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Breast Augmentation

Who is a Candidate?

Breast augmentation is a procedure that can provide a wealth of benefits to patients that extend well beyond aesthetic ends. Women of all ages consider having breast augmentation for many reasons. These include loss of volume after pregnancy/breastfeeding, congenitally small breasts, volume loss after weight loss and breast asymmetry, including tuberous breast. Creating a proportionate figure that is in harmony with a woman’s frame gives women a sense of confidence and self-esteem. For women who have asymmetry or poor breast shape, the sense of “wholeness” that they experience after surgery cannot be overly stated. There are also cases in which breasts may be abnormally shaped. When this type of problem is present, augmentation can provide a ready solution. 

I find that many women would like an improvement in their breast size, fullness and/or shape but want to avoid a result will look “fake” and obvious. In my practice many women have considered having breast augmentation for years before coming in for an actual consultation. Thanks to an evolving dynamic, which includes a more collaborative effort between the doctor and patient, 3D imaging, knowledgeable patients and the availability of a range of implants in different dimensions, including the tear drop shaped implants, women are comfortable making the decision to move forward with their surgery. They understand that natural results are possible and armed with information about options in augmentation surgery, they are confident of their choices.

Our Process

Patient coming to my office for a breast augmentation consult should allow an hour for their consultation visit. In some cases the visit lasts longer. During the consultation we will discuss your goals, explain the differences between the different styles of implants (round vs tear drop), smooth vs texture, under the muscle vs over the muscle, and the importance of dimensional planning. You will be shown different implants. I will examine you and take measurements which include your breast width and breast height. We will discuss any asymmetries you may have and how they can impact the result. Based on these dimensions, we will try on, in a bra, different implant sizes and let you see how you look standing in front of a full length mirror. We try on different tops to see how you look in your own clothes-tank top, shirts, sweaters, etc. Standing in front of the full length mirror is important because you can visualize the proportion and balance with your hips. After we determine the appropriate size, we will take pictures to show you an approximation of what your result will look like on our 3D imaging system, Crisalix. Finally, we will fully explain to you what you can expect during the recuperation period and the possible issues that can arise with implants.

Choices in Augmentation

Incision location
There are several choices for access incision: inframammary, peri-areolar, axillary and transumbilical. I prefer the inframammary fold incision for a number of reasons. The scar is well hidden under the breast, it heals well and in some cases is undetectable, any revision can easily be accomplished through this incision and it is associated with lower capsular contracture rates compared to peri-areolar.

Some surgeons prefer per-areolar incisions because they feel they are very well disguised at the junction of the areola and breast skin. I have found this to be true in some patients but certainly not all. In some patients the scar does not heal well and is noticeable on the breast. Recent studies suggest that capsular contracture rates are higher in peri-areolar incisions.

Transaxillary augmentation. The incision is placed in a naturally occurring crease in the axilla (armpit). The advantage of this incision location is that it is located off the breast and usually heals well. However, some revisions cannot be performed through this incision and in some instances the scar is noticeable when the arms are elevated. This type of procedure should be performed with the proper equipment, which includes endoscopic equipment. This allows the implant pocket to be created precisely, under direct vision. Most surgeons who perform this approach place the implant under the muscle and use round silicone or saline implants. There are a few surgeons in the United States who place tear drop shaped implants via a transaxillary incision.

Transumbilical augmentation (TUBA) in my opinion should be avoided. TUBA breast augmentation places the incision that is used near the belly button of the patient. A tunnel is then created from the belly button to the breast and the implant pocket is made via this remote incision. The implant warranty is voided by this method, it does not allow for precise and blood-less dissection of the implant pocket and only saline implants can be used in this approach.

Types of Implants
Breast implants can be filled with either silicone or saline. All implants have a shell that is made of silicone. Currently silicone implants are the most popular implant in my practice. I prefer silicone to saline implants for a number of reasons:
Silicone

  • Most natural feel
  • Lighter
  • Less tissue stretch
  • Less rippling
  • Less rupture

Saline

  • Feel firmer than silicone
  • Heavier
  • More tissue stretch
  • More rippling
  • Higher deflation rates, especially with textured shell

Implant Shape
A breast implant can be either round or tear drop shaped. The round implants have a width and height that is equal and the point of maximal projection is in the middle of the implant. Tear drop shaped implants come in a variety of footprints, where the implant base can be round, oval or classic shaped where the height is more than the width. Tear drop shaped implants produce a smooth transition between the chest wall and the beginning of the implant so one does not usually see an upper pole “bulge”. That is, there is no excessive fullness in the upper part of the breast. For patients who desire a natural result that is still full, I usually recommend a tear drop shaped implant. In addition to their natural shape tear drop shaped implants have other advantages including low rates of capsular contracture, less tendency to stretch the tissue, hold their position over time and low leak rates. Tear drop shaped implants require very specific planning and selection and patients should be sure their surgeon has experience with these implants.

