Most important choice to make when considering plastic surgery of the breast is to choose a board-certified plastic surgeon who can discuss all of your options and who performs these breast procedures regularly. (Only a surgeon certified by the American Board of Plastic Surgery has the formal training and credentialing to perform these breast procedures.)
Breast augmentation enhances the size and shape of the breast with the use of implants. Women desire breast augmentation for various reasons- to increase breast size, to replace volume lost with pregnancy, breast feeding or weight loss, to regain fullness in the upper part of the breast, to bring balance to asymmetrical breasts, or to obtain a breast size which is more proportional to the rest of their body.
Breast augmentation is ideal for a patient who has a good shape to her breast but is lacking in size or lacking in fullness in the upper aspect of the breast. A patient who has sagging of the breast and nipple may likely need a breast lift along with the augmentation for best results. Although breast implants may be used to balance asymmetries in breast size, slight asymmetries, in size or shape of a breast, are normal and should not be a concern.
A typical patient looking for breast augmentation is often a younger woman in her early twenties who has always been dissatisfied with the size of her breasts or a woman in her thirties to forties who lost volume and superior fullness due to pregnancy and/or breast feeding. Women with good self-esteem and a good quality of life are the best candidates. The ultimate goal of the surgery should be to please yourself, not a husband, significant other, or friend. The decision to have surgery should be taken seriously and thought over carefully and thoughtfully.
There are several decisions that will need to be made in regards to the augmentation. These decisions are made between you and your plastic surgeon based on your body type and your expectations. The choices are implant location, incision location, and size and type of implant.
The implant is placed either under the breast tissue only (subglandular) or under the breast tissue and pectoralis muscle (submuscular). A subglandular placement can be performed under local anesthesia and has a slightly shorter recovery.
Subglandular placement does have a greater chance of implant visibility especially if the patient has only a small amount of native breast tissue. Submuscular placement requires general anesthesia and a slightly longer recovery. There is less risk of implant visibility due to the extra layer of muscle covering the implant.
Submuscular placement can however cause creasing in the breast or movement of the breast with use of the pectoralis muscle. Viewing of the breast by mammography is effected with both locations, however the submuscular location does allow for better visualization of the breast. Although there are special views used by mammography technicians to improve the visualization of the breast tissue, a small amount of the breast tissue still may not be seen.
There are three incision options- inframammary, periareolar or axillary. The inframammary incision is on the underside of the breast at the fold. The periareolar incision is along the areola border. The axillary incision is located in the armpit. All three incisions usually heal very well with minimal scar formation.
Implant options consist of saline versus silicone and implant size. Both saline and silicone implants have an outer silicone shell. Saline implants are placed in the breast deflated allowing for a small 3 cm incision. They are filled with saline during the surgery allowing for minor size adjustments to improve size asymmetry. Saline implants may feel firmer and have a greater chance of skin wrinkling or rippling especially if the patient is thin with little breast tissue. Silicone implants are placed pre-filled and require a 5-6 cm incision. Silicone implants have a more natural feel and hold their shape better leading to less chance of visible wrinkling of the skin. Of note, the feel and look of the breasts is based largely on the amount of breast tissue present. A patient with very little breast tissue will not cover the implant as well and therefore may want to consider placing the implant under the muscle for greater coverage or using a more natural feeling silicone implant. A patient with a good amount of their own breast tissue will have very good coverage of the implant and therefore could have as natural results with a saline implant as a silicone implant.
The other big difference between the two types of implants is what occurs with rupture. Implants are not guaranteed to be a lifetime device and have the potential to leak or rupture. If a saline implant leaks, it is noticeable with a decrease in breast size, as the saline is absorbed by the body. The implant can be removed and replaced under local anesthesia. If a silicone implant leaks, it is often contained within the scar that the body has formed around it so it may likely go unnoticed. (Because of this, the FDA recommends that patients with silicone implants have an MRI performed every 2 years to look for potential rupture.) Silicone gel may diffuse into surrounding tissue and cause enlarged lymph nodes or palpable masses. Removal and replacement of the silicone implant will be more difficult, requiring general anesthetic, and resulting in greater replacement costs.
