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Robert S. Hamas, M.D.
8345 Walnut Hill Lane
Suite 120
Dallas, TX 75231
(214) 363-1073
(214) 890-7844 (fax)

Breast augmentation is the second most common cosmetic surgery procedure done in the United States (liposuction is the most common). Since the first silicone breast implants were made in 1962, breast augmentation has been one of the most popular plastic surgery procedures.

This has allowed women to enhance their shape and improve the proportions of their figure. Despite what some might think, the typical woman interested in breast augmentation is married, in her 30s and has children.

There are also many younger women who may be just entering the work force and still others who are in their 50s. This is a procedure a woman chooses when she is not satisfied with the size of her breasts, regardless of her age.

Women choose breast augmentation for themselves, not to please a spouse or partner. They usually want their clothes to fit better and be more flattering. It may be when trying on a dress or a bathing suit that a woman finally decides she has been dissatisfied with her appearance long enough, and it is time to do something about it.

You may have an idea of what cup size you want or a mental picture of the appearance you want, but this must be translated into a specific implant size (volume) that will achieve your goal. For more than 20 years, I have successfully helped women select the appropriate implant size by using sizers in a bra with a knit shirt or blouse. Experience has shown that this gives you a fairly accurate idea of the way you will look with each implant size. You can try different sizes in a bra to see what looks best on you and even get input from a friend or spouse. This is done during your initial consultation.

It is important to pick a size you will be happy with long term. Some women tend to be conservative when they try implant sizers, but bear in mind that afterward some of these same women say they could have gone with bigger implants. Only rarely do any women ever say they could have gone with smaller implants.

For most women, the implant size they select can be accommodated easily within their tissues. If a very large implant size is chosen, it takes several weeks after surgery for their tissues to stretch and accommodate the implants.

The final choice of implant size is up to you and is decided during your consultation.

Silicone gel-filled implants are no longer available in the United States for breast augmentation. They are limited to use by women who have had previous silicone gel implants or who are being reconstructed after cancer.

Saline-filled breast implants are used in the United States for breast augmentation. These have silicone shells filled with saline solution that is like the intravenous fluids that are widely used. The silicone in the shells does not have the risk of migration that occurred with older silicone gel-filled implants.

The two United States manufacturers of saline implants approved by the FDA are Mentor and McGhan. Both manufacture implants that are inserted empty, which has the advantage of allowing the implants to go through very tiny incisions. Then, they are filled with saline via a small tube that is removed. The FDA is testing similar saline filled implants imported from Scotland by Hutchison and from Brazil by Silimed. Also, a French manufacturer (PIP) is testing pre-filled saline implants. Since they are inserted filled with saline, they require a longer incision.

Though all these implants use silicone shells filled with saline, they may "feel" different on a desktop due to different fill volumes and/or certain physical characteristics of the implant shells. It is not known if these differences are meaningful, since no objective study has been done to compare the "feel" of these different implants after they have been implanted in women.

In almost all cases, a saline-filled implant is best placed under the pectoralis muscle. This allows the muscle to pad the underlying implant so there is less chance of seeing or feeling any ripples and edges of the implant. An implant under the muscle allows for better mammograms and has less chance of becoming firm due to contracture of the surrounding scar capsule (capsule contracture).

With that said, under-the-muscle implants hurt more the first few days after surgery. This is treated with muscle relaxants and pain medicine. It is beneficial to begin moving your arms immediately after surgery to prevent spasm and tightening of the pectoralis muscles, much like moving the leg after knee surgery prevents spasm of the quadriceps muscle. Also, heavy physical activity is restricted for about the first two weeks after surgery so you don’t strain your muscles.

The vast majority of women with under-the-muscle implants can engage in any activities or athletics without problem. In women who are body builders and have very well developed pectoralis muscles, extreme flexion of the muscles can temporarily pull the implants upward. When the muscles are relaxed, the implants drop back to their normal position.

Implants are not totally under the muscles – the lower outer edges protrude below the lower edges of the pectoralis muscles. In an extremely thin woman, this may be felt or even seen through the skin. In most women, there is enough soft tissue padding over the implants to hide these lower outer edges.

