Procedures | Breast Augmentation
What option is best for you?
- What type of implant should I choose?
- What size implant should I choose?
- What type of incision is best for me?
- Should my implant be above or below the muscle?
- What sort of woman chooses to have a breast augmentation?
There are two basic types of implants with various minor variations, silicone filled and saline(salt water) filled. The shell containing these fill substances are all silicone, just a longer polymer. Silicone gel implants come prefilled whereas saline implants are filled at the time of the operation.
Silicone gel implants are preferred much more than saline, at least in my practice. This is inspite of the fact that gel implants are more expensive and require a slightly longer incision for placement. Silicone gel implants, in most patients, look and feel more natural. This is because the gel which fills the implant is manufactured to mimic the consistency of the normal breast. Now that the safety issues have been settled, patients are returning to the aesthetically superior gel models.
Saline breast implants are suitable in many patients, however. Where there is sizeable breast tissue and subcutaneous fat, the less viscous (more watery) consistency of saline can be well camouflaged. The greater the volume of native breast tissue and the smaller the saline implant, the less advantageous aesthetically silicone gel is over saline.
Implants can also have different profiles and may be preferentially "shaped"-teardrop. In general, these variations from the standard implants are used for unusual problems of anatomy. I use them only ocasionally.
The silicone gel filled implant is aesthetically the best choice for most women. They are more expensive and require a longer incision to insert, but usually feel more natural after healing is complete. The smaller the breast and the larger the implant, the more cosmetically advantageous are silicone filled implants.
Saline implants are suitable for patients with already significant breast tissue. They are less expensive.
All implant covers are made of silicone. The cover may be smooth or rough (texturized). Texturization was introduced to combat problems of breast hardening - capsular contracture. I don't think there is any evidence that texturized implants decrease the risk of capsular contracture. I am of the opinion that they have a higher failure rate. Therefore, in my practice, texturized implants are used rarely.
The "gummy bear" implant is being studied for possible introduction to the US market. It is a solid implant (as opposed to a silicone shell with fill substance) of uniform soft consistency. Preliminary reports are discouraging because of unanticipated problems, but the research continues.
Implant size is left to the discretion of the patient. Much of the preoperative planning is devoted to determining what the patient has in mind. In my experience cup size, chest measurement, tryouts of various implant sizes in the bra, and posturing have all been found to be less than satisfactory in ascertaining the wishes of the patient. Patients may bring a picture of a model having the desired breast size.Our office photo gallery show patients with different breast sizes pre-op and post-op. Video imaging may also help. Using these methods of assessment, a close volume match can be provided.
I have been doing breast augmentations for many years. Almost all women, when asked a year or so later what they would have done differently, wish they had been made a little bit larger. Complaints the other way are almost never heard. This is usually because the patient has been modest or conservative when appraising the desired size. It is important to avoid the tendency to underestimate. Pick a range and lean towards the larger size of that range.
Breasts that are somewhat ptotic (droopy) will be better dealt with by a larger prosthesis. The ptosis is not corrected, but is better masked.
There are three types of incisions with definite advantages and shortcomings. The inframammary incision is placed in the crease below the breast where the breast ends and the abdominal wall begins. The peri-aveolar incision is located along the lower edge of the areola. The axillary incision is placed in the armpit.
The most commonly used incision chosen by the patients in my practice is the inframammary. It is direct and requires no dissection through breast tissue. It is very well hidden especially when standing, the breast completely covers it. Generally, it is about 1 inch in length and results in a fine white line when wound remodeling is complete---6 months to 2 years.
Second in popularity is the periareolar incision. The incision is about an inch in length along the inferior border of the areola. The scar is highly acceptable. The incision does require dissection through breast tissue for placement of the implant. This has the theoretical disadvantage of exposing the wound to bacteria that exists naturally in the milk ducts. There is scarring in the breast tissue, as well. Nevertheless, there are really no long term disadvantages of consequence and this incision is highly acceptable.
