Larger and firmer this has been perhaps the most common quest, down the ages, in the area of breast improvement. A variety of methods, ranging from the useless to the bizarre, have been attempted. Padded bras may have fooled the outside world but not a woman's sexual partner; nor did it do anything for her own sense of inadequacy. "Fillers" of abdominal or buttock fat have resulted in either failure of the filler material to "take" , or have produced irregular or scarred breasts. And liquid silicone injections, now banned, caused breasts that were hard, irregular and infected.

However, all this is now a matter of memory. Today's surgical procedures to enlarge the breasts are known to be safe and effective when correctly carried out.They can be used not only to meet the need of small-breasted women who want fuller, larger breasts but also to help lessen sagging breasts by filling out the upper breast area although, in the case of pronounced sagging, augmentation is best supplemented by another procedure, mastopexy, to tighten loose tissues and to shift up the nipple which has drooped too low. See below.

Basic to the procedure is the insertion of an implant (or prosthesis), a soft envelope made of silicone, and filled with one of a variety of materials. This is surgically inserted within, or more precisely under, the breast. There are variations not only in the filler material, but also in the site of the incision that the surgeon chooses to insert the implant, as well as where he places it in relation to the breast muscles.

Breast implants are so much in the news these days that it's easy to forget that some women, far from having any use for them, actually have the opposite kind of problem: over-large, often pendulous breasts that are not only a cosmetic liability but can also pose other problems. The physical problems include back and/or breast pain and shoulder discomfort - sometimes severe enough to cause breathing difficulties. At the practical level, the over-endowed woman is likely to have problems finding well-fitting undergarments and other items of clothing.

Breast reduction is also an option for the woman with markedly assymetrical breasts - one much larger than the other. This calls for a one-sided breast reduction (though, of course, in some cases, the woman may choose to have the smaller breast made larger with an implant).

Surgery to downsize breasts goes back nearly three-quarters of a century. Since the heaviness is invariably accompanied by sagging to a lesser or greater degree, as well as a displacement of the nipple to a lower position, the procedure is aimed at not only reducing the overall volume of the breast, but also shifting the nipple to a new level that will conform to the newly-created contours of the breast.

Since breasts are reduced to a size that's in proportion with the rest of the body, women who are as close to normal body weight as possible get the best results. If you want to lose weight, do so before having the operation.

There are a few risks associated with breast reduction. It's not for women who want to breastfeed since some of the milk ducts may be severed during the operation. Milk may be produced but not delivered, causing engorged and cystic breasts. If breastfeeding is of critical importance to you, the surgery must be postponed until after the childbearing years.

There may also be extensive scarring around the nipple and under the breast, resulting from the several incisions that require to be made. The scars may fade, but they're permanent. Also, there is a tendency after breast reduction for scars to stretch. Additionally, some women report a loss of sensation in the nipple that can last as long as six months.

Where a large reduction of volume and manipulation has been required, greatly compromising blood supply to the tissues, it can result in destruction of soft tissue and its replacement by scar tissue. But with today's level of technical expertise, it's highly unlikely that there will be a total loss of sensitivity in the nipple area - a major risk of this surgery in decades past.

On the whole, aberrations that can arise with this surgery are dealt with surgically and usually present no permanent problem. Breast reduction is perhaps the most formidable of all breast surgery, and many surgeons feel it is proper to inform a woman seeking it that there is a possibility of touch-up surgery being required a few months later. If you are told about this in advance, you are unlikely to become upset if at all it is found necessary.

Soon after surgery, the shape of the breasts is nearly normal, though approximately a year is needed for them to assume their final appearance.

Post-operative care : Breast reduction is performed under general anaesthesia. For the first week after surgery, painkillers are necessary. During this time, the breasts are firmly bandaged with bulky gauze and elastic dressings. The sutures are gradually removed and tape strips put in their place.

Following the removal of dressings, you are allowed to shower. After a fortnight, routine activities are normally resumed. In about two months you'll probably be back to all activities, including exercise or sports.

Remember the pencil test? If you can hold a pencil in place under your breasts, you're probably already worrying about droop and sag. Among the causes: hereditary drooping, pregnancy and breast-feeding in particular, weight gain which results in heavy, sagging breasts, repeated weight gain less/loss cycles and aging as the skin loses its elasticity, especially skin that has been damaged by chronic exposure to the sun's rays through sunbathing, for example. Also a possible cause: going without a bra for extended periods of time, which can deny support to the muscles of the breasts. The overall size of the breasts may remain the same, but there is a loss of the firmness erectness that kept them youthful-looking.

