Breast Implant Surgery
Augmentation Mammaplasty
 Breast Implants    
INTRODUCTION:



Augmentation mammaplasty is a procedure commonly done to enhance the size and shape of a woman's breast.  The technique is utilized for several indications.  For example, women who fell that their breasts are too small for their body size, or those who would like to balance any breast symmetry.  Finally, it may also be employed as a econstructive procedure in women who have had mastectomies for the treatment of breast cancer. Although some of the techniques are the same, the reconstruction of post-mastectomy patients will not be covered here.

Breast implant surgery was originated in the United States in the 1960's. At first the implants were made of a silicone outer layer and filled with a silicone gel.  Due to some concerns about potential health issues related to leaking of the silicone gel, the FDA placed a moratorium on the use of silicone gel implants in the United States for cosmetic use.

Breast implant surgery was originated in the United States in the 1960's. At first the implants were made of a silicone outer layer and filled with a silicone gel.  Due to some concerns about potential health issues related to leaking of the silicone gel, the FDA in 1992 placed a moratorium on the use of silicone gel implants in the United States for cosmetic use. As of spring 2007, the FDA has approved silicone gel implants for cosmetic use in the United States . However, there are still some restrictions such as the patients being over 21, and certain consents and follow-up visits that patients who seek this option need to comply with. Furthermore, there are certain recommendations such as an MRI every three years that are also in effect. These persistent restrictions and recommendations might change over the next several years as the follow-up data comes in.


Within the saline-filled class of breast implants there are not only differences in size, but there are also differences in the shape of the implants.  Although most implants used are round, there are also contoured or "tear-drop shaped" implants which some surgeons feel give a more natural shape to the augmented breast.  During your initial consultation, your surgeon will discuss with you the different types of implants, and the one he or she recommends for you.

IS BREAST AUGMENTATION FOR YOU?
 

During the initial consultation, it is important for your doctor to have thorough knowledge of your medical history especially any history of breast disease, symptoms related to the
breasts such as pain, lumps, nipple discharge, etc. and any significant family history of breast cancer.  If in the appropriate age group, your surgeon might also recommend that you have a mammogram prior to your surgery.  History of smoking, which might affect healing, or taking medications that might influence your blood clotting are also important issues to consider when planning surgery

It is also during this phase, that the surgeon will try to ascertain your motivation for having the surgery.  For a successful outcome and to optimize patient satisfaction.


it is important that your expectations are realistic and that your motivation to seek the surgery is appropriate.  The best candidates for this procedure are women who seek a better proportioned and contoured breast
for their body size.  It is important that you understand that achieving the ideal breast size or shape, or perhaps perfect symmetry might not be feasible.

In deciding which size breast implants to use, your surgeon will need information from you as to which look you are trying to achieve.  Every woman is of a different body shape and size and has different desires and expectations.  There are certain guidelines and techniques that can be utilized to help the surgeon and you arrive at an implant size that is right for you. 

Brazier size is usually given in a number followed by a letter, such as 34B or 36C.  The number is the measurement in inches of the circumference of the chest at the point of maximum breast projection.  The letter following the number is a size measurement of the breast itself according to standard fashion industry guidelines.  Thus, a tall woman with a broad back might have a large chest circumference number, but that measurement might not be necessarily related to a large breast size.  The cup size however, is a more direct indication of the size of the breast itself.

A rough number to keep in mind is that approximately a 400 cc implant (volume) will increase the breast one cup size.  The larger the implant size however, the larger the diameter of the implant.  During your consultation process, your surgeon will measure the width of your breast in an attempt to get an idea of what diameter implant your chest width will tolerate best. For women who have a narrow chest width but require or desire more volume, there are implants called "high profile" which have more volume in a smaller diameter shell, thereby resulting in more breast projection.

Placing implants of different sizes under your brassiere can give you an approximation of what you might look like with different size implants.  Another technique that can be utilized to judge the implant size is to put water into zip-lock bags and wear the bags under your brazier at home.  By adjusting the amount of water in the bags, one can get an estimate of how much volume is needed to achieve the desired breast size.  This is a rough estimate however, due to fact that implants are round and will be subject to some deformation by the skin envelope covering them after they are positioned in the body.