Silicone History- Silicone implants were FDA approved for use in cosmetic breast surgery in November 2006. The original concern about silicone implants in the early 1990’s was the possibility that leaking silicone gel contributed to autoimmune diseases. No major medical study has shown a link between silicone or saline implants and any form of autoimmune or systemic disease.
Appropriate volume is chosen based on a patient’s desires but also on patient’s own tissue as a guide. The diameter of the breast is often the starting point to determine the best fit for the patient’s breast. Implant size based on the relative proportion of a woman’s figure gives a result that is proportional to the patient’s body type. The ideal implant is one that will safely augment the breast without causing irreversible distortion of the breast. An important fact to remember is that the breast shape, after augmentation, is determined by the shape of the breast before surgery. The same size and shape implant in one patient can look completely different when used on someone else.
In breast augmentation, there are risks which can occur as in all surgical procedures including bleeding, infection and scarring. All incision options will leave a scar which is usually well hidden. However there is always the possibility of thickened scar especially if the patient has a history of poor scarring. It is normal for a small amount of blood to collect around the implant, but rarely the patient may develop a hematoma, or large collection of blood, around the implant requiring return to the OR for treatment. Infection is also a rare complication, which usually involves the incision only, and is easily treated with antibiotics. If the infection were to involve the implant, it may be necessary to remove the implant and leave it out for 3 months to allow the infection to clear before the implant can safely be replaced. Sensory changes in the breast skin or nipple can occur leading to loss of sensation, decreased sensation or hypersensitivity. These are usually temporary lasting approximately 4-6 months but permanent sensory changes are possible. Larger implants may increase the risk of sensory changes. Significant weight gain or loss or pregnancy and breast feeding can effect breast size and the long term results. Breast feeding can become more difficult or unsuccessful after breast augmentation.
Your body automatically forms a scar or ”capsule” around the implant. Usually, this capsule is not detectable by sight or feel, but occasionally, this capsule thickens or tightens causing breast firmness or giving the breast an unnatural shape. Studies have shown that there may be less risk of capsular contracture by using a textured implant or placing the implant beneath the muscle. There may also be less risk of capsular contracture with saline implants. Most often the capsular contracture is quite minimal and does not require any treatment. If the capsule is bothersome, surgical release or removal of the capsule may be needed.
Although implants should last for many years, they are not lifetime devices. Our experience suggests there is an approximate 1% rupture rate per year. The implant companies have an automatic product guarantee, which replaces the implant if rupture occurs. They also offer extra insurance policies to help with operative costs for replacement including doctor’s fees, hospital and anesthesia fees.
Rippling or wrinkling of the skin overlying the implant is a potential problem especially if there is very little breast tissue present. In this instance, placing the implant beneath the muscle will decrease the chance of rippling due to greater coverage of the implant. The muscle does not often cover the outer and lower part of the implant so rippling may still be seen or felt in those areas. The thickness of the pectoralis muscle varies between individuals therefore the amount of muscle coverage will also vary. Saline implants have a higher chance of causing rippling compared to silicone due to the less viscous nature of saline compared to silicone. The use of larger implants, which tend to stretch and thin overlying skin will also influence future rippling. It is not uncommon for patients to be aware of some rippling, but very few patients are bothered by it. If it is a problem, the implant may be overfilled at a second procedure. This technique is often used at the initial augmentation to decrease chance of rippling. Overfilling helps to fill out the wrinkles but leads to a firmer implant. Another option for treatment of rippling is to exchange the saline implant for a silicone implant.
Details of Surgery
Surgery lasts 1-2 hours and is performed under general or local anesthesia with sedation. It is an outpatient procedure done in the hospital operating room.
After surgery, patients are wrapped in an ace wrap or surgical bra and ace wrap. Patients will be tired and sore after surgery and will feel tightness in the breast area due to stretching of the skin and/or muscle. A responsible adult should be with the patient the night of surgery. We encourage walking around the day of surgery and patients may use their arms after surgery for simple tasks such as fixing their hair or putting on makeup but should avoid heavy lifting or excessive stretching of their arms. Activities that might raise blood pressure, like lifting or bending over, can cause bleeding and should be avoided. A sports bra may be worn full time within a few days after surgery and continued for several weeks. Patients may return to work within a few days to a week depending on your job requirements. Breasts will be sensitive for a month or more.