) 2. Periareolar (a semicircular cut at the junction of the pigmented skin of areola and normal skin of the breat) 3. Transaxillary ( in the armpit). Scars here are usually not noticeable, although inframammary position is not a natural area of good scar.

After complete healing of the wounds, massaging of the breasts is mandatory for 4-6 weeks as well as a life-long use of proper supporting brassiere.

A few questions that are common involve permanence of the implant and chance of cancer. It should be brought to the knowledge of the patient that as it is a foreign body (not naturally present in the body), no manufacturer will guarantee a period of more than 10-12 yrs and all foreign bodies do have the chance of getting infected. The other common complication is contracture (the implant becoming firm to hard over time). This is mostly preventable and only occasionally requires operation. It is not a life threatening complication. As regards possibility of cancer, silicone implants themselves have not been proved to cause breast cancer but an association with ALCL (Anaplastic large Cell Lymphoma) have been found. It is a condition in which the lymph nodes (glands transporting clear liquids) draining the breasts have cancer like condition.

Other material of note that can be used for increase of size of the breasts is fat. A woman who has a fatty abdomen can have her fat removed from around the navel and below to inject it in breasts. It may have to be repeated 3 to 4 times with a gap of at least 3 to 4 months as roughly 50% of the fat may get lost. Yet for those who do not want an implant, it is a procedure worth considering. Fat is also sometimes used to smoothen out the contour of an implant when its boundaries are visible.

2. Breast Lift or Mastopexy is a procedure in which the breast tissue and skin is rearranged in such a way that the nipple and areola (called NAC or nipple areolar complex) is lifted to the ideal position and the breast is given a proper shape with upper half fullness. Excepting for small lifts sometimes associated with augmentation, this procedure invariably will have scar in following areas of breast:

a. NAC

b. A vertical line from NAC to breast fold

c. Sometimes additional one along the fold. Though scar improves over time, these have to be accepted in exchange of a good and attractive shape.

Many a times a small amount of reduction may be necessary even in one breast for the sake of a good shape and uniformity in both breasts. Most of sagged breasts have loose skin and need removal. Many patients question how long will the shape remain expecting “permanent” as an answer. This is impossible as the original internal support of breasts have been lost and what surgery provides is a relocation of the breast tissue fixing it to the muscle below and tightening of the skin. Internal supports of breast in the youth cannot be rebuilt and neither the skin tone obtained in the immediate post operative period is sustainable. The gravity will take its toll. But using brassiere, the patient will have a good look and at least fight against sagging.

Mastopexy along with augmentation is a difficult operation calling for balance between amount of increase in size, tightness of closure and distribution of scar. If demands of the patient do not match surgical feasibility, it can turn out to be a disaster for both the patient and surgeon.

3. Breast Reduction: These patients are usually above 35 yrs., having undergone breast hypertrophy and subsequent sagging following pregnancy and breast feeding unless they are patients of puberty hypertrophy of breasts with gigantomastia. They also complain of physical discomfort in the form of shoulder and neck pain, difficulty in maintaining hygiene of skin in breast fold, difficult socialization and inability to wear fitting clothes There are many methods of reducing the size of breast. All involve relocating the nipple areolar complex (NAC) to its proper site ( about 19 – 21 cm from the lowest part of centre of dimple on the throat at its junction with the chest), cutting of various amounts of breast tissue and sewing up with as minimum a scar as possible to give a good shape.

In all large breasts, the single most point of concern is saving the NAC. The most dangerous complication is total or partial loss of NAC . Free grafting of NAC meaning its temporary separation from the body and replacement at an appropriate site over the reduced breast, is sometimes necessary. Under such circumstances, it is impossible to have the original protruding shape of the nipple or its sensation. It may also become whitish (loss of pigmentation) at places. Majority of breast reductions are performed by what is called a pedicled method. In the context of breast reduction, a pedicle means an amount of breast tissue containg the NAC to preserve its blood supply. Despite this, there is a possibility of partial or total loss of NAC. Another complication is loss of sensation either partial or total which in turn may be temporary or permanent. Breast feeding though cannot be guaranteed after breast reduction, it cannot be negated either. Many patients have breast fed their children after the operation. Of course the remaining breast will undergo changes during pregnancy as usual. Among other uncomfortable situations are delayed healing, discharge from the wound, need for minor operative interventions. But all these are usually manageable and ultimate benefit of breast reduction makes patients happy.

One drawback of breast reduction particularly large ones is despite it being considered a cosmetic operation, it is accompanied by a large amount of scar in different parts of breast. However, breast reduction in those patients suffering from physical discomfort should not be considered entirely cosmetic and should be covered under health insurance if used judicially.