Breast Augmentation Procedures

The following is abbreviated transcript from The Naked Truth About Plastic Surgery: Volume 2 Breast Augmentation, Breast Reduction & Breast Lift.

See The Naked Truth Volume 2 for full length video.

The purpose of this communication is to enhance, not replace the discussion and consultation with your physician so that you can make an informed decision based upon the risks, benefits, and alternatives for your specific needs and desires. After reading this, you will be able to have a more meaningful discussion with your doctor.

It is important to remember that any decision to undergo plastic or cosmetic surgery must involve a commitment on your part to carefully follow the post operative instructions. Failure to follow these instructions can create serious complications and undo the desired surgical result. Optimal results from your procedure require both your patience as well as your active involvement in your recovery by following any treatments or restrictions provided.

Even if you are the optimal candidate for the procedure and have the best technical and artistic surgical care, failure to follow the specific recovery instructions will change the desired result. Remember, your post operative commitment is as an important component as choosing your surgeon and undergoing the right procedure for you.

Breast Augmentation, Breast Reduction and Mastopexy

Breast Augmentation

Breast augmentation is one of the more common cosmetic surgery procedures performed today. It involves placement of saline or silicone prosthesis within the breast to enhance the size or shape of the breasts. It is performed safely in thousands of patients each year. Without complications, it provides an excellent way of increasing the size of breasts, improving their shape, and making different sized breasts more similar. It often allows more comfort and versatility in clothing selection and provides more self confidence for women.

(Fig 1 a,b,c) These are sample before and after pictures of a patient who underwent a breast augmentation procedure. She has changed from a B cup to a C cup bra size. The incision was placed under the nipple areola.

Fig-1a

Fig-1b

Fig-1c

(Fig 2 a,b,c) This is another set of before and after photos of a patient who had breast augmentation with saline implants. The incision again was placed under the nipple areola. Again, she increased her bra size from a B cup bra size to a C cup bra size.

Fig-2a

Fig-2b

Fig-2c

(Fig 3 This patient increased her bra size from an A to a D cup after having two surgeries. The second enhancement was done a year after the first. She has maintained a very natural look despite going significantly larger. Needless to say, she felt much more confident and comfortable in a bathing suit following this enhancement.

Fig-3

It is important to note that patients in need of breast reconstruction from cancer, trauma, and congenital deformities also have an opportunity to improve their physical and emotional state with breast implants.

There are basically two different types of implants used for breast augmentation. These are silicone and saline and they come in different shapes, profiles, and surface textures. None of them are perfect devices and each has its own particular advantages and disadvantages.

For a period of time, silicone implants were restricted for use as data was being gathered by the FDA, implant manufacturers, and various entities to assess their safety. After a very large and lengthy study, the FDA has ruled that silicone implants do not cause many of the health problems which were unfairly attributed to them and are safe enough for fairly unrestricted use. In particular, the rate of breast cancer and connective tissue disorders was no higher in patients with breast implants than what is found in the general population of women without implants. For further information, please see the FDA website.

(Also read the section on “complications of breast implants” further in the body of this document.)

Silicone implants have an outer cover of silicone, and contain silicone within the shell as well. Silicone is used in many medical devices such as pacemakers, artificial joints, and heart valves. It is also found in foods, cosmetics, lubricants, and other products commonly used and ingested.

Saline implants have an outer cover of silicone as well; however they are filled with saline solution sometimes described as salt water. Our bodies are composed of approximately 75% saline. The same saline solution that is placed in the implant is also placed in your veins if you were in the emergency room or having a baby. You can drink it.

The exterior cover of either type implant can be smooth or rough (“textured”) and the benefits of these differences will be discussed later.

Either type of implant also may be available in a more teardrop shape. Your surgeon will have a preference on which implant he or she prefers, or which one is best for your unique situation. Ask them about these choices.

Implants also can come with different “profiles?” making some “project” more than others. Generally at the same volume, “high profile implants” project more but are not as wide as “lower or moderate profile” implants. My advice to you is to inform your surgeon on the “look” that you are trying to achieve and let them pick the implant that will be suitable for you considering your anatomy. Telling him or her the exact size, shape, profile you want (usually based on a friend’s procedure) is probably a recipe for failure.

Adding another variable to the equation is the density or “cohesiveness” of silicone. The very cohesive or “gummy bear” implants which are used in Europe are currently under study in the US. These sometimes offer advantages of less rippling and peace of mind if they rupture as the liquid is more gelatinous and has the capability of staying “intact”. Rippling issues are more pertinent in patients with thin skin. It is physically difficult to determine if and when these implants rupture also and if they do, it would similarly be advisable to replace them as well. From preliminary studies, these implants have disadvantages also. They only come in shaped designs (not round) which is limiting for some primary cases and many reconstructive or secondary cases. They can only be placed through an IMF incision generally and because of the density of the implants, they are harder to squeeze through a small incision. This means the scar will be longer when compared to less cohesive implants. Again, you need to have these discussions with your plastic surgeon who can simplify the process for you.

