Dr. Dan Marsh is a leading Consultant Plastic Surgeon. His practice is on Harley Street, London. This interview is part of a larger article on cosmetic breast surgery, entitled 'Do I Really Need Surgery? An Unbiased Cross-comparison With 3 Of The World’s Best Plastic Surgeons.' The article also features advice from Dr. Patrick Mallucci and Dr. Raj Ragoowansi so, if you are considering cosmetic surgery, we highly recommend reading it.
1. How do you feel the field of cosmetic breast surgery has changed in the past 5-10 years?
Cosmetic surgery has become increasingly common. More and more people are having it, both men and women, and even more than we realise. Statistics suggest that most people we meet have had at least one operative procedure. The biggest change in the field of breast surgery is that women are opting for much smaller breasts than they did 10 years ago (e.g. 200-300ccs), and also want smaller nipples. The implants have changed too. Recent years have seen the advent of ALCL (a lymphoma that’s associated with a particular type of breast implant) so to reduce patients’ risk we use smooth implants (i.e. referring to the silicone implants’ shell). In the past surgeons used textured ones as they thought the body responded better to them (reducing the likelihood of scar tissue capsules forming around the implant but new research has disproven that) . ALCL is extremely rare, occurring in just 1 in 130,000 women but, as textured implants are associated with it, they should be avoided.
2. How have treatments and techniques available changed?
The biggest change has been callifollo – an apparatus that allows surgeons to insert the implant via a much smaller incision. One procedure that I perform using it, short scalpel breast augmentation, has been particularly revolutionary.
The callifollo itself resembles a piping bag, almost like what you’d use to pipe icing. It’s like a funnel so you put the implant at the top with a very small 3cm incision and then place the implant in underneath. Then you simply squeeze it in using a special bag that fires it in. What’s particularly fantastic about this particular procedure is that it facilitates a no-touch technique, meaning there’s a reduced chance of the patient incurring scarring or infection, and any necessary scars are much shorter. It’s amazing.
Conceptually, the field has significantly changed a lot in the past decade too. New surgeons are developing better and better techniques and apparatus, yielding a wider selection of breast looks for women to choose from. Not only relating to the breast shapes we’re able to achieve, but also to how we’re able to place, re-shape and re-size the nipple.
‘Most of my patients are yummy mummies who have had children and just want something to restore them to what they were like before. They want to be natural. Whereas the younger women who come in requesting augmentations tend to want to be bigger because they haven’t lost that volume already. My advice is: don’t just think about your body in the next 3-5 years, how it looks and how you want it to look. It will change so also think of the long-term before deciding.’
3. What about in terms of the public’s attitudes towards having surgery?
That’s changed a lot too. Nobody wants big implants anymore. In the past, women were requesting massive implants but they looked so disproportionate and really quite ugly. Now both women, and men, aren’t finding that as attractive anymore; they want a natural, but beautiful, look and as a result they’re requesting smaller implants. Most women don’t want people to know that they’ve had surgery; they want people to think it’s real.
4. What are the most common reasons women give for having breast surgery?
Most women who have enlargements have them following childbirth. They miss the old shape of their breasts but there are also a growing number of younger women who, having grown up with naturally large breasts, want breast reductions. In the past, reductions could result in larger scars but these days, new techniques mean that the scars are much smaller and shorter length-wise. We use vertical scars rather than transverse ones, complimented by smaller nipples and they’re very happy with the effects.
5. Everybody knows about breast implants and augmentation but less is said about breast reductions and rejuvenation. What is the best method currently available to rejuvenate one’s natural perky breast giving a natural effect?
The best option is fat transfer. Women are advised to use the many creams on the market; to have breast lifts, suction… all of these things; however, they actually don’t make a difference in terms of improving the breast’s perkiness. The only way to do that is by putting substance into it, either with an implant or fat. With fat transfer, the surgeon extracts some of the patient’s own fat from another area of their body using liposuction (often the inner thighs or tummy), then injects it into the breast. The liposuction and breast surgery are performed as one procedure, with the fat being removed a short time before. That’s really the only option available to get a natural looking breast without using an implant. I’d advise that patients have the reduction followed by one of these procedures for best results.
