What is Breast Augmentation?
Augmentation mammoplasty is one of the most commonly performed cosmetic surgery procedures in this country. There are well over 2 million women who have had breast enlargement surgery in the last 30 years. The procedure itself is straightforward. However, there are some drawbacks to this operation, and I want to make sure that you understand them so you can make a well-informed choice.
An augmentation mammoplasty takes about 1 hour and is usually done in my accredited office surgery suite under sedation. A pair of implants will be placed under your breasts to enhance the volume and give the impression of “lift” or a fuller upper breast. Nonetheless, you will keep your basic underlying shape in terms of cleavage and position unless we decide together than you would look better with a breast lift (mastopexy) performed at the same time. The operation involves an incision, which is over 1 inch long and usually just above fold under your breast if you have a fold. The advantage of these locations is that they are well hidden in terms of scarring. In my opinion, other less optimal incisions are on the breast skin where it is very visible or in the axilla (armpits) where it can easily show if you have not healed perfectly. I would be glad to discuss these incisions with you.
I usually prefer a round, rather than a shaped, (which are no longer available) implant for augmentation because most patients need more fullness in the upper portion of their breasts over time. Also, shaped or tear-drop implants can rotate and turn sideways or upside down. After the incision is made, the implant is generally placed underneath the muscle (pectoralis major) which is directly below the breasts. Implants in this position remain softer, and their edges tend to be better hidden in terms of masking the contours of the implant. In addition to this, an implant underneath the pectoralis major muscle yields a much clearer mammogram. The exception to placing implants behind the muscle are patients with a significant amount of volume. An implant under the breast can look more natural at first but then be more prone to develop scar tissue and get hard or look deformed over time.
One of the theoretical problems with augmentation mammoplasty is that an implant can interfere with the visualization of the breast on mammography. This is a real concern, especially in patients with a strong family history of breast cancer. Because of this, a patient with an augmentation mammoplasty will need to have special views obtained when having a mammogram to try to visualize more breast tissue. An implant under the muscle does not interfere with your mammogram as much as one above. I should mention that there have been two very large studies, one in California and the other in Canada, each with over 8,000 women, which have shown definitively that there is no increased risk of breast cancer in patients who have had smooth breast prostheses placed.
Everyone’s pain threshold is very different, but this operation can be quite uncomfortable for 24-72 hours after surgery. This is often related to the size of the implant placed. You should plan to take approximately 1 week off from work, more if your job is very physical. I can improve the pain by injecting Exparel which is a long-acting lidocaine into the wound. Botox also can be injected into the muscle for larger implants, but both of these involve additional cost. A certain amount of soreness should be anticipated for several weeks, and again, this is very variable from one patient to another. You will probably take a pain medication by mouth after the surgery for a variable amount of time.
One important decision that needs to be made before the time of surgery is what size implant is to be used. Please bring your ideal bra with you to the office at your pre-op visit. This is an unpadded bra that has the same chest wall size that you now wear (e.g. 32, 36, etc.) but with the cup size that you would wish for. In the office, we will be able to figure out what size implant fills the bra. Also, please bring a printed page of photographs from a plastic surgery website, mine, or another, of a patient who has your general proportions and is the approximate bra size you wish to be. Magazine and swimsuit models are not that helpful unless you are 6 feet tall! It is important to realize that this is not an exact science, although I think we can get a very good idea of the right size for you. I rarely switch out implants to change the size because we will spend a lot of time on this important decision. Obviously, the larger the implant, the less natural you will look, especially as time passes.
What Happens After?
I will see you in the office several days after your surgery. This will be to check for any evidence of infection or bleeding and to answer any questions you might have. You will be seen often initially after your surgery, but eventually I will see you on a yearly basis just to make sure that I am happy with your breast exam and that you are getting the proper follow-up and mammograms as you should.
There are complications associated with the implants. Everyone forms some scar tissue around the implant. I think it is very similar to an oyster which, when irritated by a grain of sand, forms a pearl. Some patients will develop a little scar tissue, while others put down layer upon layer of scar tissue. Unfortunately, there is no way to predict which patients will form a lot of scar tissue (encapsulation) and which patients will not, except that smokers tend to encapsulate more. Should a capsule form, most patients do not need to do anything about it except realize that the implant will be a bit harder on one or both sides than one would have hoped. There is also a medication that I can prescribe, as well as exercises, if we catch the encapsulation early. Occasionally, and this is around 5%, a patient will have to go back to the operating room so that we can remove the scar tissue and possibly replace the implant. Another possible complication is infection. This happens in less than 1 in 500 patients in my practice, but unfortunately when it does happen, it can mean removing the implant because antibiotics alone may not be enough to manage the infection. I would like you to email me immediately if you have any concerns. Bleeding occurs very infrequently. There is a very rare risk of numbness of the nipples with this operation, but I have not seen this. You might be a little bruised after the surgery, but rarely a patient can develop a pocket of blood which will need to be drained in the operating room. For this reason, we will limit your physical activity for a few weeks after surgery and you will avoid any medications which can have you bleed more freely.
Very slender patients with almost no breast tissue can expect that they may have some palpability of the implant or even some rippling in the lower outer portion of their breasts especially when they bend over, but this is usually not a significant issue. An implant can be chosen to minimize this risk. Rarely, the breast implants can have some motion with pectoralis muscle contraction, so I will discourage you from doing “pec exercises” with weights post-operatively. Most of the time, the scars are fine. They will stay red for about 9 months and then turn white, but occasionally, for reasons that are unknown and mainly genetic, a patient will develop a thick scar which might need to be revised.
It is very difficult to know the exact rupture or deflation rate, but it is probably about 1% per year, so say 20% by 20 years. Silicone implants often have “silent” ruptures which are not recognized until scar tissue forms or until detected on a mammogram. Silicone also feels more natural in general but requires a larger incision. Saline deflation is easy to treat surgically whereas a silicone rupture is generally not. I have been using the Ideal Implant for several years. This is a Saline Implant within a saline implant. It tends to feel more natural, like a silicone implant but with the safety of a saline implant. There is no perfect prosthetic device, and we will discuss the pros and cons of all of them in the office together. The manufacturer will sell you an inexpensive extended warranty for the implants which will help lessen any future expenses associated with deflation or rupture for a period of time. I strongly recommend that you buy this warranty as deflation is by far the most common complication. I generally use saline-filled implants for breast augmentation unless you request silicone.
Please be aware that if a deflation or encapsulation occurs which requires surgery after your initial surgery, there are surgical and anesthesia fees that will apply. Smokers heal poorly in terms of infection, encapsulation, implant loss and wound breakdown. You are advised not to smoke or use any type of nicotine products to include vaping or tobacco replacements for at least 1 month before and after surgery. Nicotine screening may be necessary the day of your surgery. IF THE TEST IS POSITIVE, YOUR SURGERY WILL BE CANCELLED.
I hope all this information has not been overwhelming. I have tried to give you all the information that I have about implants so you can make a reasonable, informed choice.
It will be a pleasure to discuss breast augmentation with you in my office. Please do not hesitate to contact me if I can be of further assistance (804-320-8545).
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