The axillary incision is placed through the armpit and is generally 1.5 inches in length. The dissection of the pocket is more difficult and requires a special tool. This does not appreciably lengthen the operation, however. The glands in the axilla contain bacteria similar to breast tissue which poses the same theoretical problem. Again, there is no increase in infection noted. However, if an open capsulotomy is required for the treatment of capsular contracture at a later date, it cannot be performed through the axillary incision. Under these circumstances, a separate incision would be required.
In general, all of the incisions end up being highly satisfactory. Every effort is made to keep them as short as possible. Mother Nature is generally forgiving of these wounds so that they are nearly invisible when the healing process is complete.
There are advantages and disadvantages to both that must be understood for an intelligent decision to be made. First of all, as noted above, present day opinion (without scientific validation) favors a submuscular placement when considering the interpretation of mammograms. It is debatable that this is a major consideration. The placement of your implant will be determined during consultation with your doctor or physician.
If a breast is tubular in shape or if it is modestly ptotic (droopy), there is a definite aesthetic advantage to placing the implant above the muscle. The ultimate shape is more natural when the implant is in this subglandular position.
As a rule, since saline implants are filled with water and not thicker silicone gel, they feel more natural when more tissue covers the implant. Women who have some breast volume to begin with can expect a more natural feel to the breast.
Consequently, saline implants are preferred deep to the pectoralis muscle all other variables being equal. More tissue covers the implant (the pectoralis muscle is another layer of tissue) making them feel somewhat more like normal breast tissue. A submuscular implant may be distorted when the pectoralis muscle is being used. During certain strenuous chest exercises such as swimming or weight training, the implant may be temporarily misshapened as the pectoralis muscle is exercised.This is very subtle and seldom a problem for our patients.
Submuscular placement does not involve cutting of any muscles and does not diminish muscular strength. Patients comment that post-operative pain is greater in the submuscular position. This generally equalizes with the subglandular placement in a few days, but is a consideration, nonetheless. After the appropriate convalescence, it is permissible to resume the normal range of activities.
Augmentations are performed on women of all ages. In my own practice, the age of the augmentation patient ranges from 17 to 60. The vast majority of women, however, fall into the 21 to 40 year old age bracket. Studies have been completed to evaluate the psychological profiles of the women who have breast enlargement. These studies show that the typical patient seeking augmentation is particular about appearance and has considered augrnentation for several years. Commonly, a friend has undergone the procedure with an enviable result. These women are found to be socially and professionally active with the operation chosen because it is perceived as a social or professional asset.
Most of the women we see have a very definite idea about the way they would like to look. Since the operation can come so very close to creating the desired breast size and shape, it is understandable that it remains popular. Some women consider breast augmentation as a means of appearance enhancement. Others have lost volume due to weight loss or previous pregnancy and simply want to reachieve their native size.
About the procedure...
- Is the operation safe?
- What type of anesthetic is used?
Simplistically, the operation involves placing a prosthesis (implant) underneath the breast. The prosthesis is positioned directly under the breast tissue in some instances or underneath the pectoralis major (a chest wall muscle) in others. The advantages and disadvantages of each area of placement will be discussed later.
A small incision is required to gain access to the area where the implant will be placed. A pocket needs to be created to accommodate the breast implant. After the implants are positioned, the breasts are checked for proper position and symmetry. The small incisions are then closed with a delicate suture.
All operations, no matter how trivial, carry risks. Breast augmentation is a very safe procedure. Almost all of the women who choose to proceed are in good health. Blood loss is minimal and the anesthesia time is short. This translates into a low-risk operation.
Infection is possible but distinctly uncommon. It occurs less than 1% of the time. In the advent of this rare complication, the implant may occasionally be saved by antibiotic therapy. More commonly it will require removal and reinsertion when the infection has been eradicated.