In terms of the fat, does that last less time than an implant? Fat transfer is permanent; however you’ll naturally lose approx. half of the fat quantity that’s injected so, as a surgeon, we always try to overcorrect to accommodate for this. For example, we’ll often inject twice as much fat as should be required if you only accounted for shape, and may perform a further 2-3 injections starting from 6 months following the initial surgery. It’s very effective – you can increase the volume by as much as 200ccs or 2 cup sizes.
‘If I was going to perform breast surgery on my wife or a relative, I’d recommend fat transfer. It would depend on their physical size as they’d need to have enough fat to allow for all transfers but, as long as they did, it’s one of the best forms of cosmetic breast surgery.’
6. Is there a perfect bust size for a natural effect? (I.e. in terms of body proportions)
Every woman is different, with a different lifestyles, frame etc. from the next woman so you need to take that into account; however there is such thing as a ‘perfect nipple.’ The perfect nipple should occupy about 30% of the breast width. (E.g. if your breast width is 12cm, studies show that most women want their nipple to cover approx. one-third of that, making it 4cm in diameter.)
7. Post-menopausal women often report losing the fullness at the top of their bust, despite the fullness at the bottom remaining the same. If they have an implant inserted and then it pushes the fullness to the top, for example, would the breast stay the same shape or would it increase under the armpit?
As women get older, particularly after they have children or menopause, the breast and nipple drop so, to make the breast aesthetically pretty, we’ll lift the breast and nipple. You can’t just put an implant in because the breast is like a ball in a sock: if you just put something in the bottom, it will look horrible. Performing a complimentary lift will rectify this.
Alternatively, if the woman has a lot of volume at the bottom, we may suggest performing a lift (Mastopexy) without an implant. It’s much better to avoid an implant if you can so definitely discuss this with your surgeon. Should it be possible for you to have this, no tissue is removed so your cup size will remain the same and the effect will be permenant. The breast is simply lifted and will sit at a much nicer shape. The size, shape and/or position of the nipple may also need to be adjusted, as, for best results, it needs to be at a particular height and distance from your belly button. That ration is determined depending on individuals' frames.
‘One of the best pieces of advice a surgeon has given me is… Don’t ever let anybody decide anything whilst they’re going through the menopause or major life events because, if they decide it during that time 1) their body is going to change and 2) their mind isn’t thinking correctly. They’re just going to be so desperate to get the desired effect, they won’t think about who they are choosing. They’ll just think ‘I really want to get this done. Let me get this done.’ and may regret it later.’
8. How many shapes of implants exist? And how should one decide which shape is best for them?
A wide variety of different implant shapes and sizes are available. The 2 main ones are round or anatomical; however we tend to diverge from anatomical ones nowadays because 15% of them will rotate when inserted. I prefer to insert the implant using a dual-plane technique (i.e.so that it’s part under the muscle, part under the breast). It’s quite a modern technique and gives the patient the benefit of having an almost anatomical shape but with a rounded implant. The good thing about implants is that it’s possible for them to last indefinitely; however you will get scar tissue around them and, as you age or go through physical changes (e.g. pregnancy, weight loss, menopause or general ageing), your breasts will also change so, typically, it’s advisable to replace them every 10-15 years.
‘Smaller implants are brilliant. They last longer, look more natural and are generally much better. In the past, women were opting for large implants, far bigger than suits their frame, and that caused their skin to stretch. It looked terrible. I always advise my patients to opt for slightly smaller breasts and, as fashion has changed as has their reasons for wanting the surgery, the majority of them are. They look great.’
And finally... when choosing a surgeon…
If a surgeon recommends non-biological fillers during a consultation, run!
Non-biological fillers are the permanent ones. There was a phase a while ago where some people were offering macrolane, injectable silicone and other permanent fillers and they’re just terrible. They cause terrible lumps and cysts and it’s almost impossible for any doctors the patient visits in the future to determine what’s happened in order to correct it. This results in it being extremely difficult for them to monitor for breast cancer surveillance; they’re at increased risk of infection; they release pus… It’s horrible. Definitely avoid any doctors offering those.
‘Best advice: Trust the surgeons who are honest with you… who say yes I can do this… no that’s not achievable… this is what’s possible… not just ones who agree with you.’