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Breast Augmentation FAQ
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Introduction: I’ve prepared these comments to be informative for you as you contemplate breast augmentation, and to also help you choose the practice that can best help you in your very important decision to undergo elective surgery. So these comments reflect my perspectives and approach. • How many breast augmentation procedures do you perform? o I have been in practice 24 years (since 1984). I perform ~120 breast augmentation procedures in a year. • Why might I choose to have my surgery with your practice? o We have a very low rate of complications and low capsule contracture rate, and a high rate of patient satisfaction. o Our approach is very individualized: first we listen to be sure we understand your goals. o Our approach is very comprehensive: we want you to know all the options, and the trade-offs. o We offer a private, fully accredited office surgical suite. We can offer greater privacy and personalized attention. Our staff is hand-picked and a dedicated team that works exclusively with me. Long before the surgery day, you will have met almost everyone who will be helping to care for you, from day of consultation, through surgery, recovery and follow-up appointments. Just as importantly, they will get to know you, as well. As a dedicated team, we work together more precisely and efficiently. My staff knows the cosmetic procedures I perform, and how I perform them. Size and Shape There are two important aspects of the implant choice: size and shape. One will influence the other. The first step in sizing is my listening to what you want to achieve. Most women will tell us their current cup size and what cup size they would like to be. This is a good starting point, but can be inaccurate, because there is no standardization of cup sizing that we can relate to specific implant sizes. Also women fit themselves very differently: one woman’s “B-cup” is another woman’ “C-cup.” The cup sizing may also vary among the styles and manufacturers bras. We know that the aesthetics of breast size and proportion is very individualistic: you know best what will give you the look you want to achieve. To help you visualize the result you want, we provide you with implant “sizers” to wear in a bra. By looking in the mirror and trying the different sizes, you’ll be able to see very specifically what you want to achieve. Once you find the size you like, we ask you to wear the implants the rest of the day, wear them home, try on different clothes, take time to see yourself in the mirror and get used to your new look, so you can feel more confident in your choice. We strongly encourage that you also go bra shopping with the implant sizers to be sure you are fitting the bras you want to wear the way you want them to fit. This is a practical step: in the past, we have had patients tell us that although they are happy with their size, they find that they “are too big for a C, but too small for a D…” Tweaking the size to fit the bra you want to wear is easy to do during the sizing process. We do know that the breast implant looks about 10% smaller when it is behind the breast and muscle, after surgery, so take this into account when you do the sizing. After doing the sizing this way, when I ask women at their 6 month and 1 year post-op visits if they are happy with their size, about 60% of women report they are very happy with their size; about 40% will tell me, “I could have gone a little bigger,” though very few women actually go through replacing the implants with a larger size. My impression is that many women initially may be a bit inhibited or worried about the prospect of “going too large,” but soon realize their choice is far from excessive, and choosing a bit larger implant would still have been a safe choice. I also have the impression that some of this feeling that going larger would have been okay may come from the adjustment, acceptance and comfort with the change from the augmentation. Based on this experience, as you do the sizing and you are uncertain about two sizes, my advice is that you go with the larger of the two sizes. The size increments among the implants are quite small: ~1/8 of a cup. So going with the larger implant size will not make the difference between “just right” and “too big.” Important: as you do the sizing, trust your visual impressions and don’t worry about the number on the implant (the size in cc’s). Very important: disregard the temptation to choose a size for yourself based upon what a friend chose, or what you may see in a before-and-after picture. The same size will look very different in different individuals because of size and shape of breasts, shoulders, rib cage, breast bone, waist, and skin tone, among many other factors that affect the look of post-operative results. I have had many patients make this mistake and regret it later, because results were not what were expected. When you try the sizers, trust what you see and your own instincts. It is important to understand that although doing sizing this way will tell you about size and proportionality; it will tell you nothing about shape! The shape of the breast and implant in the bra will be very different from your shape when you are undressed and the implant is behind the breast. How to figure out the right size implant is a major concern of almost every woman seeking breast implants. In my practice, most