Breast Augmentation Frequently Asked Questions- Pre Operation: - What happens at my first consultation?
Your consultation is always with Mr Turton. This is a detailed meeting to assess your current situation, medical history, suitability for breast enlargement, and to perform the biodimensional assessment. You will have a full breast examination, and comprehensive measurements made of your frame, existing breast size, glandular analysis, tissue characteristics, and anatomical variations in typical dimensions. The type of breast implants on the market, their safety, and the ones that have the best life span and lowest complication rate will be discussed. Mr Turton will also detail your breast augmentation options and alternatives, the potential complications, any limitations, short and long term breast changes, costs, the need for future surgery, mammography and follow-up. - What size can my breasts be increased to?
Mr Turton advises strongly against large augmentation that takes your breast size excessively out of proportion to your frame. The biodimensional assessment will enable a choice of size to be made based on your proportions. This is the safest way of balancing the desire of breast enhancement with reduced detrimental effects. Most patients desire to be a "C" cup, and although cup size is not guaranteed, Mr Turton will be able to show you how your breast shape can be augmented, and take into account your desire. Using the McGhan tear-drop anatomical implants will provide Mr Turton the greatest flexibility for a near custom size implant, based on your frame and current breast measurements, if this is the style that you decide on. If you ask for a size that is much larger than your assessment suggests then you must be aware that there may be higher risks of complications and detrimental changes: eg breast tissue sag, palpability, less natural appearance, numbness, arms rubbing against side of breasts, ache, and future malposition. - Is it possible to choose which side is done first and will that reduce the pain felt on the first side i.e. can a right handed person choose to have the right side done first?
It makes no difference which side is operated on first. The sub-pectoral dual plane positioning of the implants feels more tender in general than when a sub-glandular position is used. Often one side feels slightly tighter, or more tender initially; implant settling often occurs earlier on one side than the other. However, this is irrespective of which side is operated on first. Mr Turton's routine is always to operate on the right breast first, and this is purely due to his very specific and methodical routine. - What happens on the day of the operation?
You should avoid any medication, herbal preparations, and vitamins except those that Mr Turton has said it is OK to take. For example- No NSAIDS such as neurofen the week before surgery. You will also be fasting, and cannot take any liquids, any sips of water, or any food (no sweets, or chewing gum even), from the time specified (usually 6-hours prior to surgery). Avoid moisturiser on the breast area please. Arrive in good time, and you will be checked in first by nursing staff. You will be admitted several hours in advance of your operation so that it is completely unhurried. You should relax in your room (bring a book and magazines). Mr Turton will take your pre-op photo and mark-you up. Mr Turton's anaesthetist will evaluate you and confirm that you can proceed (If you are unwell or have developed a chest infection your operation would obviously be cancelled and rescheduled). You will be walked from the ward to the operating theatre reception for your check in, and then your anaesthetist will commence your anaesthetic- you will drift off to sleep in about 5 seconds! Your will be under full anaesthesia for the full duration of the operation. Mr Turton will additionally use local anaesthesia which provides additional comfort on wakening. Every thing is geared around you, your 100% safety, and your well being. You will be woken up in the recovery room, and supervised 1 to 1 with an experienced recovery nurse after the anaesthetist has reviewed you. You will then be taken back to your room where you may start your recovery within the comfortable surroundings provided. - How long does the operation take?
Your operation will be conducted meticulously and unhurriedly. You are positioned on a padded operating table. There are additional gel supports that will be placed under your ankles and for your arms to rest on. Your head is on a pillow. There will be pneumatic anti-thrombotic boots around your lower legs which will gently squeeze your calf muscles throughout the operation (Mr Turton has never had a patient develop a DVT), and there will be a special sterile operative warm air blanket covering your lower body (this is called the "huggy-bear". An operation time 1 - 1.5 hours is typical. Mr Turton uses various techniques to reduce operative risks such as haematoma and infection; consequently his reoperation rate is well below average. You are fully monitored throughout the operation and the consultant anaesthetist is solely with you (one-to-one consultant care). The chest area often feels "tight" and tender for a few days. You will be able to move about as normal, but you should avoid using your chest wall muscles forcibly, to avoid discomfort. This will be discussed. Individual advice varies: From 3-days to 3-weeks. You should have come off the strong painkillers before driving (such as Tramadol, Codeine, Dihydrocodeine or Tylex). You should be comfortable that you could make an emergency stop or be able to swerve sharply if needed before driving. - When can I return to work?