Smooth surface implants have been made since the 1960s. In the late 1980s, textured surface implants became available to help prevent contracture of the capsule around implants, which is what makes them feel firm. Each manufacturer’s textured surface has different characteristics. For instance, the Mentor, Hutchison, Silimed and PIP textures do not stick to the tissues (non-adherent), but the McGhan texture sticks much like Velcro (adherent).

Studies have proven that a textured surface on  silicone gel-filled implants lowers the risk of capsule contracture. Some preliminary results show that certain textured surface saline-filled implants have a slightly lower risk of capsule contracture than smooth surface saline filled implants. When placed submuscular, both smooth and textured surface saline-filled implants have very low rates of capsule contracture, making the difference between them subtle.

The exact cause of capsule contracture is unknown, although a number of theories have been proposed to explain this phenomena. If severe, this process can cause breasts to be firm to the touch, excessively round and unnatural in appearance, and even uncomfortable. Prevention is definitely preferable to treatment. This is where movement of the implant to stretch the surrounding capsule plays a role.

Movement of implants with a smooth surface and implants with a non-adherent textured surface soon after surgery seems to be beneficial in reducing the tendency of the surrounding capsule to contract. The reasons for this are still being researched. Movement of these implants in the tissues also makes the breasts look natural. After all, a woman’s breasts move slightly during her activities, so it is more natural to have her breast implants move slightly as well.

For these reasons, I feel it is important to avoid adherent textured surface implants that stick to the tissues. It is best if you move your implants during the first two weeks after surgery. From then on, normal everyday activities move the pectoralis muscles and thereby the implants.

There are two disadvantages to textured surface implants. For one thing, the shells are slightly thicker. This makes the lower outer implant edges extending below the pectoralis muscles a bit easier to feel through the skin, particularly in an extremely thin woman. Also, textured surface implants have a slightly higher deflation rate than smooth surface implants. Exact numbers are not available, but it seems that the difference is about one percent over five to 10 years.

A saline-filled implant may deflate if the shell folds upon itself repeatedly creating a pinhole leak. The saline is usually absorbed by the body over about three days and the breast gradually becomes smaller.

The likelihood of this occurring over a five-year period may be as high as three or four percent, although the exact percentage is unknown. If a deflation occurs, all manufacturers have a warranty that will replace the implant for life at no charge and pay the operating room and anesthesia costs for some time period, usually five years.

Most surgeons have a policy of replacing a deflated implant at no charge or a reduced charge for some set time period.

The procedure to replace a deflated implant is extremely simple. It is a one-day inconvenience. I have done this with just local anesthesia. Through the original incision, the deflated implant is removed and replaced with the new implant, which is then filled with saline. Most women can resume their normal activities the next day.

The implant manufacturer determines and recommends the range of saline filling for each and every implant size and type. Some implants, such as the teardrop, were designed to be more fully filled than others, such as the round. Surgeons may choose to fill implants slightly beyond the manufacturers recommended range (overfilled) under certain circumstances. There is no evidence that this is harmful to the implant.

The idea behind more fully filling or overfilling implants is that there is less chance of an implant shell folding on itself, creating a pinhole leak and deflating. However, the more fully filled the implants, the firmer they feel and the firmer the breasts will feel with the implants in place. For instance, round implants filled at the top of the manufacturer’s range tend to be more pliable and softer than the more fully filled teardrop implants. No study has shown any difference in deflation rates between softer, round implants and firmer, teardrop implants.

Round implants are used by most plastic surgeons. When a woman lies down, round implants settle back evenly, like normal breasts. When she stands up, the saline goes to the bottom of the implants because of gravity, and the implants assume a natural teardrop shape.

I proved this by studying X-rays of round and teardrop implants in women. I found that round implants have a natural shape when a woman is both standing up and lying down. On the other hand, teardrop (anatomical) implants have a teardrop shape when a woman is standing, but they also have a teardrop shape when a woman lies down, which is unnatural. This work was presented to the American Society for Aesthetic Plastic Surgery and was published in their medical journal.

Click on image to enlarge

As noted above, teardrop implants are also firmer than round implants. Additionally, teardrop implants must be kept from rotating on the chest wall or the appearance would be abnormal. For that reason, McGhan teardrop implants have a textured surface that sticks to tissues like Velcro. The disadvantage of this surface is that it keeps the implants from moving in the tissues and on the chest wall and so may not look as natural as implants that move during a woman’s activities.