women express a concern to not choose a size that will be “obviously fake,” instead of a “natural appearance.” Because there is such a variation in the shape of breasts among women, “natural” can mean many different things: what looks “natural” to one woman, may seem “obviously fake” to another. During the consultation, we will use specific pictures and drawings to determine more specifically your individual idea as to the appearance you wish to achieve. Bringing photos representative of desired results can be helpful. The “obviously fake” appearance that people notice is a result of size disproportion (the breasts appear too large for a woman’s build) or unnatural shape. The very rounded (rather than tear-drop) appearance of a breast with a distinct demarcating line in the upper chest is a tell-tale sign, as well as asymmetries or shape distortion that can result from scar capsule contracture. The “pasted-on” appearance of the excessively round breast with an abrupt edge can occur for a few reasons: 1. placing the implant in front of the muscle (prepectoral) in a slender woman with little natural breast tissue; 2. a capsule contracture; 3. too large an implant for the size and shape of the natural breast 4. an over-inflated saline implant. So properly fitting an implant to the size, shape and other tissue characteristics of your breast, chest and skin are critical to achieving a “natural appearing” result. To better fit the implant to your specific build and your size and shaping preferences, we use different implant shapes: these implants have a low-, intermediate-, or high-profile, referring to the relative height of the implant when it is placed on a surface. [Insert photo or sketch of different profile implants] For a given profile, as implant size increases, the diameter of the implant also increases. We know that it is optimal for the width of the implant to be no wider than the diameter of your natural breast to avoid feeling or seeing the edge of the implant. Also as the implant increases in size relative to the size of your natural breast, the implant increasingly shapes the breast. That’s why “large” implants make the breast very rounded. If the implant is wider than your natural breast tissue, it is easier to feel or see the edges. This increases the chance of seeing and feeling ripples. Because the implant is a fluid (saline or gel) filled bag, the soft surface of the implant (the “shell”) will have undulations as the fluid shifts with movement. It is normal to feel (not see) these ripples right in the crease of the breast, when you are standing or sitting up, because the drape of the implant in this position creates some scalloping of the implant shell. However, we want to minimize feeling this scalloping or rippling along the sides or top of the implant. By choosing an implant that is just a little narrower than your natural breast tissue, we can minimize this feel (palpability) because the breast tissue is covering the implant; so, we feel breast, rather than implant. The same is true for avoiding visible wrinkles or ripples: if there is only skin covering the edges of the implant, we can see the ripples and a sharper edge of the implant. When the implant is narrower than your natural breast, the breast tissue covers the edge of the implant, hiding the ripples and softening the transition from the edge of the implant. Another consequence of having too large an implant is possible disruption of some of the supporting tissues to the breast and the implant, like the breast crease or cleavage. This can result in a drifting of the implants across the breast bone, too far to the side, or downward on the chest. Repairing these “malpositions” can be very challenging. So using an implant that fits your chest and breast is very important to getting the shape you want and minimizing risks. During the consultation, I will take all your preferences and priorities into account to guide your choice of the best combination of implant size and shape to achieve your goals. I will also inform you what tradeoffs may be involved in the choice of a specific type of implant. Silicone vs. Saline: In January, 2007, after years of reviewing hundreds of studies looking at the safety of the silicone gel-filled implants, the FDA released the restrictions it had placed on these implants for cosmetic breast augmentation. Since that time, 60-70% of women having breast augmentation in my practice have chosen silicone gel implants. Silicone gel implants feel much more like a breast. The implants seem to “disappear behind the breast and are much less easy to feel or distinguish from the feel of the natural breast. They seem to drape and move more like a natural breast with far fewer ripples, and less edge feel. The FDA still wants to continue to gather information about these implants and has asked that women who know choose silicone implants to get an MRI scan 3 years after surgery, then every 2 years. The FDA wants to gather more data about longevity and leakage of silicone gel implants. Today, we use more advanced gel implants that are very cohesive: the gel sticks to itself. If you cut an implant, the gel does not “run.” If you squeeze the implant after you cut it, the gel bulges and then comes back, like squeezing a marshmallow. This is great in terms of the integrity of the implants if the shell wears down through the years, but makes it impossible to clinically detect (by feeling the breast) a leak. We suspect that there are