With the advent of computers, there are programs which by plotting in the woman's height, weight, chest circumference and implant size, can project a virtual model of the approximate breast size in relation to the body size.  By hitting the link below you will be taken to a page which will allow you to perform this task.


Although all of these techniques are useful in estimating the desired implant size, your surgeon will most likely make the final decision in the operating room.  During the operation, there are seizers that the surgeon uses to arrive at that decision.  The surgeon will fill the seizers with different volumes until the desired size and shaped is achieved.  The surgeon will then pick the implants which match this volume.

Besides issues of technique and choosing implant size, a question that women often have regarding this operation revolves around future cancer detection, whether via clinical exam or mammogram.  The data available up this point seems to suggest that there is no difference in cancer detection in women with and without breast augmentation.  Special techniques (Eklund) have been developed specially for women with breast implants in order to optimize the yield of mammography.  Furthermore, there is no evidence that implants will affect in any way fertility, pregnancy, or the ability to nurse.

UNDERSTANDING THE SURGERY:
 
Augmentation mammaplasty is usually an ambulatory procedure and can be performed in a hospital, same-day surgery center, or office OR setting.  It can also be done under general anesthesia or intravenous sedation.  Your surgeon and anesthesiologist will discuss these options with you.

In placing the implants, there is a choice of several incisions which can be used.  These include the following:
   

Axillary:  the incision is made in the hair bearing area of the arm pit.  The advantage of this incision is that it is well hidden and does not involve the breast at all.  The disadvantage is that it sometimes makes it more difficult to reach the implant pocket, especially in revision surgery.

Inframmamary
:  the incision is made on the skin in the fold under the breast.  This incision makes it easy to dissect and access the implant pocket, but its drawback is that the incision is made on the skin of the chest wall, and can sometimes be noticeable.

Periareolar:  the incision is made on the inferior aspect of the areola at the junction between the breast skin and the darker areolar skin.  This junction camouflages the scar well and this approach to the pocket is easy and direct.  The disadvantages of this incision are that the approach involves going through some breast tissue, and there is a small risk of partial loss of nipple sensation

 
Umbilical:  A more recent approach is the incision in the umbilicus (belly-button). This incision avoids any breast scars, but the makes the track to reach the implant pocket much longer, requiring special (endoscopic) instrumentation during the procedure.  This is a newer technique which is not yet being utilized by most surgeons.  With this technique, there might be some rippling or irregularities of the abdominal skin, usually temporary.
 


 

No matter which incision the surgeon decides to use, the rest of the surgery involves the dissection of a pocket into which the implant will be placed.  The pocket will be dissected just behind your breast and here there are two options as well.  The pocket can be made just behind your breast tissue but superficial to the chest muscles (pectoralis muscle).  This implant placement is said to be subglandular.  Another option is to make the pocket deep or behind the pectoralis muscle in what is called a subpectoral placement.  There is some literature to suggest that placement of the implants in the subpectoral position might lead to a decrease in one of the potential postoperative complications of this procedure, capsular contracture.

Besides the usual complications with any surgery such as reactions to anesthesia, bleeding, infection, scar formation etc., there are certain complications particular to this operation.

Asymmetry:  Any time when operating on both sides of the body, symmetry is usually one of the goals of surgery.  People however, are not completely symmetrical on both sides of the body whether it is the face, the hands, or the breasts.  Not only are the native breasts not only usually different in size, but the location of the nipples or of the breast itself on the chest wall can often vary from side to side.  When placing breast implants, the surgeon is always trying to achieve the best symmetry possible.  The normal differences between the two sizes however, can often make perfect symmetry an impossible goal to achieve.  Most often the asymmetry is so minor however, that it is not immediately obvious, especially when dressed.

Capsular Contracture:  This occurs when the scar which normally forms around the implant begins to harden.  This can make the breasts feel hard around the implants, and can be associated with pain or discomfort.  Occasionally, the capsule hardens to the point that it displaces or distorts the implant.  Studies seem to suggest that implants placed in a subpectoral pocket might have a decreased rate of capsular contracture.  If this condition occurs, sometimes surgery is necessary to treat it.  This surgery usually involves removing or releasing the capsule and an exchange of implants.