Usually after 1-week. Some patients return after less time, ie 3-days, and some longer. Jobs that involve strenuous lifting should be avoided for 2-weeks, and then discussed with Mr Turton. - How do I decide on the size of the implants?
The average breast size in the UK is a "B" cup. The starting point for breast augmentation for most patients is AA, A or B- cup. Some women are larger than this to start but as they have previously had children and a bigger bust request the volume of the breasts to be further increased to fill out the loose skin. Most patients desire to be a "C" cup. It is vitally important not to become fixated on "cup-size" as bra size is not standardised. It is the look that you want to achieve and can achieve that is important, particularly in relation to your frame. If you want to stay in proportion to your frame, as most of Mr Turton's patients request, then you will be told the implant volume once the dimensions of your frame and the implant dimensions have been calculated. It is far superior to work around your dimensions to choose the implant volume, than to chose a particular volume of implant without doing this. This is one area that an experienced cosmetic breast specialist will excel at. Bring pictures with you or review your surgeon's album. Mr Turton likes you to review the breast augmentation pictures on his web site, and encourages you to print-off the post-operative pictures that seem closest to the size and shape that you want to achieve. This is a useful starting point to get you and your surgeon on the same wave-length. Asking for a natural shape augmentation is common. This produces a natural slope to the upper breast (see the side views in the post-operative photos for patients who have had anatomical implants). Not many of Mr Turton's patients request a prominent rounded appearance in the upper bust, although this can be readily achieved if desired. Round implants can still be used to produce a natural look, but not in all patients, and not with some baseline tissue characteristics. Anatomical implants (shaped) produce the most natural shape of breast enhancement. There are specific cosmetic techniques that can be used to give you a proportionate result. - How long will I be in hospital?
If you have surgery in the afternoon or evening you will normally stay overnight. Expedited recovery surgery is coming soon as part of Mr Turton's practice, and will enable you to go home just 2-hours after surgery. But for now, you will be reviewed by Mr Turton the morning after surgery and only released when ready. This is normally always by mid-day. - Can sex be resumed immediately after the operation?
For your comfort, Mr Turton advises waiting a few weeks as the breasts will be too tender to touch during this time. After this gentle sexual activity, without pressure on the breasts, can resume as long as no pain is experienced. Generally, it takes 6-weeks before you are able to lie on your front at night, which is a useful guide as to how pressure will affect your comfort. Breast massage must be avoided for a minimum of 6-weeks. - What forms of sports activity can I do after surgery after an augmentation with anatomical tear drop breast implants?
Anatomical implants (also called tear drops and shaped implants) need time to settle, and for tissue in-growth onto the textured implant surface to reduce future risk of a rotation. Different implant manufacturers have different types of texturing, which has an influence on Mr Turton's choice of breast implants. Not all texturing allows tissue in-growth. In addition, excess movement early on (first 6-weeks) will prevent in-growth and encourage a small seroma to form (like blister fluid) further preventing in-growth. Therefore, you will have more restrictions with your recovery programme, that must be followed to allow for this. Typical rates of progress that will not hinder your recovery from breast augmentation are as follows: No excessive stretching/movement should be undertaken for 6-weeks. With round breast implants the restriction is much less, especially if the implants have been placed in the sub-glandular ("overs") position. Walking- no restriction, and it is important to mobilise straight away. Cycling - from 3-weeks Paddling in a pool, Sauna/Steam room use- from 3-weeks Jogging - from 6-weeks; Weight lifting - from 3-months Cross trainers, Gym, Yoga, Pilates - from 6-weeks Gentle swimming- from 6-weeks Pole dancing, Belly dancing - from 6-weeks Aerobics- gentle reintroduction from 6-8 weeks Golf- from 3-months (except chip-and-putt); Scuba diving -from 3-months Tennis/Squash/Badminton - from 3-months Athletic swimming - from 3-months - Will I be able to fly after operation?
Yes. UK domestic flights can be taken within 48-hours. International flights are best avoided for 3-weeks. This is more to do with Mr Turton being able to assess your recovery. Long-haul flights in general increase your risk of DVT, and you should wear anti-thrombotic stockings, stretch your legs, and perform leg and foot exercises during such flights. There is no altitude affect on your silicone implants (they are not at risk of bursting!). - If I lose/gain weight will my breast size reduce/enlarge?
