Breast Augmentation

Breast enlargement, or augmentation mammoplasty enhances the body contour of a woman who is unhappy with her breast size. It may also be used to correct volume loss after pregnancy, to help balance breast size asymmetries as well as a reconstructive technique following other breast surgery.

While breast augmentation will enlarge the breasts, it will not alter basic defects in breast shape or form. Major asymmetries may be improved, but will not be completely corrected. A slight difference in the size or shape of the two breasts is considered normal and should not be a cause for concern. If breast size or nipple position asymmetries are severe then additional procedures to further improve symmetry may be necessary.

A breast implant is composed of an outer silicone shell filled with saline or silicone gel. The outer surface may be smooth or textured, and implants come in various shapes to meet the individual woman’s needs. Texturing and shape options can further be discussed with your surgeon upon consultation. The FDA re-approved silicone breast implants in November of 2006. These are now silicone gel versus the “old” liquid silicone implants. Women must be at least 22 years old to select this option as directed by the FDA to ensure their emotional maturity in accepting the possible risks of having these newer implants placed. There is no perfect breast implant and both the saline and silicone gel implants have advantages and disadvantages. The silicone gel implants feel softer and more natural, have less chance of rippling, but are more expensive and have a higher chance of developing tightening of the scar tissue around the implant known as capsule contracture. Saline implants are very safe and if they deflate your body will absorb the water. Saline implants are more prone to rippling and feel less natural than silicone.

The breast normally covers a muscle on the chest wall called the pectoralis muscle. Breast implants can be placed above or below this muscle. When implants are placed below the muscle, it is called a submuscular or a subpectoral placement. When the breast implant is placed above the muscle, it is called a subglandular or submammary placement, meaning that it's below the mammary gland. Submammary or submuscular placement is dictated by the existing breast form including the amount of existing tissue and also the patients goals regarding augmentation.

There are several ways in which the breast implant can be inserted. An incision can be made under the breast (inframammary), around the bottom of the areola (periareolar) or in the armpit (transaxillary). The incision under the breast (inframammary) is the most common, but is our least favorite for a number of reasons. First, it is the area that most people relate to breast enlargement surgery. Also, it may not always end up in the new inframammary fold where it would be hidden the most. More importantly, this approach places the scar very close to the implant. If the incision should get infected, it may be more likely that the infection could reach the implant. Finally, although inframammary scars usually heal well, we have seen some instances of scar thickening that were very difficult to improve. However, the incision has been used for decades and remains a good option that usually has no major problems.

The periareolar incision is made in a semicircular fashion around the lower half of the areola approximately 4-5 centimeters in length. It offers the advantage of keeping the incision far away from the implant and allowing good surgical exposure of the entire pocket. The incision may have a slightly higher risk for loss of nipple sensation and difficulty with lactation as compared to the other incisions, but it also remains a good incision option.

The endoscopic transaxillary incision offers several advantages. The incision is approximately four centimeters in length placed high in the armpit. The incision usually heals very well leaving no visible scar on the breast itself. The use of endoscopic surgery has allowed us to carry out breast augmentation with more precision and less bleeding. Special instruments designed for this purpose allow us to work through the small incisions, monitoring the operation on a video screen. The pocket is tailored under direct vision rather than the traditional blind dissection. The improvement is obvious since it is always better to see clearly what one is cutting.

In selecting the size of the implant, the general choice should be jointly made by the patient and the surgeon prior to surgery. While ultimately, the choice of size is made by the patient, she should recognize that there are advantages to a conservative selection. Capsular contracture (discussed later) and rippling are more common with larger implants. Postoperative numbness and long term sagging are also more common with large sizes.

The shape of your augmented breasts depends on the implant size and shape along with how your breasts appear prior to surgery. Many patients desire fuller cleavage. Although larger implants will give more cleavage, the patient’s nipple position, chest shape and breast shape largely determine the amount cleavage that can be achieved. Also, the same size and shaped implant on one patient can look completely different on someone else. Therefore, one should avoid picking a size or shape solely on what ‘looks good’ on someone else. A thorough consultation and pre operative screening with your surgeon is critical to determine your options and ideal treatment plan.

