Breast
enlargement, or augmentation mammoplasty, enhances the
body contour of a woman who is unhappy with her breast
size. It may also be used to correct volume loss after
pregnancy, or to help balance breast size asymmetries,
as well as a reconstructive technique following other
breast surgeries.
The
operation is carried out in our Cosmetic Surgical Center
under general anesthesia on an outpatient basis. An
implant (prosthesis) is placed through an incision,
under the breast tissue or under the muscle. The incision
can be made under the breast, around the nipple or in
the armpit. It generally takes two to three hours to
complete the entire procedure. A breast implant is composed
of an outer shell filled with saline (salt water). The
outer surface may be smooth or textured, and implants
come in various shapes to meet the individual woman’s
needs.
While
breast augmentation will enlarge the breasts, it will
not alter basic defects in breast shape or form. Major
asymmetries may be improved, but will not be completely
corrected. A slight difference in the size or shape
of the two breasts is considered normal and should not
be a cause for concern. If breast size or nipple position
asymmetries are severe then additional procedures to
further improve symmetry may be necessary. Long experience
with this operation has demonstrated it to have highly
satisfactory results for the majority of patients who
are considered suitable candidates for the surgery.
24
Hour Breast Augmentation
For
most of our patients, getting back to work early
is a priority. Thanks to an innovative post
operative regimen designed by Dr. Thomas, return
to work the very next day is possible now. A
special set of exercises instituted on the first
post operative day helps to reduce the discomfort
and tight feeling after surgery. Fifth generation
silicon gel implants are preferred for augmentation
as the feel is closest to natural. US FDA has
declared silicon gel implants as safe for breast
augmentation.
Current
Status of Breast Implants
The
US FDA has approved both saline and silicon gel implants
for breast augmentation. Studies have shown that implants
do not increase the risk for breast diseases. Detection
rate of breast cancer is unaffected if mammography and
physical breast examination are combined..
Durability
of Breast Implants
Based
on current experience, the prosthesis should last for
many years. However, since no breast prostheses have
been implanted for a full life span, it is impossible
to give an unequivocal statement in this regard.
Risks
As
is the case in all surgery, there are certain risks
that are inherent in this operation. Irregularity or
thickening of scars can occur which might require revision.
Rarely, hemorrhage may require removal of prosthesis
to control the bleeding. Infection is probably the most
serious risk of breast augmentation. If an infection
occurs, antibiotics alone will rarely clear up the infection
unless the implant is removed. It is necessary to leave
the implant out for a period of about three months before
it is safe to attempt replacement. The risk of infection
is less than 0.5%. Infection is usually confined to
the early post op period, however infection can show
up much later, fortunately the prosthesis can usually
be successfully replaced at a later time after the infection
has completely resolved.
Another
potentially serious complication is implant rejection.
Silicone is the least reactive material used for implant
construction. Most patients tolerate the material without
difficulty. Nevertheless, a very small percentage will
react to the material making successful augmentation
an impossibility.
Sensory
changes can occur resulting in numbness or discomfort,
and while these symptoms are usually not long-standing
or severe, they can be in some cases. Temporary sensory
changes are common and usually last 2 to 6 months. No
studies have indicated that implants interfere with
nursing.
Late
Complications
Capsular
Contracture
The
natural tissue capsule that forms around the implant
within the body can sometimes thicken or contract causing
unnatural firmness or shape to the breast. This condition
is called "capsular contracture". This is
a very uncommon complication which can be reduced by
exercises. If it occurs open or closed capsulotomy may
be required.
Rippling
Rippling,
or surface irregularities over the implant that can
be seen or felt, is a potential problem with any type
of breast implant. The added risk of rippling is the
trade-off for the increased safety of the saline filled
device. Because of the potential problem, placement
of the saline filled implant under the muscle may be
indicated to help decrease the risk of rippling. This
may be particularly true for patients who have very
little mammary tissue.
Implant
Size
In
selecting the size of the implant, the general choice
should be jointly made by the patient and the surgeon
prior to surgery. While ultimately, the choice of size
is made by the patient, she should recognize that there
are advantages to a conservative selection. Capsular
contracture and rippling are more common with larger
implants. Postoperative numbness and long term sagging
are also more common the large size selected. However,
despite the increased problems with larger implants,
it is rare that our patients complain of being too large
following breast augmentation. In general, our patients
say they are extremely pleased with their new size,
with 3-5% saying they might have gone slightly bigger
if they had to choose over again. The shape of your
augmented breasts depends on the implant size and shape
along with how your breast appear prior to surgery.
The same size and shaped implant on one patient can
look completely different on someone else. Therefore,
one should avoid picking a size or shape solely on what
‘looks good’ on someone else.
