Breast Augmentation

Since the first breast implants were made in 1962, breast augmentation has been one of the most popular plastic surgery procedures in the United States. Breast implants allow a woman to enhance her shape and improve the proportions of her figure. While the typical woman interested in breast augmentation is married, in her mid-30s and has children, many others are in their 20s or 40s. This is a procedure a woman considers when she is not satisfied with the size of her breasts, regardless of her age.

 

A woman chooses breast augmentation for herself, not to please a spouse or partner. She wants her 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.

 

 

Choosing the implant size

 

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 30 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 an accurate idea of the way you will look with each implant size. During your initial consultation, you will try different sizes in a bra to see what looks best on you, and even get input from a friend or spouse.

 

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. It takes several weeks after surgery for 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 implants

 

Even with the recent FDA approval of the silicone gel implant, many women in the U.S. regard it as a “tainted” product and remain concerned about safety issues related to possible shell rupture, which is called “silent rupture” because it cannot be detected on a physical examination. Detection of shell rupture requires an MRI scan, and replacement usually requires a general anesthetic.

 

The silicone gel implant did not receive a “clean bill of health” from FDA when approved in November 2006. A number of safety issues of concern are listed in the FDA-mandated Patient Information Brochure that women must read and sign prior to receiving a silicone gel implant. Prominent is the explanation that ruptures of the implant are usually “silent” and undetectable by physical examination. Detection of implant rupture requires an MRI scan of the breasts at a cost of approximately $2000. The importance of monitoring a silicone gel implant for silent rupture, and removal if rupture is detected, is emphasized.

 

The FDA-mandated Brochure notes that at 2 years, 10% of women with a ruptured implant have silicone gel move from inside the scar capsule to the surrounding tissues. This is probably the basis for the FDA monitoring recommendation to women and surgeons that an MRI scan be done at 3 years post-operatively and then every 2 years for life.

 

Silicone gel implants are marketed today as “cohesive” gel implants. Unfortunately, many plastic surgeons and women think the term “cohesive” means all the silicone gel stays inside the implant if there is a “silent rupture.” In fact, it does not all stay inside because pressure applied to the implant in everyday activities and body positions causes some of the silicone gel to extrude out of the implant. Since it is a very sticky material, it smears onto the inside of the surrounding capsule and onto the surface of the implant.

 

Silicone gel extruded from a “silent rupture” tends to stay within the surrounding scar capsule, unless the capsule is torn. In that case, globules of silicone gel can move outside the capsule, but a globule must be at least 4mm in size to be visible on an MRI. The lack of visible extra-capsular silicone gel on an MRI of a ruptured implant does not mean there is no extruded silicone gel in the tissues; it only means that there is no globule of extra-capsular silicone gel at least 4mm in size.

 

When there is a “silent rupture,” silicone chemicals diffuse out of the implant and into the tissues. These potentially toxic chemicals are residuals from manufacturing the silicone gel polymer and are always present in minute amounts within the silicone gel. That is why the shell is made with an internal barrier layer that prevents almost all of these chemicals from diffusing out. However, if the shell is ruptured, the barrier layer is defeated and these silicone chemicals diffuse out of the silicone gel and into the tissues. It is not known how much diffuses into the tissues from a ruptured implant and if this has any clinical significance or long-term effects. Because these chemicals are diffuse and are not in the form of globules in the tissues, they cannot be detected on an MRI.

 

 

Though the silicone gel–filled implant feels somewhat like breast tissue, it requires a slightly larger incision than a saline implant because it is filled when manufactured and can be damaged if forced through a small incision.

 

 

Standard saline implants

 

On a tabletop, the standard saline-filled implant does not have the natural feel of breast tissue. However, when implanted, most women are very pleased and satisfied with their results. It requires a relatively small incision since it is inserted empty and then filled with saline through a self-sealing valve. Placing it under the chest muscles keeps it from sloshing or bouncing.

 

If a saline implant ruptures, the implant deflates and the saline is harmlessly absorbed by the body over a few days. Detection of a rupture is obvious and replacement can be done under a local anesthetic in many cases. General anesthesia is usually not needed, saving expense and the need to make arrangements for someone to bring you in for the procedure and stay with you afterwards.

 

The edge of the standard saline-filled implant is somewhat raised above the chest wall, a situation made worse by the common practice of over-filling with saline. For this reason, I do not over-fill standard saline implants.

 

 

Over the muscle or under the muscle

 

In almost all cases, breast implants are 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 (saline or silicone gel). 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 chest 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, whether the implant is saline or silicone gel. In most women, there is enough soft tissue padding over the implants to hide these lower outer edges.

 

 

Deflation and rupture

 

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 is about three percent. If a deflation occurs, the 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.

 

The procedure to replace a deflated saline 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.

 

In contrast, when a silicone gel implant fails due to repeated shell folding, you do not know you have a leak because the implant does not get smaller. This is why it is called a “silent rupture.” The likelihood of this occurring over a five-year period is about three percent. Physical examination is not reliable for diagnosis of a silicone gel implant rupture; an MRI scan is required. The procedure for removal and replacement requires general anesthesia.

 

 

Round or teardrop shape

 

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 or silicone gel moves 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.

 

Additionally, teardrop implants must be kept from rotating on the chest wall or the appearance would be abnormal. For that reason, 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 so may not look as natural as implants that move during a woman’s activities.

 

 

Incisions

 

Breast implants are inserted through periareolar or inframammary incisions. Post-operative sensation in the nipples is the same for both. The incisions are closed with absorbable sutures on the inside, so there are no sutures to remove. You can shower the next day.

 

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.

 

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.

 

 

Effect on breast shape

 

Breast implants make your breasts look like a bigger version of their same basic shape. In certain situations, for instance a narrow rib cage, high-profile implants are used to give more projection for a given volume than the usual moderate profile implants.

 

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.

 

 

 

 

Creating cleavage

 

Cleavage comes from either using large enough implants or a push-up bra to make the breasts extend together in the middle of the chest. Cleavage is not due to positioning the implants toward the middle of the chest. 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 a natural appearance, breast implants must be centered behind the nipples.

 

 

Exchanging implants

 

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 or silicone gel 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.

 

 

Future pregnancy

 

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 Uplift

 

 

Life expectancy of breast implants

 

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

 

 

After-care

 

The most natural-looking result occurs when implants can move slightly within their surrounding tissues. You are encouraged to move the implants immediately after surgery to enhance this. Since a bra is restrictive, it is discouraged during the 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 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 day of surgery, movement of the implants is begun and continues for about two weeks.

 

Most women have only moderate swelling, which resolves by two weeks. You can return to light activities such as a desk job by about three 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.

 

 

Risks

 

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

 

 

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