Procedure

The operation is carried out under general anesthesia in an out patient surgery center. Thus, you may go home after the surgery and will follow up on the first post operative day. The selected incision is made and this is followed by dissection of the proper plane of placement. This is followed by placement of your permanent implants through the incision. Symmetry and form are evaluated and after only excellent results, the incisions are closed with dissolvable sutures. The incisions are dressed with cloth tape and a compression bra is placed.

Recovery

Your breasts will be bruised, swollen, and you may experience some mild discomfort for a couple of days. The pain is generally well controlled with oral pain medication. In the recovery stage, it is important to wear the bra at all times until otherwise directed.

Patients follow up on post operative day one for general re-evaluation and then at one week. At that post operative visit, the cloth tape is removed and replaced with flesh colored dressing tape which falls off on its own with in the following week. Your incisions will be noticeable immediately following surgery but they will gradually fade and flatten for up to a year after surgery. Massage exercises may be started and the compression garment wear will be tailored.

Recovery is generally one to two weeks. It is important to limit lifting weight to less than five pounds the first week and ten pounds the second week. It is also important to limit lifting your arms above your shoulders as much as possible the first two weeks. Patients usually return to light activity within two to three days after surgery. Full activity is resumed within two or three weeks but no vigorous bouncing type activities (jogging or horseback riding) are recommended for 6 weeks. Although the breasts usually look good almost immediately after surgery, there is an improvement in the shape over the following several months.

Following augmentation routine examination and imaging as indicated by the AMA/your primary care physician, the FDA or the implant manufactures is important.

Possible Complications

Infection is rare but probably the most serious risk of the operation. Infection involving the implant will rarely be treated by antibiotics alone and treatment usually entails removal of the implant. It may even be necessary to leave the implant out of the pocket for up to three months while the infection resolves. Implant rejection is another rare but serious potential complication. It is extremely rare that an individual would react to the material, but these individuals cannot undergo augmentation. More often, implants “reject” due to inadequate soft tissue coverage for an implant selection that was too large. Implant exposure is more common in patients with diabetes, a history of radiation, autoimmune disease or smokers.

Smoking can alter you wound healing capacity causing your incision to heal unfavorably. If you smoke it is recommended that you quit 4-6 weeks prior to your procedure to maximize your healing potential but smoking is not a contraindication to performing the surgery.

Sensory changes can occur resulting in numbness or discomfort and while these symptoms are usually not long-standing or severe, they can be in some cases. Minor sensory changes are common and usually last 2 to 6 months. Implants could possibly interfere with nursing although many patients nurse after the operation without difficulty.

One problem that can occur with breast implants is related to the natural tissue capsule that forms around the implant within the body. Sometimes this capsule thickens or contracts causing unnatural firmness or shape to the breast. This condition is called “capsular contracture”. In severe cases, calcium deposits can develop and the patient can also experience discomfort or pain. In mild cases, breast compression exercises may allow the capsule to stretch and soften. Although in more advanced cases, further surgery and possible replacement of the implant is required. Unfortunately, there is no certainty that the scar tissue will not reform.

Rippling, or surface irregularity over the implant that can be seen or felt, is another potential problem with any type of breast implant. It occurs more frequently with saline filled implants because the water in the implant is less viscous than silicone gel. The more soft tissue coverage over the implant, the less the likelihood of rippling. Also, the greater the size of the implant with more tissue stretch, the greater the likelihood of rippling. Smooth surface implants seem to have less of a chance for rippling than textured surface implants

Patients who have moderate sagging of the breast may be at risk for a problem known as the ‘double bubble’ deformity. This deformity can occur when implants are placed below the muscle in women with some droop to their breasts. The deformity presents as a ridge in the lower pole of the breast where the previous inframammary fold was located. If we notice significant droop of your breasts we will recommend a breast lift or placement of the breast implants above the muscle to avoid this problem. Realize though that placing an implant above the muscle in breasts with droop will ultimately result in larger droopier breasts with time.

Overall, the procedure provides immediate results which are very gratifying. The type and amount of augmentation will be a joint decision based on the patients goals and options discussed with the surgeon during the complimentary consultation and pre- operative appointments.