In general, "Yes". Breast tissue is composed of thick glandular tissue and soft fatty tissue. Just as when you put on weight you find that it goes onto the bottom/hip area, you will also often find some of it goes onto the breast area. Big shifts in weight are therefore not desirable. Most people have minor weight fluctuation of 2-4 lbs, which has negligible consequences. If your starting breast size was very small (A to AA cup size), then losing weight tends not to make the augmented breast smaller, but reduces the thin normal fatty tissue layer under the skin, and in the breast tissue layer- this makes the implant edge more easily palpable (particularly in the outer edge near the arm-pit, and in the skin crease area under your breast). Implants that are partly under the muscle have the additional coverage of soft tissue that this provides which is particularly helpful in thin individuals, but remember- the pectoralis major muscle does not fully cover the implant, generally just the upper half. - How can I prevent sagging in future years?
You can't. However careful choices can modify your risk. Your breasts will always change as you get older, and this is irrespective of whether you have breast implants or not. This is because of biological changes that occur with ageing: loss of elastin, stretching of collagen, atrophy of breast tissue, loss of skin elasticity, sun damage to skin, smoking related damage, effects of weight change on skin and breast tissue, effects of pregnancies and breast feeding on skin and breast tissue, hormonal changes, weight of breast tissue and implant weight and size. The biodimensional assessment goes some way to reducing excessive implant sizes being chosen by patients. You should very much speak to your specialist breast surgeon / cosmetic breast surgeon about this. The larger the implant the greater the long term detrimental effects. This is because of the additional weight, and the compressive force of the implant on the surrounding tissues, which become thinner, and more stretched. Avoid very large augmentations (eg over 350cc) and implant sizes that exceed your natural dimensions. Sub muscular breast implant augmentation may provide additional support to the implant. Wearing a well-fitting bra after your recovery is important (usually from 6-weeks). An underwire bra is safe and recommended. Wearing a comfortable sports bra at night is also very useful. A shock-absorber type bra should be worn during sport. Keeping the skin over the breasts moisturised helps to maintain the elasticity (bio oil is possibly advantageous here). Avoid the use of sunbeds and do not smoke at all (both have a very detrimental effect on skin elasticity and quality, as well as micro-vessel blood flow). Maintain your weight in the healthy range for your body mass index. - Are implants/surgery guaranteed for any length of time?
Each implant manufacturer has slightly different guarantees that relate to implant rupture. No manufacturer or surgeon can offer a guarantee against long term changes which will always occur, may be subjective, and are biological rather than anything to do with the implant or the initial surgery. For example: McGhan (now owned by Allergan) anatomical implants carry a lifetime guarantee against rupture. If they rupture then McGhan will provide new breast implants free of charge (please check for updated confirmation from your surgeon). The cost of the operation (surgeon's fee, anaesthetist's fee and hospital fee) is NOT covered. However, as the McGhan anatomical implants cost approximately £1200 for two, this is a very good contribution. Future surgery will be an additional cost that must be factored in before undergoing breast augmentation. Beware of anyone offering guarantees, or free follow-up for life, as it may not be worth the paper it is written on. As an example, I was recently consulted by a lady with faulty saline implants. She had experienced 3 deflations in 3-years and as her surgery was guaranteed against this, she had undergone each operation with the same surgeon and the same poor quality product being replaced. She had bad scars as a result and was very frustrated. I advised her against using the same product and performed revisional breast augmentation with a very satisfactory and more durable outcome. - If something goes wrong during/after operation is surgery guaranteed & will problems be resolved within cost?
Complications from breast augmentation surgery under Mr Turton are rare, but he will be unable to give you a categorical guarantee that they won't occur. The sorts of problems that can occur are haematoma around the implant in the first 24-hours needing evacuation, or implant infection needing implant removal in the first few weeks. If these complications do occur you will be covered by the fixed price package for further surgery. For example, if you need to have the implants removed because of an infection in the post-operative period, this is covered, as is the subsequent operation to replace new implants. Fixed price packages tend to cover you for complications during the first 3-months after the operation, as this is the time that surgery related complications occur. They do not cover the more long term changes with implants like: rippling, palpability, breast sag, capsulation, rupture, and malposition. They also do not cover dissatisfaction with the size, or shape. Mr Turton will always strive to meet your expectations but if there are limitations as to what can be achieved (often related to your starting point) then these will be discussed. It is important to be realistic. - Are follow up consultations chargeable - even at the request of the consultant?
