VOL: 100, ISSUE: 02, PAGE NO: 30
Angela Hall, MSc, BSc, RGN, DN, DipBreast Cancer Nursing, is community nurse tutor, Trinity College, Swansea University, Carmarthen
Until the last century, women had little choice but to accept what nature had given them in terms of breast size and shape. Today, in UK society, breasts are associated with sexuality as well as being integral to a woman’s health and well-being (Andrews, 2001). For some women who perceive their breasts to be too small, breast size becomes a major issue that cannot be solved by wearing padded or push-up bras or breast enhancers. The issue can dominate their lives, affecting their self-esteem and confidence (Clifford, 1983). The options available today for women who are dissatisfied with their breast size include surgery. For women and indeed female nurses who are happy with their breast size the idea of surgery for this reason may seem quite radical.
For some patients, the first time they have to consider breast surgery will be following a diagnosis of breast cancer or in relation to prophylactic mastectomy if they are at high genetic risk of the disease. Nurses may also have some awareness of the emotional trauma these women go through and some knowledge of the risks of this type of surgery (Resnick and Belcher, 2002).
Surgery to increase the size of the breasts usually involves an implant. This form of cosmetic surgery is designed to make the breast fuller and larger, and has been available for a number of years. About 77 per cent of breast implants are performed for cosmetic reasons and the remainder for breast reconstruction after surgery, mainly after cancer but also to address a congenital or development abnormality (Box 1) (National Breast Implant Registry, 2001). It is now the most common cosmetic surgical procedure performed in the UK (Gerszten, 1999).
Nurses should remember that this issue needs to be handled very sensitively because breast size and shape can be an emotive subject. It is particularly important to remember that breasts are a subject frequently in the media for a variety of reasons and patients may be ill-informed. Perhaps the subtle external pressure on girls and women to have a perfect figure has increased, so the reasons for wanting the surgery need to be gently explored. Some women say that pressure from husbands or partners is the reason that they need surgery or that they hope the surgery will relieve sexual inhibition (McGrath and Burkhardt, 1984).
Clinical nurse specialists in breast care should be involved in discussing the concerns of patients considering breast surgery. Specialist nurses should be aware of the evidence in relation to cosmetic breast augmentation (Sarwer et al, 2000). These nurses are able to show the women the implants and let them try the external prostheses (which are silicone breast form shapes similar to enhancers worn in a bra). The patients can take external prostheses away for a period of weeks, to give them the opportunity to try different sizes and carry out their daily activities with larger breasts to see which size they wish to be. Some patients may change their minds about their desired size while others may decide on the external prosthesis as being the permanent solution for them, rather than having the surgery.
The implants, sometimes referred to as ‘internal prostheses’, are basically firm silicone rubber cases filled with either silicone or saline. The silicone gel comes in different consistencies, and both types have been used for several years. The implants come in a variety of shapes and sizes. They may have a smooth or a textured surface.
The surgeon and the patient decide on the exact position, size and type of implant. An incision is made (most commonly in the crease below the breast but sometimes around the areola or under the axilla) and an envelope of skin is created. The implants are inserted under the skin and are placed either under the pectoris muscle or directly under the breast tissue, which leaves the breast tissues largely untouched.
Immediately after the surgery there will be some swelling, bruising and discomfort. Perioperatively, advice on wearing a bra, exercise, lifting, driving and so on varies and depends on the type of surgery and the surgeon’s preferences. There may be temporary and permanent changes in breast sensation and the surgery will leave a scar. Depending on the type of employment, patients may need to take time off work.
There is no evidence to show how many patients opt for surgery, much of which is done in private clinics and hospitals. It is not known what the satisfaction rate is. The procedure is expensive, at about £2,000-£3,000, and is potentially painful and harmful. As with any invasive surgical procedure, and one that usually requires a general anaesthetic, there is an associated risk. Some patients are very pleased with the results and feel that their quality of life and self-confidence improves as a result, but for others the surgery will be unsuccessful.
The patient’s overall health, body shape and healing will affect the results of surgery. Smoking, alcohol intake, any previous breast surgery and any existing scarring or stretch marks may affect healing. Infection and bleeding, although rare, usually require the implant(s) to be removed. If rupture or leaks occur, surgery may be necessary to remove the implant.
Patients are asked to consent to being added to the National Implant Registry. Following recommendation from the Department of Health, the registry identifies patients with implants and the data can be used for health protection, since patients can be notified of any manufacturer’s concerns.
Breast implants do not last a lifetime and will need replacing in the future. This timespan will vary among patients. Some surgeons replace them after 10 years. Younger patients will need to have several operations through their lifetime.
Nurses should ensure that patients considering breast surgery understand the potential risks involved. Informed consent is a major issue. For some women the potential benefits of this surgery will outweigh the risks.
Department of Health (2002)
General Medical Council, 178 Great Portland Street, London W1W 5JE Tel: 020 7580 7642 www.gmc-uk.org