many women who may have developed a leak in the shell of their implant, and we don’t know about it, because their breasts feel completely normal. Sometimes, the only way we discover that a woman has had a leak of a gel implant is our coincidental unanticipated discovery of a leak at the time of surgery performed for another reason; e.g., to change size, repair a capsule contracture, or electively remove the implants. The capsule contains the leaky gel; it does not get absorbed by the body and the breast does not change size. Especially with the new cohesive gels, even scans have a significant error rate in determining whether there is a leak. For this reason, some patients elect to change their gel implants every ten years, to replace them before the implants are likely to have a chance to “wear out” and develop a leak. Recent data has shown that the incidence of gel implant leakage in the first ten years is less than 3-1/2%. On the other hand, saline implants are filled with intravenous fluid that is absorbed by the body. If a saline implant leaks, the saline is harmlessly absorbed, and the breast deflates, usually within a few days. In such cases, it is best to replace the implant within a couple weeks, so that the capsule does not shrink as the implant deflates. If the capsule doesn’t contract and there is enough room for the new implant, replacement surgery is most often a quick (~1/2 hour) procedure, done with local anesthetic through the existing surgical scar. Since the cutting is limited to the skin and there is no internal surgical cutting, recovery is the same a small skin surgery (like a mole removal). You can immediately resume almost all normal activities. Under these circumstances, this surgery is pain free, except for the injection of local anesthetic, and you can drive yourself to and from the appointment, without taking any further time off from work. The development of a saline implant leak is not dangerous: it is a nuisance, because it causes deflation of the breast. The incidence of leakage of saline implants is about 1% per year; after 10 years with saline implants, you will have had a 10% or 1-in-10 risk of having an implant deflate; after 25 years, a 25% or 1-in-4 risk of having developed a deflation. It is very important to read the implant manufacturer warranty to understand what is covered and what out-of-pocket expense you may incur, if you were to ever develop a leak or deflation. The incision can be as small as 2cm (~3/4 inch) with saline implants, because the implant is inflated after it is inserted. Silicone implants require a 3-4cm (1-1/4 to 1-1/2 inch incision) It is important to understand that no implant will be completely “invisible;” if you can feel your ribs, you will be able to feel the implant. Textured vs. Smooth Surface Implants About 30 years ago, texturing of implants became very popular because of the lower capsule contracture rates seen with these implants. As implant technology advanced, the incidence of capsule contracture with our current smooth implants is no different from the textured implants in women having cosmetic breast augmentation. The disadvantages of the textured implants include a thicker shell that is more palpable leading to more edge feel or visibility and a less natural or stiffer feel to the implant. Textured implants also have more potential for rippling and a higher deflation rate. Textured implants may still be preferable for women who have had previous capsule contractures or when tear drop shaped implants are used (the texturing prevents the rotation of the implant). Spherical vs. Tear Drop Shaped Implants Tear drop implants are very useful for shaping in breast reconstruction, but less so for cosmetic augmentation. The spherical implant assumes a tear drop shape when a woman is upright. When a woman lies back, the implant flows and flattens just as a natural breast does. By contrast, tear drop shaped implants tend to stay upright on the chest even when a woman lies flat, creating an unnatural (“obviously fake”) appearance. Also, tear drop implants must necessarily be textured to prevent rotation of the tear drop in the wrong orientation. Textured implants have the disadvantages of less natural feel, more rippling and higher deflation rates. Capsule Contracture Capsule contracture is the term we use to describe a process that can occur resulting in a hard unnatural feel of the implant. This can also result in unnatural looking lack of implant motion, distortion of the shape of the breast, or pain. I have found that we can achieve a lower than average rate of capsule contracture through careful adherence to proven surgical techniques and by carefully educating our patients about capsule contracture and emphasizing how to prevent its occurrence. During surgery when we first create the space for the implant behind the breast or behind the muscle, we create a space (a “pocket”) large enough for the implant to move as a natural breast moves. The body’s normal reaction to this surgically created space is to “heal it” by scarring it down. We prevent this from occurring by massaging or manipulating the implant, starting the first day after surgery. Moving the implant helps to maintain adequate pocket dimensions, preventing the scarring down of the space around the implant. We will demonstrate and instruct you on how to effectively perform the manipulations the first day after surgery, and review this important manipulation at each post-op visit. Effective