Your first post-operative follow-up is included in your surgical fees. Subsequent follow-ups will always incur a standard follow-up fee (cost approximately £100; please check with Mr Turton's secretary). You will generally require one further follow-up and then can take up the offer of annual or 2-3 yearly review depending on your circumstances, with a view to having an MRI (cost approximately £550) at 10-years to assess your implants. Mammography and USS (cost approximately £160 each) can be arranged depending on your age during the follow up period, if required. Costs reflect Mr Turton's time, and the charges for his rooms, administration and running costs. You are not charged if you attend for review by an out-patient breast nurse. At your follow-up with Mr Turton, you will always see Mr Turton- any follow-up is not delegated to someone else. - Will breast augmentation change my life?
Breast augmentation may make you feel more confident within yourself but will not change things if you are dissatisfied with your lifestyle. Surgery in itself will not change a life situation, but the confidence and self-assurance which result from it can indeed empower you to make the required changes, allowing you to live and enjoy your life, to the full. Some patients can rarely have a general problem with body image, and remain dissatisfied with their appearance even when the result has been within the expected and described range. This may be because of something called "dysmorphic body image syndrome". Patients who have a general body image problem are unlikely to gain benefit from cosmetic breast surgery or any cosmetic surgery and should avoid it. Mr Turton would also want to avoid operating on someone who he suspected of having such a problem. - Can I still wear the same style of underwear?
Due to possible changes in shape it may not be possible to wear the same styles. - Do I need to wear some form of support at all times or can I go without a bra?
Once you have recovered from surgery there is no reason why you shouldn't go without a bra on occasions. As long as you feel comfortable it will not have a detrimental effect. In the long term, however, breast tissue will be more susceptible to droop if you do not wear a bra most of the time. Post Operation Questions - How will I feel after Breast Augmentation Surgery?
The vast majority of Mr Turton's patients feel relaxed and comfortable immediately after surgery. Breast tenderness and a tight feeling, usually become apparent in a gradual manner. At this stage Mr Turton is happy for the nursing staff to dispense Paracetamol and an anti-inflammatory tablet for pain relief. You will usually need to have a stronger pain killer as well, such as Tramadol or Codeine. This combination is best taken regularly for the first 4-days. After this, the Tramadol can be just taken at night if required. It is usual to stop the Tramadol after 1-week. The anti-inflammatory and Paracetamol combination is very effective and can be continued for a few weeks according to how you feel, but should not be taken on an empty stomach. It is quite common for one breast to be more tender, and to swell slightly more (this is often the right side). Similarly one breast will often recover more quickly and this is quite normal. Although this would be very rare, the gradual appearance of a great discrepancy in size would not be normal and should be assessed. Similarly if you feel unwell, feverish and devlelop a temperature you would need assessment. If the skin over the breast swells and becomes reddened and tender you would need assessment. Changes like this would be very unusual indeed, but it is important to know that should they occur, a prompt review is required to assess the cause and treat it. Some patients don't like Tramadol (may feel too light headed, or the room feels as if it is moving, or nausea), but will tolerate Codeine (and vice versa). Adjustments will be made if needed. Occasionally patients feel nauseated as the anaesthetic leaves the system, or sometimes as a result of morphine that may have been given by the anaesthetist during the operation. Both of these are soon out of the system and generally gone by the following morning. - What happens after the operation?
