Dr Graham has chosen to stop performing cosmetic procedures in 2015, due to the significant demand of patients requiring cancer and other reconstructive surgery. He apologises for any inconvenience this decision causes to his patients.

He will continue to see women who require reconstructive surgery for breast cancer and breast implant complications.


Breast enlargement using implants (breast augmentation) is one of the most commonly performed cosmetic procedures. If the surgery is properly planned and performed one can achieve a very natural looking result. The salient points are discussed below.

Breast implantsTYPE OF IMPLANTS

These days 99% of all breast implants used in South Africa are filled with silicone gel (previously, saline-filled implants were in greater use). The concerns that people had about using silicone were dispelled several years ago when data from large clinical trials in America was released. Silicone does not cause any of the autoimmune conditions (where the body produces antibodies that attack itself) that is was alleged to produce.

Early implants were filled with liquid silicone, which could leak out into the breast tissues if the shell of the implant developed a tear. This could cause a reaction from the body with the production of silicone lumps. These days the silicone used in implants takes the form of a gel which holds its shape and does not leak out of the implant even if the shell is breached. In addition, the shells of modern implants are much stronger than they were in the past. They are now made with multiple thin layers of silicone that are strongly bonded together so the incidence of the shell tearing is very low.


These days there is a wide range of different shapes and sizes of implants. The main distinction made is between the anatomically-shaped implants and those that are round.

Anatomically-shaped implants are more of a tear drop shape, being flatter towards the upper part and fuller towards their lower end. They are most often used for augmentations in very thin women who have very little breast tissue and give the most natural look. The only downside about anatomical implants is that they cost twice as much as round implants.

Round implants are circular in shape and are more commonly used for augmentations than the anatomicals. This is partly because of the cost difference but also because they give a very pleasing shape in the large majority of women.

All implants are available with various degrees of projection (this gives an indication of how far the implant sticks out from the chest) ranging from low projection to super high projection. The degree of projection determines the amount of "bustiness" that one ends up with. If someone wants to be bigger but not to look too augmented then one would use a moderate to moderate plus projecting implant. If someone wanted to look considerably bigger then one would use a super high profile implant.   


There are several different incisions that one can make to do a breast augmentation: around the areola, in the crease under the breast and in the arm pit (I do not include the incision made in the belly button because this only applies to the use of saline implants).

There is now a lot of agreement that the best incision, which has the lowest complication rate, is the incision made in the crease under the breast. The other incisions have a higher risk of poor scarring and in particular there is a higher risk of the implants not being positioned at the same level.


One has to make a decision whether to place breast implants under the pectoral muscle (submuscle) or between the pectoral muscle and the breast itself (submammary). The general rule is that if someone is thin then one needs to provide some additional cover for the implant and one places the implant under the chest muscle.

If there is enough breast tissue to easily camouflage the implant then it is quite safe to position the implant between the chest muscle and the breast tissue. This is less painful than the submuscle position (just initially because after about a week there is no discomfort in either position) and there is no risk of the pectoral muscle contracting over the implant and squashing it, which causes intermittent changes in breast shape.


It is advisable not to do any significant exercise for at least two weeks after a breast augmentation. This is to allow the implants to become fixed in position. Too much leaping about too early on can cause a shift in the position of the implants (usually upwards) and result is asymmetry. After two weeks one can start doing exercises that don't cause any significant bounce of one's breasts. One can become increasingly more active over the ensuing weeks until the eighth week is reached when full normal activity can be resumed.


Capsule formation

The biggest potential long-term problem with breast implants is the development of a capsule around the implant. Capsules result from formation of additional scar tissue around the implant and make the implant (and breast) feel harder. The reasons why capsules form have not been fully elucidated. There is, however, a lot of evidence to suggest that a mild low-grade infection is present which causes enough irritation around the implant for scar tissue to develop and thicken. The bacteria causing the low level of infection are not necessarily introduced during the operation but may have spread via the blood stream in the weeks or months after surgery. The incidence of capsule formation is quoted from as little 1 percent to as high as 10 percent. If a capsule develops, the treatment varies depending on the severity. Mild capsules can be left alone but if they progress and become more marked with obvious hardening of the breast then further surgery may be required. The treatment of an advanced capsule involves removing the entire capsule with the original implant and then inserting a brand new implant. Interestingly, if one has developed a capsule and had it treated then one is not at any higher risk of another capsule developing.


On rare occasions (about 1 in 1000 operations), an overt infection develops after a breast augmentation. The symptoms are pain, swelling and inflammation of the skin of the breast. If this happens, one has to remove both breast implants because, unfortunately, it is very rare to cure an infection around a breast implant with antibiotics. One may appear to have succeeded but a severe capsule almost always ensues, which needs to be operated on anyway. It's far more expedientsafer and less costly to remove the implants knowing that one can always re-do the procedure six to nine months later with no greater risk of infection than the norm. (To prevent infections from happening, all breast augmentations are done in the utmost of sterile conditions and a large dose of intravenous antibiotics is given at the time of surgery)


In thinner women, implants may be palpable under the skin and it may be possible to see slight folding of the edge of the implant through the skin (known as rippling). This is far less of a problem with modern implants, which are filled with gel silicone. This holds its shape better and prevents folding of the shell of the implant. One can further reduce the incidence of rippling by positioning implants under the chest muscle in thinner women.

Changes in sensation

It is not uncommon for changes in sensation (may be increased or decreased sensation) of the nipple and areola to occur but this is usually short-lived (weeks)Occasionally, it may take much longer for numbness or increased sensitivity of the nipple and areola to disappear and one may have to wait between several months and one and a half years for this to happen.