Non-surgical options to remedy sag have included "firming" and "toning" creams, most of which are a cross between a moisturizer and an astringent and produce a temporary tightening effect by drawing water into surface skin and causing it to swell. Some also include albumin - egg whites, the same thing old-time movie stars used to use for instant "face lifts" before going on camera. The effect created can translate into better tone for an hour or two - no substitute for a surgical uplift, which is the only way we know at present to uplift sagging breasts.

Surgery, known as mastopexy, can give breasts the same kind of lift as that provided by a well-fitting bra, but this lift is provided by a re-contouring of your own tissues. The substance of the breast is left untouched; it is only the skin envelope that is trimmed and tightened. There is a variety of approaches, depending on the extent of droop, as well as on whether you want some other cosmetic improvement in the breasts such an increase or a reduction in their size. For a slight droop, the solution today may involve just the removal of a crescent-shaped piece of skin above the areola, the pinkish-to brownish tissue surrounding the nipple.

About one-and-a-half centimetres is removed and the skin is sutured, placing the nipple a bit higher on the breast. The well-hidden scar generally fades within a few months. You can usually return to work in less than a week, but should limit physical activity - in particular, stretching, which can widen or lengthen scars - for up to six weeks. Since the nipple maintains its blood supply, sensation is usually only temporarily numbed, and the ability to breastfeed is not normally affected.

For more severe sagging, a conventional mastopexy is required. Here, the surgeon makes an incision around the areola, and another from the six o'clock position on the areola straight down to the fold of the breast, where a horizontal incision is made. Then a new opening is created for the still-attached nipple and areola to emerge through, the breast is reshaped, excess skin is trimmed away and all three incisions are closed. The anchor-like scar sounds worse than it looks, and it fades within a year to a shade resembling a stretch mark. To keep scars from becoming raised or thickened, pressure bandages need to be worn over the incisions 12 hours a day for several months.

In cases where one of the above procedures is not quite sufficient to restore firmness and fullness, mastopexy may be combined with a small breast implant. Alternatively, mastopexy can be combined with a breast reduction procedure (where sagging is accompanied by heaviness).

In inexpert hands, breast upliftment surgery can carry the risk of several complications. But if you've selected your surgeon with care, these complications are less frequent and less severe. Sometimes one breast may end up looking a little larger than the other, or the nipples may appear unequal in size, but both problems are generally surgically correctable. While it is impossible to carry out an effective breast lift without any scarring, in the majority of cases, the result is such a cosmetic improvement--over what existed in the first place that most women find the scarring acceptable enough.

The infra-mammary (under-the breast) incision : This is the most common site for the surgical incision for breast augmentation. A cut, about two inches long, is made in the fold beneath the breast and a pocket developed behind the breast into which the implant is placed. The wound is sutured and generally causes no problem to the woman. During the healing stage the scar is hidden from view under the breast fold and, over time, it matures to the point where it becomes virtually impossible to detect.

The areolar incision : This is a semi-circular or U-shaped incision that curves around the outside of the lower half of the areola (the pigmented portion of the nipple). The incision carries through to the potential space between the breast and the muscles of the chest. The chief advantages of this incision are that it heals rapidly and with almost no detectable scar since this is hidden within the darker-pigmented margin of the areola. On the other hand, since the areola and the nipple itself are the seat of the greatest erotic sensations, an incision here can often cause temporary and sometimes permanent loss or reduction of sensitivity. But the nerve supply in this region is so rich that total or even major loss is all but impossible.

Remote-site incisions : The quest for a natural-looking, scar-free breast was given a fillip with the greater malleability and versatility of the saline-filled implant. Today, increasing numbers of surgeons are abandoning the breast fold or the nipple areola as entry points for the implant, since saline implants enable them to go even farther afield -as far as the underarm (axilla), the navel or even the pubic region! The incisions made at these alternative sites are virtually undetectable.

But, as always, the advantages are tempered by drawbacks, and each candidate must decide, in consultation with her surgeon, which route is likely to be optimal in her case.Thus, the distance between the underarm and the breast helps to minimize the visibility of the scar, but it also makes the operation less direct and therefore technically less desirable. All the same, surgeons who have developed expertise in this method believe that, on balance, this is often the proper route.

Going via the navel is a simpler, and less traumatic procedure than going via the pubis, but if previous surgery has been done in the pubic or the lower abdominal region, or if the breast implantation procedure is going to be combined with, say, a mini abdominoplasty, the public route may be preferred to the navel.

