Breast augmentation with implants

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Breast augmentation surgery or using breast implants is a procedure where plastic surgeons ideally do not touch the actual breast gland at all during the surgery. Most breast augmentation procedures involve making a skin incision and then tunneling around or under the breast gland to create a pocket to place an implant which will give the breast mound more projection and a slightly larger base diameter to their breast. Occasionally, breast lift procedures are performed in conjunction with a breast augmentation and this does involve manipulating the breast gland itself.

Complications are minimized by avoiding touching the gland itself during routine breast augmentation surgery. Breast augmentation surgery can be performed by a variety of methods and there is no one method which is best for all patients. It is common in most practices that the patient makes various decisions regarding their breast augmentation surgery. Like everything in life, there are advantages and disadvantages for each option and every patient has different opinions and desires, so you are encouraged to discuss the various options with your plastic surgeon at length to find out which option is best for you. Your plastic surgeon will review a few common options and some of the advantages and disadvantages of each option. There are several incisions used for this procedure. The most common incision used for breast augmentation is still the inframammary crease incision and is made under the breast mound in the crease or fold of the breast and chest wall. The advantage to this incision is it offers very good access to the implant pocket regardless of whether the pocket is above or below the pectoralis muscle and is quick direct access for any additional procedures which may be necessary in the future such as capsulectomy or capsulorhaphy (manipulating or removing the capsule that forms around the implant). The disadvantage to this scar is that it may be noticeable if the patient doesn't have a well defined crease under her breast or when lying down. The peri-areolar incision is another very popular incision and is made between the colored portion of the areola and the adjacent skin. This scar is in the most conspicuous place; but most often is barely perceptible because the scar is camouflaged due to placement within the existing natural color change of the areola. This incision also allows excellent access to the implant pocket and for any revisions of the capsule in the future. There has been speculation that this incision may have higher incidence of injury to the nerves of the nipple/areola. This is not necessarily true if the plastic surgeon does not go through the breast gland, but instead tunnels around it in the subcutaneous plane as previously mentioned. Another potential disadvantage is increased risk of infection as the nipple ducts can harbor bacteria which may contaminate the surgical field. This method has an advantage for the release of inferior breast gland tissues from the skin envelope which can sometimes aid in slightly lifting the breast in certain cases where minor breast sagging occurs but isn't severe enough to require a full breast lift surgery (mastopexy). The other incisions used for breast augmentation are a distance away from the breast mound and because of this, they may compromise some of the access to the capsule and implant pocket. The axillary, arm pit, incision is still popular and has the advantage of being away from the breast mound in terms of scarring on the breast. The axilla has important blood vessels, nerves and lymphatic tissues which can increase potential risks and this incision can be slightly more painful following surgery. Some plastic surgeons will leave drains following an axillary approach as the lymphatic drainage may increase the risk of fluid collections. The umbilical, belly button, approach is the furthest away from the breast mound and it would be very difficult to do anything else aside from placing an empty saline implant which can then be filled in the pocket. It is important for your plastic surgeon to offer their patients a choice and spend time educating them on the pros and cons of each option so they can make an informed decision. Patients also have a choice as to whether they want their implant placed above or below the pectoralis muscle and the advantages and disadvantages to this depend mostly on each patient's individual anatomy. Placing the implant below the muscle allows more of the patients’ own tissue to cover the implant and look more natural. It also can cause more distortion of the breast mound with muscle movement. Most submuscular (below the muscle) procedures are only partially under the muscle as the lower border of

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the breast mound is below where the muscle would attach to the rib cage and this is released during the surgery. Each patient will need to discuss their anatomy and physical characteristics with their plastic surgeon to decide which placement is best for them. Patients must also decide which type of implant they want and, once again, there are advantages and disadvantages to both saline and silicone gel devices. Although both devices were initially used in the early 60's, the silicone gel devices are the implants which have undergone the most change and controversy in the past 40 years. The first generation devices were thick shelled and fairly durable but soon gave way to the second generation devices which had a very thin outer shell and very thin liquid silicone inside. These devices were not originally regulated by the FDA and in the late 80's came under extensive public scrutiny due to the relatively high rate of rupture which was complicated by the practice of closed capsulotomy common during that era (a process in which the plastic surgeon would squeeze the breast capsule very hard in an attempt to break the patient's tissue capsule but not rupture the implant inside). Due to a variety of problems, including mounting public pressure, the FDA ordered all of the silicone gel devices off the market in 1991. Saline devices soon controlled the market and to this day remain a very safe alternative. Some of the disadvantages of the saline devices involve the feel of the saline filled bag. Although your body is 60% salt water, most of this is in your muscles and organs. Your breast tissue is mostly fatty tissue and this is why it has a unique soft feel (although the fat percentage may change over the years and there is a lot of variability amongst patients). The silicone gel feels much more like natural breast tissue because of it's density and consistency. The current implant market uses the fourth and fifth generation devices which have a thicker outer shell and a thick, viscous inner gel. Although all of the gel implants use a cohesive inner silicone gel, some devices use an extremely thick inner gel which is form stable. These devices are called form stable cohesive gel devices (sometimes referred to as "gummy bears") and are currently not available in the United States outside of specific research studies. It may not be possible to place the form stable cohesive gel devices (gummy bears) through an axillary or umbilical incision. Both plastic surgeons and the implant industry are hopeful the FDA will approve these devices for clinical use sometime in the relatively near future. After a thorough examination of your anatomy and tissues, your plastic surgeon can recommend which device may be a better fit for you. Ultimately, it will be your decision based on the pros and cons of each device and your confidence in that implant.