When the surgery is finished, the anaesthetic will stop and you will gradually wake up over about 5-minutes. At this point you are taken to the recovery area. You are supervised by the anaesthetist and the experienced recovery nurse and then by the recovery nurse alone. The tube that was in your mouth will have been removed and you will feel sleepy. You stay in recovery until fully alert and then you are taken back to your room where you will be made comfortable. The nursing staff adjust your medication as needed. Your throat may feel slightly sore from the breathing tube but you will be able to sip water straight away. At this stage there is still a drip in your hand, and this is taken down when you are drinking properly. The venflon (the name for the plastic needle in the back of the hand) is taken out the following morning, but can come out earlier if you are comfortable and not feeling nauseated. There will be a drain by your side and this should be kept laid out straight alongside your body so that the tube is not curled up, otherwise it can kink, and stop the suction. This is removed the following day, and is not painful. Your breast area feels tight and there will be a tubigrip (elasticated support) over your breasts. Often this is in a double layer overnight and then pulled down to a slightly looser single layer the next morning. There may also be a stabilising band (like a thick white elasticated belt) across the upper part of your breasts, which limits swelling in the upper pole of the breasts. You will go home wearing both the tubigrip and stabilising band night and day, without removing either. The dressings and the tubigrip must be kept dry. This helps reduce the risk of wound infection. You should therefore have shallow baths (run the water just up to cover your legs) and keep the tubigrip on (but dry) even when you are in the bath. It is good to get help with hair washing. Sponge wash the under arm area and pat dry afterwards. You will be seen by Mr Turton the following morning after surgery and the nursing staff informed as to when the drains can be removed. You will be given the "take home medication"- painkillers and antibiotics and should have clear instructions and understanding as to when to take them. Please ensure you discuss this with the nursing staff if not sure and If you have any queries after discharge you will be instructed to ring the ward for immediate attention. Mr Turton should be informed of any problems. - Are there any side effects to the operation?
The commonest one is feeling sleepy for a few hours. Sometimes the anaesthetic or morphine make you feel sickly, but usually for a short duration only. You may feel slightly bloated for a few days. This is often due to slight constipation caused by morphine, codeine and tramadol medication. A gentle laxative (lactulose, movicol or senna) will help resolve this. - What clothes should I bring in to wear leaving hospital after the operation?
A loose button front shirt is ideal. Nothing that needs pulling on over your head. - Do I need to take time off work after surgery?
Yes. Please check with Mr Turton in relation to what you do. Generally 1-week off. 2-weeks or more may be needed if your job involves lifting or heavy manual work. If very sedentary, you can occasionally return after 3-days, but remember that you will still be taking Paracetamol and Voltarol, but should have stopped the Tramadol. - When is it possible to resume household chores?
It is really important not to start household chores straight away. You may be glad to know that husbands/partners/friends will certainly need to help here. I advice against vacuuming and ironing for the first 3-weeks, and then only lightly for the following 3-weeks. The golden rule is "if it feels sore, then don't do it". Listen to your body. You want to avoid repetitive tasks that will stop implant settling and tissue in-growth on to the textured surface of an anatomical implant. If you don't have anatomical implants, you can resume chores more readily after 2-weeks. - When is it possible to resume Shopping?
You can go shopping the following day. You should not carry heavy shopping bags for 3-weeks. I would advice against bra shopping for 6-weeks as this is when implant settling would tend to have occurred. - When is it possible to go out to a restaurant?
You can go out to a restaurant straight away. You should avoid a very heavy meal and avoid more than a glass of wine or champagne in the first week. Many of Mr Turton's patients go out to a restaurant the very next day. - When is it possible to resume Decorating?
As this can be strenuous you should wait a minimum of 6-weeks. - I have small children; am I okay to play rough and tumble?
As this can be strenuous as well as painful, especially if you get knocked, you should wait until after 6-weeks. - Is it okay to sunbathe after the operation?
Yes, but you should use factor 50 + suntan lotion, or keep scars taped and completely covered by clothes. Remeber that you can get sun-burn through thin cotton. If the scar does get sun burn it causes a permanent redness. - How will my breasts look & feel after the operation?
During the first 3-weeks, the breasts tend to feel quite tight and swollen. After implant settling the breasts generally feel firm once all the swelling has resolved. - When can I lift my arms above my head?
After 2-weeks usually, unless Mr Turton advises you of specific exercises as part of the expedited recovery programme. - What pressure will it take to rupture silicone breast implants?
A car accident at 30/40mph could rupture the implants, or for example falling off a horse and hitting the breast area very hard. You would normally have obvious signs of a breast injury (swelling and bruising and tenderness), and a scan would be needed to evaluate this further. Minor trauma is very unlikely to cause a problem, and the modern implants that Mr Turton uses are extremely durable. The outer 3-layered membrane of the McGhan implant is very strong. Each batch of these high quality breast implants will have been through extensive quality assurance tests by the manufacturer before being released for use. - Is it possible to get larger implants after the 1st operation?