Implant Leak or Rupture
:  As with all other medical devices, breast implants have an inherent failure rate.  The last figures on implant rupture as of 2005 are approximately 4% at seven years.  With normal wear and tear, there is the possibility that the implant might develop a small hole through which the contents leak.  If the whole is small and the content is saline, the patient might notice a gradual decrease in size of the implant over time.  If the leak is large enough, the breast may become small very rapidly as the saline is absorbed by the body, usually within a few hours.  If this occurs, the implant will need to be replaced by a new one.  Implant manufactures usually guarantee their implants for life, and will replace a ruptured implant free of charge.  The patient might be responsible for some charges related to the operating room, anesthesia services and surgical services to replace the implant.  It is helpful before the operation to familiarize yourself with the policy of the implant manufacturer regarding implant rupture.  Some manufacturers offer additional warranties which can be purchased, that even cover the hospital costs in the event of an implant rupture. 

Rippling
:  If you envision a water-filled plastic bag or balloon, it is easy to picture the pleats or ripples that form in the outer shell as you hold the balloon or bag from the top.  This same phenomenon happens with breast implants.  Although most times these pleats are subtle and can not be seen with the implants in the proper position, sometimes they can be noticeable especially in thin women with thin skin and not a lot of native breast tissue.  Saline implants are most noted for this.  Although some surgical techniques can be utilized to camouflage the ripples such as making sure the implants are covered by muscle, or overfilling the implant slightly, sometimes the only way to correct severe rippling is to exchange saline implants for silicone gel implants, which are less prone to this complication.

Loss of Nipple Sensation
:  Any time an incision is made, there is the possibility of severing some of the nerves providing sensation to the overlying skin.  If the incision is close to the nipple, there is the possibility that you might experience a loss of sensation to the affected area.  Although most of these are temporary and sensation returns to normal within a few weeks, there is always the possibility that the sensation loss might be for an extended period of time, or even permanent.  There is also the possibility that the affected area might be overly sensitive for a period of time.

Infection
:  With any surgical procedure, there is always the possibility of infection.  If however, an infection occurs around a prosthetic device, the possibility always exists that the infection will not be resolved until the device is removed.  Infection around implants, although rare, will sometimes require the removal of the implant in order to treat it.  A new implant can then be placed once the infection has resolved.

Bleeding
:  Although this is a rare complication, significant bleeding onto the implant pocket will result in a tight, painful breast which is larger than the opposite side.  If you experience this during your postoperative period, please contact your surgeon immediately.  Often, it is necessary to return to the operating room to drain the blood clot and stop the bleeding.

 
WHAT TO EXPECT AFTER THE SURGERY:
 


 

Breast augmentation is usually done on an outpatient basis and the patient is discharged home the same day as the surgery, once she has recovered from the anesthesia.  The surgeon will sometimes place a wrap around the breasts or place a special brazier to keep the implants in the desired position.  Usually there is significant soreness for the first two to three days which can be controlled with pain medication.  The surgeon might ask you to take off the wrap around the chest in about 48 hours or you might be asked to leave it until you come to the office for a follow-up visit.

Depending on which sutures are used, these might have to be taken out at the post-op visit or they might dissolve on their own.  Other than for some soreness, you will be able to perform most normal daily activities by day three or four after the surgery.  Your surgeon might ask you to massage the breast and instructions will be given to you on how to do this if the surgeon feels that massage is indicated.  You will be asked to come to the office for regular visits so that the breasts and the implants can be examined.  For several days and up to several weeks after the surgery, you might experience a sloshing sensation coming from your breasts when you move or raise your arms a certain way.  Although most women think that this is the saline inside the implants, it is actually fluid that accumulates in the pocket around and outside the implant.  This process is from the surgery.  With time, this fluid is absorbed by your body and the sound should disappear.  Proper communication with your surgeon will optimize your results and address complications early if they do occur. Regular mammograms will also be recommended for women in the right age group or with other indications


THE NEW YOU:
 

Breast implant surgery when done for the proper indications on the appropriate patient yields excellent results.  You will be able to enjoy breasts that are better proportioned to your body and will give you a more feminine and enhanced figure.  If satisfied with the results, you can anticipate feeling better about yourself, with the added self confidence that your new look will bring.

   
The information provided above is for educational purposes only.  Individual results may vary.  A personal consultation with your plastic surgeon is the best way to gain information about your particular complaint, and about potential treatment options to address the same
 
 

 
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