For a detailed interview and discussion with Dr Garth Fisher regarding his personal opinion and advice on selecting implant type, shape, size, etc, Please click on this link which will take you to his interview in the 2008 Aesthetic Buyers Guide.

Incision Location

(Fig 4) Implants can be placed in your breasts through incisions under the arm (a), under the nipple (b), under the breast (c), or from within the belly button (d). Your surgeon will have a comfort level with one or all of these possibilities and will discuss his and your preference. Excellent or poor results can be seen with any approach. If you are considering the approach through the belly button, be sure to discuss with your surgeon the additional unique risks and complications from this procedure. Dr Fisher and many other surgeons feel that there are no real advantages with this technique however, there are extra risks.

Fig-4

Implant Location

(Fig 5) Breast Implants can be placed on top, below, or partially below the muscle. (This graphic shows the implant on top of the muscle in (A) which is commonly called subglandular placement, totally under the muscle in (B), and partially under the muscle in (C). Again, there are certainly patients with excellent and poor results from every technique. Usually the different locations of the implant in turn results in different shapes, risks, and other characteristics. You should discuss these options and preferences with your surgeon as well. Your unique individual tissue characteristics often will make one location more preferable than another. In general, implants on top of the muscle will not move with flexing of the chest muscles while working out. Movement with flexing is more common if totally under the muscle and less so if only partially under. As will be discussed soon, capsular contracture rates, or hardening of the breasts has been reported to be slightly more frequent if the implant is on top of the muscle. Those patients with thin skin also benefit more by having implants under the muscle as this adds more tissue coverage for the implant. This added tissue coverage in turn, decreases the chance of seeing rippling of the implant.

Breast implants are not filled with helium. They have weight and the larger the implant the more it weighs. They will not lift your breasts up but they do fill out the excess skin to make them fuller. The larger the implant, the more cleavage and fullness you will get. However with the increasing weight the greater the risk of them drooping lower and faster as gravity affects them. Breast implants can disguise or treat the earliest stages of drooping. More severe drooping or “ptosis” should be corrected with a breast lift which is discussed in the breast lift section.

Fig-5

Bra Sizing

Bra sizing is a very inconsistent communication tool and cannot be guaranteed. An A cup in one company is a B cup in another, and a C bra size to one person is a D to another. Since this is so subjective, your surgeon can only attempt to achieve the size you want. Communication of your desires is important. Some doctors require pictures of breast sizes you desire, while others may ask you to fill zip lock bags with rice or water to estimate the size you want. Of course, the patient’s unique anatomy, elasticity of skin, and muscle tightness present limitations as well. Because of these limitations, it may not be physically possible to place the size implants you desire in your breast.

Possible Complications of Breast Implant Surgery

Complications can be frequent with implantation surgery. A list of possible complications of breast augmentation surgery will now be covered.

Alternatives

You should always consider the alternatives to having breast augmentation with implants. You might be a candidate for enhancing your breast size or shape with your own body’s tissue instead of an implant. Other options may include changing your present diet or beginning a new diet program, changing your exercise routines, or possibly addressing a current medical problem if applicable. Other techniques promoted to possibly change the size or shape of the breasts include various medications, pills, and creams. Of course you certainly can find a different style brassier with or without fillers to achieve a desired affect. If you choose not to have surgery, you will avoid the risks associated with having the surgery. You should consult with your doctor about available alternatives other than breast augmentation. No surgery means no risks of surgery.

Capsular Contracture: The most common problem associated with breast augmentation with either silicone or saline implantation is capsular contracture. This means hardening of the breast as the capsule of scar tissue around the implant tightens. When a foreign object is placed within the body, the body is very smart and realizes that it is foreign. The body then forms scar tissue around the object or device in an attempt to protect the body from the device.

(Fig 6) This picture of an orange can be compared to a breast implant with surrounding capsular contracture. Imagine the center of the orange being the implant, and the orange peel is the scar tissue that surrounds the implant. This scar formation phenomenon is similar to what happens when a chin implant, pacemaker or other prosthesis is placed within your body. It is a necessary and unavoidable event. This is NOT a rejection or allergic reaction! The problem is that a reasonable percentage of women will form very hard scar tissue around the implant. These percentages vary widely with different studies but are approximately 5-15% according to some national statistics. This hard scar tissue can result in painful, distorted breasts, which could require additional medication or surgery to correct. Sometimes, the pain, deformity, and hardness can be permanent despite multiple operations.