Implants
may be round or teardrop-shaped (anatomical). The choice
depends on the look you want to achieve. While teardrop
(anatomical implants) may seem like a good idea they
have some drawbacks. Teardrop implants widths are different
than their length and any rotation may produce an unwanted
asymmetry. Round implants are the same diameter all
around but not ball shaped. They come in a variety of
widths and varying amounts of projection that helps
fit the ideal implant for ones goals and anatomy. One
such factor to consider prior to surgery is breast width,
which along with nipple position and implant size determines
the amount of “cleavage” between your breasts. The outer
curves of your breast are also determined by all the
above and should fit your upper torso but also balanced
with you hips.
We
recommend that our patients purchase a soft non-padded
bra in the approximate cup size that they believe they
would like to achieve. Padding the bra by using baggies
filled with cloth to estimate the approximate additional
volume they desire can help estimate the size implant
that would be required to achieve their desired result.
The final decision, of course, will be made during the
time of surgery, based upon the patient's desires, as
well as which implant seems to look and fit best. In
some cases, this could result in the breast being augmented
slightly more or less than the patient had anticipated.
Above
or Below the Muscle
The
breast normally covers a muscle on the chest wall called
the pectoralis muscle. Breast implants can be placed
above or below this muscle. When implants are placed
below the muscle, it is called a submuscular placement
or a subpectoral placement. When the implant is placed
above the muscle, it is called a subglandular or submammary
placement, meaning that it's below the mammary gland.
A
possible advantage of submuscular placement is that
it may allow better mammography. It is generally felt
that there is less chance of missing a lesion on mammography
when the implant is below the muscle. The pectoralis
muscle tends to hold the implant against the chest wall
during mammography. Another advantage of submuscular
placement is that the implant is entirely beneath the
breast tissue, decreasing the possibility of interference
with breast function.
It
is also felt that submuscular implants are less likely
to develop firmness (capsular contracture). This may
be the result of pressure or internal massage of the
muscle around the implant and its associated scar tissue
(capsule). While this has not been definitively proven,
it is our feeling that patients have less capsular contracture
when implants are placed in the submuscular position.
Disadvantages
of submuscular implant placement include a more painful
recovery than the subglandular approach and longer healing
times. Although soreness is typically somewhat more
that for submammary implants, the increase in discomfort
is not long term and most patients feel back to near
normal in 2 weeks. The most severe pain last for one
week on average. We tell our patients to avoid lifting
anything over 5 pounds the first week and 10 pounds
the second week. Patients should also avoid raising
their elbows above shoulder level the first 10 days.
Over use of the arms and pectoralis muscles can cause
the submuscular implant to ‘ride up’ initially. And,
submuscular implant position does require more time
to settle than submammary implants. Slight flattening
beneath the breast should be expected initially. This
requires one to two months on average for the breast
tissue to stretch and soften in order for the breast
to ‘round out’ in the lower half.
Incisions
There
are several ways in which the breast implant can be
inserted. An incision can be made under the breast (inframammary),
in the armpit (transaxillary), or around the bottom
of the areola (periareolar). We offer all of the three
incision choices, but prefer the inframammary incision
in most cases. The incision under the breast (inframammary)
is the most common, and is a favorite due to a number
of reasons. First, it is the area that is hidden in
a crease and hemostasis is easy. Finally, inframammary
scars usually heal well and the incision has been used
for decades and remains a viable option that usually
has no major problems.
The
periareolar incision is made in a semicircular fashion
around the lower half of the areola approximately 4-5
centimeters in length. When placing implants above the
muscle, we often make the incision around the areola.
Although this technique is somewhat more difficult,
it offers the major advantage of a smaller and much
less noticeable scar. It also offers additional advantages
of keeping the incision far away from the implant and
allowing good surgical exposure of the entire pocket.
The incision may have a slightly higher risk of more
sensory compromise to the nipple/areolas complex compared
the transaxillary incision, but remains an excellent
incision option. If a simultaneous breast lift is required
this incision is often used since there will likely
be nearby incisions that are already going around the
areola.
Since
blood around the implant can organize and eventually
lead to thickened scar tissue, it is important to perform
the surgery in as bloodless a field as possible. The
use of endoscopic surgery has allowed us to carry out
breast augmentation with more precision and less bleeding.
Special instruments designed for this purpose allow
us to work through very small incisions, monitoring
the operation on a video screen. The dissection is performed
under close observation using an endoscopic telescope
with a built in video camera to project the inside of
the pocket on a large operating room screen. The pocket
is then tailored under direct vision rather than the
traditional blind dissection. The improvement is obvious
since it is always better to see clearly what one is
cutting. This is Dr. Thomas's area of expertise due
to his mastery of Endoscopic Surgery - first in India!