The procedure can often be performed on an outpatient basis, under general anaesthesia, in less than an hour. An incision is made in the lower ridge of the navel, or in the pubic region as the case may be, and a pocket created. Through this pocket, the surgeon introduces a rigid tunneling device, known as the breast tunnelor, in effect creating a tunnel from the incision site right up to the breast. It is through this tunnel that the tubing, carrying the implant, is introduced. The implant, not yet filled with saline, is rolled into a double-leafed cigar shape and attached to one end of the tubing. To the other end of the tubing is attached a hanging bag, containing the saline, that will be injected through the tubing, to inflate the implant, once it is in place. If a problem arises in the course of introducing the tubing - say, the tunnel is not wide enough to allow the smooth entry of the implant - the tubing can be withdrawn and the tunnel widened. Smooth-textured saline implants have been found to glide in more easily and also can be rolled into a smaller diameter than the more bulky textured implants. The latter type also occasionally produces a "rippling effect" in some women over time.

Massage is introduced in the second week after surgery. The sutures are removed around 10 days after surgery. In three weeks, you can get back to your exercise routine.

Though surgeons have found the early post-operative results to be good and patient satisfaction high, the long-term incidence of capsular contracture, muscle paralysis and infection are not yet known.

The Silicone Implant : Medical-grade silicone has long been the preferred material for breast implants, in large part because it is considered the least likely of any foreign substance to cause a reaction within the body (one reason it's used to coat injections and pacemakers). It should not be confused with liquid silicone which is now known to be dangerous, and the use of which is considered unethical. The silicone gel implant is enclosed in a silicone capsule.

However, a run of scares in the United States in the 80's gave rise to certain areas of concern :

Over time, silicone can leak out of its envelope if the implant ruptures. This does not imply, as it may seem to, that silicone explodes into the breast. In fact, most ruptures are tiny openings the woman may not even be aware of. If there's definite evidence that the implant is leaking, it is better to have it removed, since leaking silicone can pose risks. There are four methods to determine this: a physical exam, a mammogram, sonography, and mammoscopy in which a tiny video camera is inserted into the cavity surrounding the implant, allowing the surgeon to actually see the implant on a screen.

There have been some reported cases in which some women with silicone implants were found later to be suffering from debilitating auto-immune disorders such as scleroderma, raising questions about whether the implants had caused or increased the risk of developing these disorders.To date, there is no proof that silicone causes auto-immune reactions and, though the issue remains contentious, the body of medical opinion is that if there is such a causal link, it is likely to exist for only a small proportion of silicone-implanted women, most probably those who are genetically predisposed to develop such auto-immune disorders.

Until a few years ago, another fear that centred around silicone implants related to breast cancer detection. Conventional mammography techniques could not see clearly through silicone and this fact somewhat impeded their ability to detect breast cancer at its earliest, most curable stage. Today, however, special mammography techniques to reduce implant obstruction are available. Experts also recommend a displacement technique, in which the implants are manually pushed back against the chest wall, exposing more of the breast tissue. There is also growing evidence that supports combining sonography with mammography to check on silicone-implanted breasts, though not everyone agrees on sonography's worth.

The polyurethane implant: The search for an implant that would reduce a persistent problem in breast augmentation surgery, i.e.capsular contracture, or hardening of scar tissue around the implant, gave us the polyurethane implant which created waves during the fag end of the last decade, but also eventually ran into rough weather. This implant too was made of silicone, but it was coated with a "fuzzy" layer of polyurethane; this textured surface helped to redistribute pressure on the implant, cutting the rate of breast hardening from about 25 per cent to perhaps 2.

However, studies with rats, though done under extreme test conditions, showed that the polyurethane foam released a cancer-causing substance as it broke down. Though no studies conducted under conditions found normally in the human body have produced the cancer-causing chemical, polyurethane implants have been withdrawn from the U.S market, following bad press and lawsuits, though the parent company, Bristol-Myers Squibb, is still financing studies to resolve this issue. (Today, silicone implants are also available with a roughened or textured finish).

The Saline Implant : The outer capsule of this implant is also made of silicone, but it is filled exclusively with saline. Though more prone to leakage, either slowly or over time, its advantage is that the saline causes no harm to the body. However, it can cause a suddenly flattened breast which can be socially embarrassing and which requires reimplantation.

A separate advantage of the saline implant is that X-rays can see through saline more easily than through silicone.

Whichever type of implant and whichever type of incision are used, the surgeon - and you - have a choice of positioning it either above the chest muscles or below them. There are advantages and drawbacks associated with both.