manipulation takes only 10 seconds twice a day, and is very effective in preventing capsule contracture. It is important to continue the manipulations as long as you have the implants. Once the implant is in the surgically created pocket, the body has a natural reaction to this foreign body. To prevent irritation by the implant to the tissue surfaces (the ribs, muscle and breast), the body creates a thin, delicate and smooth slick lining around the pocket. (By analogy, this is like the oyster reacting to a grain of sand in creating the smooth pearl.) This lining is the capsule. It is called a capsule, because it looks just like the joint capsule, the smooth white lining that allows for motion in the joints like the knee, shoulder, elbows and fingers. The capsule formation is an important part of the successful breast augmentation as the capsule allows for the flowing motion of the implant with the breast. It takes about 6 weeks for the capsule to form and mature, so during that time, it is important to refrain from any activities that will cause excessive irritation of the tissues. Such irritation will cause more inflammation and scarring, resulting in capsule contracture. For that reason, we recommend the following activity restrictions for 6 weeks after surgery: no high impact activities, such as jumping or jogging; do not lift more than 15-20 pounds; no sudden or big arm swinging motions, such as in tennis or golf. It is also important to avoid certain repetitive arm motions like those with scrubbing, painting or using a vacuum cleaner. Bleeding in the tissues signals injury to the body and creates a scarring reaction. If there is blood in the space around the implant after surgery, this will signal the body to produce more scar around the implant. To prevent this from occurring, I must be very careful to minimize trauma at surgery and seal off any bleeding that may occur. It is also very important to avoid anything that might thin the blood and cause more oozing after surgery. For this reason, we ask you to stop taking any substances that can act as blood thinners, such as aspirin, ibuprofen, multiple vitamins and herbal supplements a full 14 days prior to surgery. It is important to check the ingredients on any medications you might take to be sure they do not contain a blood thinner. We will provide you with a list [Insert link] of many common over the counter medicines that contain blood thinners. Even a single baby aspirin taken a10 days before surgery can make a big difference! We will also recommend specific vitamins and supplements that are not blood thinners and are helpful in preparing for surgery and the healing process. Research has shown that bacteria can get into the blood stream during a surgical procedure or when you have your teeth cleaned by the dentist or hygienist. The body’s reaction to the presence of bacteria in the blood stream can lead to capsule contracture, even years after breast augmentation. This can be effectively prevented by taking a single dose of an antibiotic ˝ an hour to an hour before the procedure. We strongly recommend this very cost effective preventive measure for as long as you have breast implants. We will provide you with a prescription (usually Amoxicillin, if you do not have a penicillin allergy), and we are happy to provide you with refills. Most women find it most convenient to let their dentist know so they can be reminded at the time of their dental appointment. To avoid having to cancel the appointment, many dentists keep the antibiotics in the office to give to patients who may have forgotten. Please note that antibiotic prophylaxis is very important for teeth cleaning, root canals and gum surgery, but is not usually necessary for fillings or crowns. If you are uncertain, please consult with our office or your dentist. Although it is impossible to guarantee against the development of capsule contracture, adherence to all these measures can lower your risk substantially In front of the muscle or behind the muscle? In creating the pocket or space for the implant behind the breast, we may lift the pectoral muscle and place the implant behind the muscle and in front of the ribs. [Insert diagram] The pectoralis is a large muscle of the chest that creates a triangle from the shoulder to the breast bone and the lower ribs. The broad flat muscle lies just deep to the breast and lies over the ribs. The muscle is used to pull the shoulder and upper arm inward across the chest and to stabilize the shoulder when you use your arm. We place the breast implant behind the muscle (“subpectoral” or “submuscular”) for a few reasons: • There is a lower capsule contracture rate with a subpectoral placement; • The draping of the muscle over the implant helps to create a more natural tear drop shape to the implant; • The draping of the muscle over the implant creates a softer transition over the edges of the implant, resulting in a more natural appearance; • The muscle adds soft tissue coverage over the implant; this added tissue helps to conceal ripples (visible or palpable) and creates a more natural feel and appearance to the implanted breast. This is especially important in slender women with little breast tissue and fat to cover over the implant. In certain special instances, it may be preferable to place the implant in front of the muscle (“prepectoral” or “subglandular”). In my practice, this is rare, as I have found that the advantages of subpectoral placement usually