A hematoma or blood clot around the implant and within the breast pocket occurs 1-2% of the time. This is usually from a small blood vessel that was not bleeding at the time of closure but begins to ooze later. These are seen in the first 24 hours after the operation - rarely later. Although the amount of blood is usually a small amount, it does require evacuation and control of the bleeding vessel. This, of course, requires an auxiliary operation as soon as the problem has been identified.
Breast augmentation may be performed under general anesthesia or with a combination of intravenous sedation and local anesthesia. General anesthesia is almost always used in this operation, however. Both techniques are equally safe but differ in several important ways. An understanding of the differences will decide which anesthetic will be chosen.
General anesthesia is performed in a surgery center or hospital under the direction of an anesthesiologist or anesthesist. The technique requires insertion of a tube into the upper airway with ventilation controlled by a machine. There is no pain experienced during the operation, although an IV catheter must be inserted through the skin before anesthesia is begun. There is no recollection of any portion of the operation.
In "twilight anesthesia" no intubation is required, although supplemental oxygen is sometimes given by a mask. Intravenous pain medication and sedatives are given to relieve pain, control anxiety, and create temporary amnesia. Discomfort is perceived, but is well tolerated during the administration of the local anesthetic, which numbs the breast. It is generally not remembered after the operation. The operation itself is relatively painless because of the local anesthetic.
Obviously, not every patient is suited for the intravenous technique. Patients who have their implants placed in the subpectoral position usually require general anesthesia. There is no significant safety advantage of one technique over another.
This manuscript was written to outline the general concerns of most patients. It is not intended to be an exhaustive review of every aspect of breast augmentation. Similarly, many questions may occur to you, as a patient, that are not addressed in the above text. These questions should be asked during one of the several interviews before the operation. The office will take all the time that is necessary to ensure that you are informed to your satisfaction regarding all aspects of the procedure. We will also be glad to answer any questions by telephone or email. The telephone number is are: (404) 814-1100. Email questions to firstname.lastname@example.org.
Important information to know...
- Can anything be done to prevent capsular contracture?
- What are the chances that I will get a capsular contracture of my breast implant?
- Does the presence of a breast implant influence the development of breast cancer or its detection?
- Do breast implants cause arthritis or other diseases?
- Possible complications
- What are the post-operative instructions?
Anytime a foreign substance is placed in the body, it is recognized biologically as foreign. The body attempts to isolate the alien material and wall it off from the rest of the body. This happens with any foreign material--a piece of glass, a splinter, a bullet, a metal hip prosthesis, or a breast implant. The body accomplishes this by depositing a thin layer of collagen (scar tissue) around the prosthesis. This is probably a beneficial event. The prosthesis is effectively isolated from the body even though it is contained within it.
The capsule, however, has the ability to contract or "shrink" around the prosthesis. If this "shrinkage" is excessive, the capsule squeezes the prosthesis. This phenomenon leads to a breast that feels firm - a capsular contracture. This hardening is referred to by some colloqially as "capsules".
Remember, however, that everyone with implants develops capsules. Most of the time they do not squeeze the prosthesis so as to create hardness. A better term to describe hardening of the breasts is "capsular contracture".
Many variations to surgical techniques, implant materials, pre-operative and post-operative care have been suggested to decrease the chance of capsular contracture. In addition, medications of varying types and combinations have been advocated. Unfortunately, no combination of medication, activity, or implant type can prevent capsular contracture. Furthermore, it is not clear whether anything decreases the incidence of breast hardening due to capsule formation.
For a long time, it was generally accepted that an implant placed below the pectoralis muscle was less likely to suffer from hardening than one placed directly below the breast. Critical review of both groups of patients has shown that if there is a difference, it is minimal. Furthermore, one form of treatment of capsular contracture, the closed capsulotomy, is decidedly more difficult if the implant is below the muscle.
Steroids placed within the implant in a timed-release form have been shown to be effective in decreasing the incidence of capsular contracture. They are not used routinely because of their side effects, some of which can be severe. When the dose of the steroids reaches the level of effectiveness against capsular contracture, the incidence of steroid complications begins to increase. Major wound healing problems have been reported. Therefore, their use is restricted for special cases. When used, the dosage must be carefully controlled.