Fig-6

(Fig 7) This is a picture of a patient with a capsular contracture on the right. You can see that the implant has risen up and become tight, and would feel very hard if touched.

Fig-7

(Fig 8) This is another example of a contracture. With her hands raised, you can see that the breast on the left side has assumed a very round and tight appearing shape. If you touched this breast, it would be very firm. Again, these rates of contracture vary from surgeon to surgeon depending on several variables, but it is the most common problem to be concerned with prior to considering breast augmentation.

Fig-8

Some studies suggest that implants placed under the muscle have a lower contracture rate than those placed above the muscle. The difficulty in evaluating studies is the wide variation in the skill of the surgeons contributing to the data. With that being said, one of the most important contributors of hardening is the amount of bleeding intraoperatively. This should be kept to a minimum by your surgeon to further decrease this risk as extra blood stimulates thicker scar tissue formation. The amount of bleeding varies with technique and surgeon. Postoperative infection increases the risk of hardening, as does contamination of the implant. Almost all implants however may become contaminated. They are placed within the breast tissue, which is not normally sterile like the heart or the brain. Breast tissue is commonly filled with bacteria, much like the nose or mouth, as the ducts of the nipple are in contact with the outside world. These bacteria can cause contamination and eventual infection. Breast implants may have textured or smooth surfaces. A textured surface has been shown in some studies to further decrease the risk of contracture especially if the implants are placed above the muscle. Many surgeons however feel there is a downside with textured implants. They can have a less satisfactory “feel” with palpation and can increase the rippling appearance on the skin. Some studies also report higher rupture rates with textured implants. (Personally, I prefer the smooth surfaced implants in my over 20 year experience.) Unfortunately, there are other causes of capsular contracture that we are not aware of in this day and age. Currently, studies are taking place to find out more about this problem.

If capsular contracture does happen to occur, there are different degrees of hardness. Breast hardness can range from slightly and not noticeably firm to very hard. Slightly firm breasts usually do not require treatment however hard breasts causing symptoms do. More frequent massaging and certain prescribed medication may be effective in softening the breasts. If necessary however, hard and painful scar tissue buildup can be successfully treated and removed with a surgical procedure called “open capsulectomy”. The breast then returns to its soft desired state, however the risk of becoming hard again remains. “Open capsulotomy” is a surgical procedure where the scar tissue is loosened by making incisions within the scar tissue and allowing it to stretch, rather than removing it. Capsular contracture generally occurs most frequently within six months of surgically receiving implants, if it is going to happen. There appears to be another spike in occurrence frequency around the time of pregnancy and breast feeding. However, as long as the implants are in your body, you are at risk for the scar tissue to contract and cause symptoms. “Closed capsulotomy” which is very vigorous squeezing to break up the scar tissue often under anesthesia has been condemned. It can cause distortion of the breast, damage to the implant, and recurrence of contracture is very likely.

Often, multiple surgeries are required, and rarely a patient may resort to the option of removing their implants (explantation). Again, in the majority of cases, the capsular contracture is correctable. However repeated surgeries and or the removal of the implants can result in permanent pain or deformities of the breast. These issues can become very debilitating and expensive.

(Fig 9) Here are photos taken of a patient 5 months after her implants were removed. She had a history of capsular contracture for many years and had developed a low-grade infection. She was not happy with the appearance of her breasts with the extra sagging skin and decided to have implants placed again.

Fig-9

(Fig 10) These “after” photos were taken 3 months after replacing her implants. The appearance of the breasts following removal of implants as well as the reconstruction possibilities vary greatly among patients. Often, removal of implants can result in emotional depression as well as deformities that can not possibly be satisfactorily corrected with reconstructive techniques.

Fig-10

Hematoma: Sometimes after surgery, a collection of blood from postoperative oozing can develop within the breast pocket containing the implant causing swelling and pain as shown in (Fig 11). This is called a hematoma and can require another surgery to evacuate. This risk is usually around 5%. This patient had the original surgery performed outside of the country. However, as you can see, ended up with a very acceptable result despite these problems, following her corrective surgery.

Fig-11

Infection: Perhaps the worst possible complication of augmentation is that of developing a severe infection of the breast that involves the implant. Fortunately, this also occurs less than 5% of the time in most studies. If the implant is involved, it usually must be removed indefinitely prior to putting it back in. This is usually an emotional nightmare and also can be quite expensive.