Breast implants can be inserted through one of three incisions. Post-operative sensation in the nipples is the same for all three incisions. All are closed with absorbable sutures on the inside, so there are no sutures to remove. You can shower the next day.

1. Periareolar – along the lower edge of the areola, the pigmented area around the nipple. Incisions in this area have the advantage of fading within a matter of weeks in most women. Scars are quite inconspicuous because of the nature of this skin. A secondary procedure or revision is easy since the incisions are in the center of the breasts giving good exposure to all areas.
2. Inframammary – at or near the breast fold. These incisions usually take one year or more to fade out to permanent white lines just above the breast folds.
3. Axillary – arm pit. These incisions usually heal well. However, if the scars are apparent, everyone knows what they are and they are hard to hide. If any sort of secondary procedure or revision is needed, exposure is more difficult because of the location of these incisions.

Breast implants make your breasts look like a bigger version of their same basic shape. If there was loss of volume due to pregnancy and/or nursing, this can be restored so the breasts look more like they did before pregnancy. Breast implants do not lift the nipples higher. If the breasts are drooping, a breast uplift can be done at the time of breast augmentation. For more information see breast uplift.

Cleavage results from using implants large enough to make the breasts large enough that they extend together in the middle. It is not due to positioning the implants toward the middle. If that is done to try and create more cleavage, the lateral side of the breasts (the side nearest your arm) will appear abnormally small, and the nipples will appear off-center, pointed outward. This is an incorrect position of the implants and is not the way to create cleavage. For an appropriate appearance, breast implants must be centered behind the nipples. Cleavage comes from either using large enough implants or a push-up bra.

Some surgeons still insert a tube to drain the area after surgery. I do not. A textured surface implant normally has a small amount of fluid between the implant and the surrounding scar, so there is no reason to drain away this fluid.

The most natural-looking result occurs when implants can move slightly within their surrounding tissues. You are encouraged to move the implants during the first two weeks after surgery to enhance this. Since a bra is restrictive, it is discouraged during these first two weeks. If a bra must be worn because of social or job requirements, it should be very loose fitting. After this time, any bra may be worn as desired.

Most women have muscle spasms and soreness for the first three to five days and need muscle relaxants and pain medicine for relief. Swinging of the arms right after surgery stretches the pectoralis muscles and keeps them from going into spasm. On the second day after surgery, movement of the implants is begun and continues for about two weeks.

Most women have only moderate swelling, most of which resolves by two weeks. The swelling is about equal to one additional cup size.

Most women can return to light activities such as a desk job by about four or five days and to full athletics without restrictions by two weeks.

Some areas of bruising on the breasts or the chest may last between two and four weeks. This should be protected from the sun.

Some of the risks include infection, bleeding, altered sensation, asymmetry, implant deflation, interference with mammograms, capsule contractures and scarring. Detailed information is provided during the consultation.

As the breasts enlarge with pregnancy, the implants are usually unaffected since they are behind the pectoralis muscles. For this same reason, the ability to nurse is unaffected by the presence of breast implants. If the breast tissue is significantly stretched by pregnancy and/or nursing, then a breast uplift may be desired. This tightening of the overlying breast tissue and skin does not affect the implant.

Breast implants show wear over time as do all implanted surgical devices, such as knee replacements, pacemakers, etc. However, if there is no deflation or other problem, there is no reason to remove and replace your breast implants. Implants do not need to be removed after any certain period of time.

Silicone gel implants were usually placed on top of the pectoralis muscles, although sometimes they were placed beneath them. In either case, old silicone gel implants and their surrounding scar capsules can be removed and replaced with new saline-filled implants of the same, larger or smaller size depending on your preference. Occasionally, an uplift may be necessary to improve the shape of the breasts and can be performed at the same time the implants are exchanged.

Cosmetic surgery is done in my own accredited office operating room facility. Click here for more information.

Is there financing?

You may wish to use your VISA or MasterCard to pay for your surgery. Should you desire a personal loan, your own bank or credit union is your best source since they are already familiar with your credit history. If you prefer, the office will recommend a source for financing your cosmetic surgery.

For more information, or to schedule a personal consultation, call 214-363-1073

Robert S. Hamas, M.D.
8345 Walnut Hill Lane, Suite 120
Dallas, Texas 75231

Certified
American Board of Plastic Surgery

A Complete Guide to Cosmetic Surgery