Vitamins, both pre- and post-op have never been shown to be of any benefit. Breast massage and other breast "exercises" similarly have been advocated by some but have never been shown to effect the softness of the breasts. As a matter of fact, several plastic surgeons have claimed that capsular contracture is increased by vigorous post-op manipulation. I do not recommend massage of the augmentated breast.
Antibiotics are given routinely to our patients to guard against infection.Some reports claim that a low grade infection may contribute to the development of breast hardening. The raw data to support this is lacking but the possibility does exist. All plastic surgeons employ meticulous sterile technique. In addition, it is my practice to irrigate the pocket during the operation with an antiseptic solution plus an antibiotic solution. Intravenous antibiotics are given during the case and post-operative antibiotics are taken for five days. These precautions may decrease the incidence of capsular contracture but do not eliminate the problem.
Biofilms. One possible cause of capsular contracture is a biofilm. This is a relatively new area of interest in many areas of medicine and has been posited as a culprit in capsular contracture. A biofilm (eg. plaque on the teeth) may form by contamination at the time of placement of the implant or bloodborn at a later time. A theoretical argument for not using the axillary or periareolar approach is that they create the pocket for the implant through an unsterile pathway. The breast is not sterile as bacteria can reside in the ducts. One can make the theoretical argument that the inframmary approach is preferred since it is a sterile path. I reiterate, this is, at the moment, a theoretical argument.
It is not known why capsular contractures occur. It does not seem to effect any particular ethnic group the way scarring problems do. It does not effect any specific age group more than another. It is unrelated to the type of incision used. It may involve one breast and not the other.
Capsular contracture is not an all or none phenomenon. That is, some breasts may be completely soft, others slightly firm yet still pleasing, others firm but attractive, and still others exceptionally firm and unnatural in appearance. About 5-15% of women will develop enough firmness to be labeled as having a capsular contracture. Fortunately, most firmness is modest and requires no treatment. I have had many patients tell me that their breasts were more attractive after they became slightly firm. Nevertheless, this is labeled a capsular contracture.
About 5-10% of all augmentations will develop enough firmness so that some sort of therapy will be required to soften them. The simplest treatment is called a closed capsulotomy (breaking up the capsule). This is a short office procedure that involves compressing the breast firmly in an attempt to break the capsule. It is easier to perform if the implant is subglandular (directly under the breast tissue).
If closed capsulotomy fails, an open capsulectomy (complete removal of the capsule) may be required. This is a formal operation that requires opening up the skin incision and surgically removing the capsule. The procedure is usually successful in softening the breast or breasts but a new capsule will form and a secondary capsular contracture may occur.
It is important to remember that a capsular contracture poses no health threat. It is a compromise to the aesthetic result only. Many women choose to keep a slightly firm breast rather than undergo an auxiliary procedure.
There has been an enormous amount of work done to answer these questions. It is impossible to say if the implant is completely safe. Clinical and experimental studies have examined relative risks of implants. The statements made henceforth reflect what is known about the safety of implants at the present time. The questions continue to be studied and new information may change the accuracy of these conclusions. Silicone is not only used in breast augmentation, but also in joint replacement, volume enhancement, and as a biological substitute for tendons and ligaments. It is now known that women with breast implants have a slightly lower incidence of breast cancer than women without. This is statistically significant meaning there is a slight, but measurable protective effect of the implant against cancer. The mechanism is unknown. This is certainly not a reason, of and by itself, to proceed with augmentation, but the patients who undergo the procedure may take comfort in the fact that they are not increasing the risk.
Breast implants do influence the interpretation of mammograms, the radiographic screening test for breast cancer. There is little question that interpretation of a mammogram is made more difficult with the presence of an implant- but not the accuracy. It is often heard that the interpretation is somewhat easier if the implant is below the pectoralis muscle rather than directly behind the breast (an arguable point). When a mammogram is obtained, the technician should be alerted to the presence of the breast implant if the breast has been augmented. This allows for special views which some radiologists request to better visualize the portion of the breast obscured by a breast implant.