Implant Position
The implant can be placed over or under the pectoralis major muscle. There are pros and cons of each:
Over the muscle

  • No dynamic distortion
  • Best for patient who need mastopexy
  • Less discomfort long term
  • Less tissue seen on mammogram

Under the muscle

  • Possible dynamic distortion and displacement
  • More tissue stretch especially with smooth

Safety of Silicone Implants
Breast implants have been rigorously studied over the past 20 years. The safety of silicone implants is well documented but a review of the history of silicone implants is helpful. In the early 1900s, the silicone implants in use at the time were filled with a silicone that had a watery consistency and the shells were not as substantial as they are today. There was a fairly high “leak” rate and there was concern on the part of both patients and physicians that the silicone which was “’leaking” into the tissues had harmful effects, such as auto-immune diseases including lupus and the like. There was a moratorium placed on the use of silicone implants for a short period of time. During this time, data was reviewed comparing patient who had implants and those who did not, to see if there was any difference in the rates of these auto-immune diseases in the two groups. No significant difference was found. The FDA decided to move forward with prospective studies to evaluate the safety of silicone implants. In a prospective study patients are evaluated prior to treatment and then at intervals after the treatment. After 14 years of prospective studies silicone implants were FDA approved for general use in November 2006. On-going studies continue to validate the safety of these devices. During the study period, only select plastic surgeons were able to offer their patients silicone filled implants. As an investigator for the clinical trials of Allergan’s gel implants and style 410 cohesive shaped implants, I was able to offer silicone filled implants, both round and shaped, to my patients who were appropriate candidates.

Implant Brands
There are 3 brands of implants that are FDA approved for use in the United States. These are: Sientra, Allergan and Mentor. Each company has a range of dimensions and styles, which permits a high degree of customization for each patient. Each brand has both round and tear drop shapes available. Each brand uses a different texture and the silicone inside the implants is slightly different as well.

Gummy Bear Implants
Gummy Bear is a term coined to refer to silicone implants made by the brand Sientra. However, some people use this term to describe tear drop shaped implants, so be sure you and your doctor are referring to the same thing. When we talk about the silicone in the implant, we are talking about the cohesiveness of the silicone. Silicone can be anything between a watery consistency up to a solid consistency, such as a facial implant. Allergan and Mentor, in their round (non-tear drop) implants use a silicone that plastic surgeons refer to as “gel”. This gel flows in the implant. Allergan and Mentor, in their tear drop shaped implants, use a gel that is more cohesive than the gel. This creates an implant that is slightly less compressible and holds its shape. Sientra’s implants, including both the round and the teardrop, are made with high strength cohesive gel. To summarize, in the round implants Allergan and Mentor are filled with silicone gel and Sientra has the high strength (more cohesive gel). In the tear drop shaped implants, all manufacturers use their most cohesive gel. There are other subtle differences between the implants which can be discussed during your consultation. I am familiar with all 3 brands, the pros and cons of each, and select the implant that is best for you based on your tissue characteristics, measurements and goals.

The Surgical Procedure
The procedure is performed while the patient is under general anesthesia. Prior to surgery, the patient takes a muscle relaxant which helps minimize any post-operative discomfort. Many patients do not require any additional pain medication, such as narcotics. During the procedure your arms are positioned on your hips to prevent distortion of the breast. The procedure usually takes between 1 and 2 hours. At the end of the procedure I place long acting numbing medication in the pocket to minimize discomfort post-operatively. The incision is closed with a special suture, called Quill, which helps minimize inflammation around the incision and helps produce a very fine quality scar. The incision is covered with paper tape. Drains are not used except in special circumstances, such as revisional surgery.

Recovering after Breast Augmentation
Patients recover quickly after surgery. The key to a quick recovery is for the surgeon to follow the principles established by Dr. John Tebbets of Dallas. These principles are precise, bloodless pocket dissection under direct vision with minimal tissue trauma. This minimizes post-operative discomfort. As in all surgeries, the body undergoes an inflammatory process which results in healing. This inflammatory process is greatest during the first 72 hours after surgery. During this inflammatory period, a lot of one’s energy is directed towards the healing process. Patients should “listen” to their bodies and rest when they feel tired. During this 72 hour period swelling, a normal part of healing, will continue to increase each day and peak at 72 hours. It then starts to subside. The majority of swelling has resolved by 3 months. While there is swelling, the breast and implants may feel firm and stiff and the breasts are not”jiggly”. Round implants start to feel soft and “jiggly” around 3 months; tear drop shaped implants take longer to reach this stage, typically 6-9 months. Properly performed breast augmentation rarely results in bruising. Most patients feel comfortable wearing a slightly compressive bra. In revisional surgery wearing a bra is usually mandatory. The paper tape is kept on the incision for 3 months. Scars continue to improve in appearance over the first year, gradually fading.

 
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