The plastic surgeon will perform specific measurements using the notch at the apex of the patient's sternum as a fixed reference point to determine the amount of breast tissue, amount of breast skin, laxity of skin and sagginess (or ptosis) of the breasts. The ideal candidate for breast augmentation surgery is a patient who has no ptosis or droopiness of their breasts and desires more volume or fullness of their breasts. Some patients experience deflation of their breasts following breast feeding and these can be ideal patients for breast augmentation as well. It is recommended that patients wait at least 6 months following breast feeding cessation before undergoing breast surgery. Other patients who never had adequate breast volume or have uneven breast volumes are also excellent candidates for breast augmentation surgery. It is not uncommon for a patient to think they desire a breast augmentation when, more appropriately, that patient needs a breast lift procedure. It usually takes considerable time to explain to a patient with sagging tissues how an implant may not improve the sagging and in some cases make it appear worse. The scars for a breast lift (mastopexy) surgery can be a considerable deterrent for patients who want to improve the appearance of their breasts.

Discussing how a misshapen breast is not aesthetically pleasing even if there are minimal scars and the trade off of an aesthetically pleasing shape to the breast with scars is still a difficult decision for some patients.

The immediate recovery will depend upon what type of anesthesia that your plastic surgeon will employ for the surgery. A total intravenous anesthesia (TIVA) technique which wears off relatively quickly has minimal side effects such as nausea. Various anesthetic agents affect patients differently and will dictate the patient's recovery. Many plastic surgeons also incorporate extensive local anesthesia into the tissues which can allow patients to wake up pain free. The local anesthesia will begin to wear off in 3-4 hours and most patients will say they feel "very tight" at this stage. Some patients relate the sensation to that of engorged breasts when their breast milk came in during pregnancy (the difference of course is you cannot breast feed and relieve the engorgement). Most patients will have this sensation for a few weeks as the tissue tension gradually subsides and they will use pain medication to relieve this. If a patient chooses to have her implants placed under the muscle, she may have discomfort with raising her arms overhead for 3-4 weeks. There are no specific restrictions following breast augmentation surgery aside from no soaking for a week. Patients may shower the following day; but no Jacuzzi, swimming or soaking in the tub for a week. Most plastic surgeons want to see their patients back in the office 5-7 days after their surgery to examine their incision and implant position. They may then instruct them on implant manipulation exercises and scar care at that time. For most plastic surgeons, there are no sutures to remove. It is most common to use absorbable sutures which melt on their own within a few months and the outer skin is often times sealed with skin glue which flakes off in a few weeks. One of the potential risks of surgery is infection and this usually manifests itself around 5-7 days after surgery if it occurs. This is usually effectively treated with oral antibiotics if caught early; but can be devastating if the infection becomes advanced or involves the implant which may necessitate removal of the implant. The risk of this is less than 1 in a thousand but is one of the more serious risks of implant surgery. Other risks of breast augmentation include anesthesia problems or adverse reactions, scars, bleeding, hematoma (blood collection), implant malposition, contour irregularities and hardening of the implant capsule.

Your plastic surgeon will go over all of the potential risks and complications with you prior to surgery

so that you can make an informed decision regarding the risk to benefit ratio for their proposed surgery. The actual “full� recovery period from breast augmentation is at least a year and this involves a gradual softening of the tissues around the implant and time for the implant to settle into its natural position. A significant amount of the recovery occurs within 2-3 months; but it will take the external scar a year to soften/mature and the internal tissues undergo similar softening. Immediately following breast implant placement, most implants will appear high up on the chest wall with a very rounded upper pole. Over the course of a year, this "implant look" will soften and the upper pole of the breast will develop a more natural slope with the breast mound assuming a more natural appearance as well. Occasionally, the capsule around the breast doesn't soften or becomes more firm and this is called capsular contracture. There may be some early treatment options for this and this will be discussed with your plastic surgeon during your early postoperative visits. Some of the long term adverse complications from breast augmentation surgery include capsular contracture (previously mentioned) or implant rupture. Rupture of a saline filled device is easy to determine as the breast loses volume. The larger the leak, the quicker the volume loss; but could be as quickly as a day or slowly decrease over several weeks. The usual treatment of a ruptured saline implant is to replace the device. This should be done relatively soon after diagnosed to minimize the shrinking of the capsule which may require more work to expand if allowed to shrink too much. Rupture of silicone gel devices are much more difficult to diagnose. Quite often patients will have a ruptured device for years and not note any difference in appearance or feel. Diagnostic imaging is notoriously inadequate as there is no gold standard test which has a high sensitivity or specificity (low rate of false negative or false positive results). MRI scans are the most accurate but are only about 85 % specific for ruptured silicone gel and they are quite expensive. Mammography is excellent for detecting early breast CA; but not very helpful in detecting ruptured silicone gel implants. Most clinicians would recommend replacing a known ruptured silicone gel implant, but there is no proof or agreement of untoward sequelae from long term ruptured silicone gel causing physical symptoms or problems despite many anecdotal reports and junk science on the subject. Other long term potential complications are related to each patient's own tissues and the loss of elasticity in those tissues. The amount of sagging which can occur in these tissues is also dependent upon whether the implants were placed above or below the muscle. Most plastic surgeons would agree that breast implants don’t last forever and the most recent studies suggest that most patients who have breast implants placed will have another breast implant operation during their lifetime. Breast augmentation surgery is a lifelong commitment and appropriate follow up should be anticipated. You may also be interested in the following procedures Nose Surgery, Liposuction or Face Lift.