Furthermore, all breast lumps must be treated as potential breast cancers even in the augmented patient. It is possible for the implant to create a breast lump. This judgment must be made by the plastic surgeon, however, and not the patient.
The lay press has stated that silicone (at least in breast implants) can cause a number of auto-immune physical problems. The complaints fall medically under a group of problems called " collagen-vascular" diseases. There has been a general acceptance by the public that breast implants and these conditions are linked. This misconception was further reinforced when the FDA asked for a voluntary moratorium on women seeking breast augmentation for the first time in the 1990's.
In fact, none of this happens to be true. There are now a number of studies demonstrating that there is no relationship between silicone filled breast implants and systemic diseases. Silicone gel-filled implants are now available to any women interested in augmentation.
Plastic surgeons and implant manufacturers remain vigilant to safety issues. Patients choosing silicone gel implants are immediately enrolled in an ongoing study to establish data over long periods of time. This includes the harvesting of data regarding overall health issues and specific aesthetic issues such has hardening or misshaping of the implants.
Complications are very uncommon after breast augmentation. When they do occur, they are treatable best if they are recognized and addressed immediately. The complications that may occur after the operation and before the first office visit are infection, wound separation, or hematoma (this is an abnormal collection of blood in the implant pocket).
The following observations require an immediate call to the office:
1. Excessive drainage, especially if it is foul smelling.
2. Fever and chills.
3. An excessively swollen or tight breast especially when compared with the opposite side.
4. Severe pain not responding to the prescribed pain medication. Obviously some pain is to be expected. It should get better, not worse, with each day.
Other observations may be made that are not listed here. This does not mean that they are not important. If anything causes concern, please do not hesitate to contact the office.
Rest and leave the dressings in place for first 24 hours after the operation. After the first 24 hours, you may remove the support bra (provided to you at the end of the operation) and dressings.You may shower if you wish but try to keep the steri-strips covering the wound dry. Place small pads over the incisions and allow the support bra to hold these dressings in place. (The incisions should not be immersed in water while sutures are in place.)
Allow the steri-strips to remain in place until they begin to come detached by themselves. Many times they will remain adherent until the first post-op visit. At other times, they may detach themselves. If this happens, you may remove them. New steri-strips need not be applied.
A small amount of drainage is expected for several days after the operation. Large amounts of drainage that soak the dressing should be reported to Dr. Zubowicz.
Other than when showering, the support bra should be worn at all times, including sleeping. After one week, you may use a sports bra or another bra that is supportive, but no underwire bras for 6 weeks.
Shampoo your hair only with assistance for several days. The patient should not lift their arms over the head until the pain has subsided. Furthermore, lathering in hard to reach areas should be done by an assistant.
After the first 24 hours, light activity is permitted if it is comfortable. This would include walking, riding in a car, or any activity that is not strenuous and does not involve use of the arms. Driving may commence when the pain has gone.
(Light exercise may begin in one week after procedure if the pain has subsided and the arms will not be used.) Tennis, swimming, running and golf are not permitted. Furthermore, any exercise that involves excess movement of the breasts is to be avoided. Walking is a superb exercise, as is riding an exercise bicycle.
Four weeks after the operation, most patients can resume their normal lifestyle and exercise habits. You will be seen in the office at this time and receive a medical clearance. It is advisable to work into your exercise routine over several days.
Work may resume if it does not involve strenuous physical activity or use of the arms and there is no pain. Most patients can return to desk-type jobs in 4-5 days. If the pain increases or excess fatigue occurs upon work, go home and rest.
Sleep on your back as much as possible. Sleeping on the stomach will put pressure on the chest, while sleeping on the side requires extension of the arms. You may put pillows at your sides for comfort.