It is important to avoid unnecessary surgery. Redo breast augmentation carries additional risks and limitations. Further surgery years down the line is likely to be needed at some point, and it is better not to have this done simply for larger implants. When further surgery is required at a later date, implant size can be increased, but the same criteria and judgments need to be applied as for the first operation. It will still be the case that the bigger the size the more unwanted and permanent effects will appear both in the short and long term. - When can I wear an underwired bra?
Usually from 6-weeks. You should avoid trying on multiple bras at this stage. Get professionally fitted and buy from that shop initially. If the underwiring is uncomfortable go back into a sports bra and get refitted in a different shop. - When can I lay on my stomach?
Usually at 6-weeks; before this it is uncomfortable. - Is it possible to have the breast area tattooed?
There should not be a problem with this except for a small risk of implant infection. Tattooing temporarily injures the skin and it is conceivable that you could get cellulitis (redness caused by skin infection), which could allow the bacteria to travel through the breast lymphatics onto the implant. You may want to consider a short course of preventative antibiotics to reduce this risk. - It says no heavy lifting - what is classed as heavy?
Heavy is anything that is uncomfortable. In general terms lifting shopping bags that are full is what I would term "heavy". Lifting a kettle is OK. Lifting a baby is not. It is also important to try to avoid using your arms to shuffle yourself up and down the bed, for the first 6-weeks. When you do so, you are pushing hard with your hands onto the mattress and this is forcibly contracting the pectoral muscles. - Will I be able to breast feed with implants?
Yes. As long as your implants are placed through a conventional inframammary incision it will not alter your ability to breast feed. They do not alter the production of milk. The amount of silicone in the milk from a bottle is higher than that from breast milk; both are of course negligible. Some women cannot breast feed for other reasons of course. - Will a general or local anaesthetic be used?
The operation is carried out under full general anaesthetic and this is regarded as the safest approach. Pure local anaesthesia is an uncomfortable way to perform a breast augmentation although Mr Turton has done this on a patient with an unresolved phobia. "Twilight anaesthesia" carries a level of risk of losing control of the airway if the patient's level of consciousness falls and should be avoided unless there is a very specific reason to use this route. If a request is made for Mr Turton to perform a breast augmentation under twilight anaesthesia, he would still insist on a consultant anaesthetist being present to maintain the patient's 100% safety. This should never be an area of compromise simply to reduce the cost of breast augmentation. - If I have excess breast hair is it possible to have treatment to remove them?
Mr Turton does not offer this service personally but a reputable clinic should be able to advise. Small amounts of breast hair are commonly seen in all age groups and are dealt with differently by different people. Laser therapy or electrolysis therapy to get rid of the hair root is still possible after breast augmentation surgery. - How long do implants last?
It depends predominantly on the type of implant used, and the manufacturer The current 5th generation McGhan implants probably last far longer than previous types. In the biggest study performed to date, the rupture rate was extremely low (ie <5%) at 10-years obviating any need for automatic implant exchange as has previously been recommended. Mr Turton advises, clinical check-up, USS and MRI to assess implant integrity. If all is well, there is no need for implant exchange, which otherwise costs over £4000! There are many implants that are available to use for augmentation that do not have the same quality, safety, quality assurance, or longevity. These implants may cost a lot less and enable the price of the breast augmentation surgery to be much lower (this is sometimes done by competitors to encourage customers on the basis of price) but is almost certainly a short sighted approach. Low quality implants have a much higher rupture rate and capsulation rate. - Can I have them removed at a later stage if required & if so what are the consequences?
Yes. Implants are easy to remove, even under a local anaesthetic should it be required. The breasts will of course be empty, devoid of fullness, and the skin will be loose, usually with some wrinkles and sagging. The difference is profound as there will be age related changes that will have occurred and much less native breast tissue. - How long is the scar tissue healing time?
Skin healing occurs in the first 7 days, but continues to mature over 6-12 months. The scars must be cared for and you should avoid touching or feeling along the scar line for the first 8-weeks. Mr Turton gets his patients to tape the scar for 3-months to keep the scar line like a fine pencil line. The scars gradually fade over the first 12-months to a pale colour. This can be speeded up by using bio oil on the scar after 3-months, or a silicone gel called Dermatix (only available over the counter). |