outweigh the disadvantages. What are the disadvantages of subpectoral placement? • Elevation of the muscle can hurt more in the early post-op period. Our use of the anesthesia/pain pump has made an enormous difference in reducing post-op discomfort. • There can be some motion of the breast implant when you forcefully contract the muscle (exercising). New techniques in redraping the muscle and breast over the implant have reduced this occurrence, but some motion is likely. Incision placement Breast implants can be placed through incisions in the crease below the breast (inframammary), at the edge of the nipple-areola complex (periareolar), through the armpit (axillary/transaxillary), or through the belly button (umbilical/transumbilical). Inframammary incisions are preferable because they conceal well in the breast crease, are generally the smallest incisions and allow the most direct approach for effective release of the muscle and redraping of the breast over the implant. The incision can be as small as 2cm (~3/4 inch) with saline implants, because the implant is inflated after it is inserted. Silicone implants require a 3-4cm (1-1/4 to 1-1/2 inch incision). The inframammary approach is least disruptive to breast tissue. The incision is actually placed about Ľ-inch above the crease so it will not show below swimsuit top, if it rises up a little when you raise your arms. This scar remains well concealed under the breast. Undressed, you will be able to see the scar if you lift the breast or when you lie back The periareolar approach places the scar along the lower half of the circumference of the edge of the areola. This scar can be quite hard to see, but if the scar does thicken or loses pigment, it is a conspicuous location. The length of the incision is the same for silicone and saline (about 1-1/2 inches). This approach is more disruptive of breast tissue, is more likely to cause changes in nipple sensibility, and has a higher capsule contracture rate than the inframammary approach. It is also harder to perform certain breast redraping techniques from this approach. The transaxillary approach has the advantage of placing no scar on the breast, but the incision in the armpit will be about 1-1/2 to 2-inches in length. If the scar thickens or pigments, it will be conspicuous if you raise your arm when you wear sleeveless tops or swimsuits. More importantly, it is technically much harder to get an adequate muscle release and breast redraping from the armpit. In fact, among women who have transaxillary placement of breast implants, about 20% have an implant malposition: usually the implant appears to sit too high or look too full on top. When I first started in practice, I used this approach most often; when new improved techniques in muscle release developed, and we recognized the inherent disadvantages of the axillary incision, I stopped using this approach. Transumbilical approach puts an incision in the belly button (umbilicus) and tunnels up to the breasts under the skin of the abdomen (tummy). This approach presents the greatest technical obstacles to adequate muscle release, breast redraping and proper implant positioning. The umbilical approach probably carries the highest rate of complications. To me, the tradeoffs aren’t worth it, and it’s not a technique I use or recommend. Nipple Sensibility The vast majority of women regain normal nipple sensibility after breast augmentation. About 4% of women will permanently lose sensibility with breast augmentation. About 10% may have a long lasting noticeable change. In most women, temporary changes in nipple sensibility are caused by the stretching of the nerves from enlarging the breast. It is common to notice brief shooting pains during the weeks or months after breast augmentation, as the nerve heals from the stretching of the augmentation surgery. These pains are temporary; they dissipate and disappear over time. Nursing after Breast Augmentation Most women have no trouble nursing after breast augmentation. Because the implant is completely behind the breast, it poses no obstruction to nursing. The inframammary approach minimizes any trauma to the breast, so there is typically no disruption to breast glands or ducts. “How do I know if I Need a Lift?” The need for a breast lift procedure can often be determined by looking at the height of the nipple relative to the breast crease. If the nipple has drooped below the level of the breast crease, a lift is probably desirable to produce an attractive improvement. Although implants do fill out a deflated breast, implants do not lift the droopy breast. Important Considerations: • It is important to remember that all plastic surgery involves trade-offs and compromises. I will do my best to let you know what these may be. • Although we strive for perfection, no plastic surgery is perfect (Neither is Mother Nature!) • If you will tend to focus on imperfections after surgery rather than on the improvements you have achieved, do not undergo cosmetic surgery: you will be frustrated and no happier for your efforts. • Each operation will have flaws: be sure you understand what they may be and that you can live with them. • It is impossible to guarantee the results of any surgery; but I can guarantee that I will do my best for you! • There are many areas in plastic surgery where experts may disagree. These comments reflect my understanding of best practices of plastic surgery.
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