(Fig 12) These are photos of a patient who had very large implants, developed a severe infection, and had to have her implants temporarily removed. Although the severity of infections varies, as does the appearance of the breasts when the implants are removed, these are her pictures 3 months after explanation or removal of her implants. This represents one of the worst case scenarios with breast augmentation. During the time the implants are out, it is a very tough experience for both the patient and the doctor. Again, the appearance varies widely with these types of experiences.

Fig-12

Rippling: Rippling is a fairly common postoperative issue that occurs particularly in woman with thin skin and implants on top of the muscle.

Breast implants are relatively “under-filled” and thus, all have some sort of rippling or ridges. You can see these ridges on the edges of the implant as shown in (Fig 13). These ridges can be seen occasionally under the skin surface but again, usually only if the patient has thin skin or little breast tissue. If the implants are placed under the muscle, or the skin is not thin, it is usually not an issue at all.

Fig-13

(Fig 14) Here is a photo of a patient with rippling. You can see the little ridges along the side of the breast and especially when bending over.

Fig-14

Sensation Loss: With any surgery on the breast, you can certainly lose sensation in your nipple and other areas of your breast. Sometimes, the sensation can be enhanced and even become painful. The chance of losing or altering the sensation of the nipple or breast skin has more to do with the size of the implant than the location of the incision. The larger the implant placed, no matter where the incision is made, the more chance of stretching out or disrupting a nerve to change or disrupt its function. Although these changes are usually temporary, they can be permanent. Be sure to discuss this with your surgeon if it is a priority for you.

Asymmetry: No person is symmetrical from one side of their body to the other. If you look as scrutinizing at your breasts before surgery, as you will after, you will realize that one breast may be larger, or one nipple or fold below your breast is higher. Your doctor may try to make your breasts more even, but complete correction is unlikely. Many people are right handed and their muscles are larger on that side of their body, or they have some degree of curvature of the spine, which creates differences in the chest wall and ribs. Look in the mirror carefully to scrutinize your anatomy before your procedure.

Malposition: (Fig 15) This patient came to see me concerned that her implants were not positioned ideally as they were placed to close together. I was able to perform a corrective surgery by developing new pockets for the implants as well as choosing smaller implants.

Fig-15

Synmastia: Synmastia is a deformity where the breast implants are placed to close together or possibly migrate close together essentially producing one breast.

(Fig 16) This is an example of a patient with synmastia where the pockets for the implants have joined in the middle and the skin along the sternum has lifted up. Although a formidable problem, it can often be corrected as shown here after I performed her reconstructive surgery.

Fig-16

Breast Deformity: Breast implant surgery can lead to a myriad of breast implant deformities. This includes “double bubble deformities” and irregularities of the inframammary fold as show in this picture (Fig 17). These are very difficult problems to correct. In this patient, the surgeon attempted to lower the natural inframammary fold (arrow) and was very unsuccessful and subsequently created this deformity

Fig-17

Breast Feeding: Although any operation on the breast could prevent your ability to breast feed, it is unusual. You should be able to breast feed after breast augmentation. Some women are unable to breast-feed even without breast implants.

Mammography: Currently, there is no evidence that breast cancer occurs more often in women who have breast implants than in women without breast implants. Implants do however, decrease the visibility of your breast tissue on screening mammograms. This happens because the implant itself can block the view of some of the breast tissue, especially if significant scar tissue forms around the implants. Calcium deposits can also form within this scar tissue. These deposits can create some confusion with diagnosis as they may look similar to those calcium deposits seen in breast cancer. You should check with your radiologist performing your mammograms to discuss these issues with him prior to breast augmentation, especially if you have a family history of breast cancer. The ability to visualize the breast tissue with mammograms varies based on the experience of the radiologist. Placing the implants under the muscle allows greater visibility than if the implants are on top of the muscle. Other studies such as MRI and ultrasounds can assist in visualizing your breast tissue and the integrity of your implants as well.

For more information about screening mammograms and other studies to evaluate the breast with implants, please visit the American College of Radiology website at www.acr.org.

Currently, recommendations by the American Cancer society are that women over 20 years old should self-exam their breasts every month and have a breast exam by a doctor every 3 years between ages 20 and 40. A clinical exam and mammography should be performed for woman over 40 every year. Those patients with positive family histories of breast cancer should discuss an earlier and possibly more aggressive exam and mammography schedule with their physician.

Connective Tissue Diseases: There is no medical evidence that silicone implants are responsible for any major diseases of the whole body. Their relationship to connective tissue diseases such as connective tissue diseases is unsubstantiated.