Positioning the implant above the chest muscles is a less traumatic procedure since the surgeon has to cut through less tissue, facilitating healing. This positioning also lowers the chances of capsular contracture if smooth implants are used, because the movement of the pectoral muscles provides a kind of massage, helping tissue stay soft. Because the muscles aren't pushed forward and made more prominent, athletic women don't have to worry about unsightly ripples across their chest when their pectorals contract. And if breasts have sagged more than slightly, implants above the muscles provide more uplift.

If, on the other hand, an implant is placed under the muscles of the breast, the muscle may prevent the implant from being noticeable, say, when the arms are raised. It can also be a boon for very athletic women by reducing 'bounce'. The most important reason for tucking an implant under the muscles may well be that it decreases the amount of breast tissue that the implant obscures during mammography.

• Realize that, though breast surgery is a well-controlled, well-tolerated surgery, it is an invasive procedure after all, and that there are always risks associated with any surgery.
• Make sure you go to a competent surgeon. In skilled hands, the risks are greatly reduced. Half of the complications associated with breast implants, such as infection, poor placement or miscalculation of the skin's stretchability, are due to problems with the surgeon, not the product. Choosing the right surgeon is your toughest task.
• Ask for and read the package insert which comes with every implant. The insert lists many potential complications associated with surgery and with the product.
• You should be sure you have all the information you need to make a sound decision. This includes :
  
  

  1) the type of implant to be used and why

  2) the size of the selected implant which should be harmonious with the rest of the body. In particular, there should be an aesthetic balance between the shoulders, breasts, waist and hips. Also, the extent of enlargement possible is limited by the amount of skin available, though tissue expanders can today often get around this problem.

  3) the type of anaesthesia that will be used, and whether the surgery can be performed on a daycare basis or will require an overnight stay in the hospital.

  4) the cost of the surgery

  5) whether the doctor will provide post-surgical revisions as needed either without fee or at a reduced fee

• Finally, weigh the potential risks against the psychological benefits of implants. While there's no denying risks, neither can you ignore the results of one recent American survey: The majority of women with breast implants report that, without a doubt, they'd do it again.

You can be taking food and medication by mouth within three to six hours after surgery. You can also be out of bed and moving within several hours after the operation. If the surgery has been done on an outpatient basis, you can return! home four to six hours after it's over. You'll be prescribed medication to control pain and infection and sometimes to help you sleep.

Twenty-four to forty-eight hours after the surgery, the bulky bandages and dressings will be removed, and a soft bra may be worn. You can shower about 48 hours after surgery, using soap. Bed rest and limited activity are advised for about 48 hours, with your head elevated on pillows at about a 30-degree incline. For about two weeks, you'll need to sleep on your back, not on your side or abdomen since this can disturb the position of the implants.

From about the fourth day following surgery, you can gradually resume normal activities, with these exceptions: lifting heavy objects, rapid reaching of the arms overhead, driving an automobile, engaging in moderate to strenuous exercise.

By the end of the first week, the sutures will have been removed and fine tape strips applied across the wound. They stay in place for about a week to 10 days.

Four weeks after the surgery, you can resume all normal activities and revel in the dramatic new look of your figure.

The incidence of major complications in breast augmentation is very low today, but they do exist.

The primary complication is, what is known as "capsular contracture". Your body reacts to the implant as it would to any foreign intruder, forming a thin veil of scar-like capsule around the implant. In some women, a thin capsule formed, in others, a thicker one.If it is excessively thick, the implant constricts the capsule and forces it into the shape of a ball, making it firm, at times uncomfortable and occasionally visible. This complication can affect about 15 percent of patients. The chances of it happening can however be minimised. One way is by moving and manipulating the implant shortly after surgery, which helps to maintain a larger pocket and reduces the chances of contracture.

A similar kind of massage is provided, as mentioned above, by placing the implant under, rather than over, the muscles of the chest.

Textured implants, as also mentioned earlier, help to redistribute pressure over the implant, dramatically reducing the rate of capsular contracture.

If contracture does result, two corrective options are possible. One is to apply external pressure over the breast and the capsule with enough force to crack the scar and allow the breast to become soft and natural again.This can be done more than once if necessary.

The second option is to partially open up the surgical incision and to release the scar tissue that has formed at the margins of the implant. This allows expansion and softening of the implant.

In rare cases, there is repeated capsule formation which cannot be controlled by manipulation, surgery or medication. In these cases, it is necessary to remove the implant entirely.

Sometimes, there may be assymetry of the breasts resulting from differences in the healing process on the two sides. Generally, however, it is not more pronounced than would be found in normal breasts.

A loss of nipple sensitivity, generally temporary, can sometimes occur. It is more likely to be permanent (though partial) if the incision has been made in the areola.