Implant Lifespan: The lifespan of a breast implant is not known but they do not last forever. The chances are great that a woman will out live her implants and future surgery will be needed. As technology evolves in implant manufacturing, they will last longer. If a saline implant were to leak, the saline would just be removed from your body in your urine without harm. One study reported a 5-10% frequency of deflation of saline implants over 10 years. You should have yearly exams with your plastic surgeon and follow your routine radiology surveillance plan especially if you have sustained a significant trauma to your chest. (i.e.; seat belt injury or fall).

The rate of silicone implant failure is not known however the silicone typically is confined within the capsule of scar tissue and does not spread through your body. Ultrasound and MRI imaging are helpful in diagnosing possible ruptured silicone implants, and if they are not intact, corrective surgery is advised. A limited warranty can possibly be purchased from the manufacturer, in case of the possibility of implant failure, to help defray some of the costs necessary in replacement.

Extrusion: Extrusion of the implant is a very rare event. This is a condition in which the implant becomes visible through an opening in the skin. It is often associated with infection, trauma, or poor circulation and generally requires removal of the implants for an indefinite period of time.

Health Insurance: It is possible that health insurances may exclude coverage of breast diseases of any kind in women who have implants. Be sure to review your policy or the one you are considering for their limitations.

Other: Other complications can result from any surgery including poor scarring, permanent pain or deformities, need for expensive revisional surgery and even death. There are certainly other risks that could occur, and the rate and severity vary. You should discuss all these issues with your plastic surgeon. Related financial obligations should also be discussed prior to surgery with your doctor in case further surgery or hospitalization is necessary.

There are numerous necessary reasons to undergo revisional surgery. Capsular contracture and possible associated pain continues to be the most common reason for reoperation. Other necessary reasons include bleeding or hematoma, extrusion, infection, and implant failure. There is no rule that implants should be replaced every ten years. In fact, most surgeons feel that if you are not experiencing any problems, you should not contemplate replacing them.

I have personally removed implants from a patient which had been in for 40 years and remained intact! It is comforting to know that technology is better today than it was then.

Some of the elective reasons patients choose to have revisional surgery include desire for a different size, change to silicone or saline implants, or desire for newer technology. Frequently after pregnancy and or aging, a breast lift may be requested and implants could be changed. In general, revisional or reconstructive surgery is more difficult, more unpredictable, and has a higher risk of possible complications.

Lifelong commitment: I feel that a woman should consider breast implants as a lifelong commitment. It is very doubtful you will decide to remove them once they are in place. Once they are removed, the breasts will most likely not look as good as they did before they were placed. In fact, you may be so unhappy with how your breasts look, that you ultimately want the implants back in. This is not only because of the surgical effects of implant placement, and the scar tissue that formed around the implants, but also because of the natural aging process of the breasts over the period of time the implants were in place.

Silicone vs Saline

When comparing silicone to saline, silicone implants feel more natural and have less visible rippling in a patient with thin skin or little breast tissue. In a person with thicker skin or more breast tissue, there is really minimal difference in appearance or how they feel.

For a detailed interview and discussion with Dr Garth Fisher regarding his personal opinion and advice on selecting implant type, shape, size, etc, Please click on this link which will take you to his interview in the 2008 Aesthetic Buyers Guide.

Anesthesia, Operating Time and Postoperative Instructions

Although the majority of surgeons perform breast augmentation under general anesthesia, it can be done under a local anesthesia with sedation. Keep in mind that a general anesthesia where you are put to sleep is very safe today. The statistical risk of death or catastrophic event from a general anesthesia in a healthy patient should be less than your drive to the office for the consultation.

The actual time it takes to perform the surgery varies greatly with the surgeon, and should be discussed with him or her.

It is important that all patients carefully follow their postoperative instructions to increase the likelihood of a favorable result. These will vary depending on your surgeon. Generally, sutures need to be removed by your doctor and your breasts should be examined during the healing process. Be sure to keep all of your scheduled postoperative appointments. These appointments give your doctor and his staff the opportunity to evaluate your healing process and diagnose and address any possible complications early.

The recovery period and amount of discomfort also varies greatly depending on technique, surgeon, and patient. One of the most important variables relating to a patients postoperative discomfort is how the individual tolerates pain. Some people don’t have much pain at all, and others complain of excruciating pain. You should ask your friends who have had the procedure to get a sampling of different experiences. The average patient in Dr Fisher’s practice is able to get back to a desk job in one week and the gym in one month with unrestricted activity.

Large and Inverted Nipples

There are procedures available to address and improve large, small or inverted nipples. Ask your surgeon about these options if it is a concern of yours. Generally, the surgical technique utilized to correct the inverted nipple however, prevents you from being able to breast feed through that nipple.