Breast augmentation is the surgical procedure to help enhance breast size and appearance. Many changes will occur to the breasts due to the affects of time, pregnancy, and basic hereditary factors. Many of these changes may be corrected and improved surgically. The breast augmentation procedure is focused on restoring or adding volume to the breast tissue with the ideal individual being one who has otherwise good support and basic positioning of breast tissue but desires more volume. This patient is likely to experience highly desirable results from the augmentation technique.
Breast augmentation surgery alone will not fundamentally change basic defects, major asymmetry, or droopiness and there may be the need for procedures that address these concerns. If there is more than mild or modest droopiness of the tissue (ptosis) then a breast lift may be needed.
Breast augmentation is a safe procedure that generally produces pleasing and satisfying results. Refinements in technique and implant technology have minimized most of the older problems and concerns. Patients who will benefit the most will be those who have realistic expectations and are psychologically stable. Overall, breast augmentation mammoplasty is a safe and effective cosmetic enhancement option that is generally highly satisfactory in outcome.
The current breast implant choices are between saline and silicone gel. We are currently awaiting final approval for a third option, "form stabilized silicon" or as has been coined "gummy bears".
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The saline implant has a long track record of overall safety and offers some advantages in incision size considerations. As the implant is inflated once positioned it can be inserted through a very small incision. Additional advantages include the complete absence of any risk from leakage as the worst case scenario would be deflation that is easily fixed. There is likely as much as a 1% yearly volume loss with saline implants. Unlike silicone, saline causes no tissue inflammation or other problems that have been occasionally associated with silicone implants-generally old styles. This has been dramatically reduced as a problem with new silicone gel implants.
Saline implants are best suited for those who have somewhat more breast tissue for coverage to help reduce the tendency to see rippling of the implant. Although the feel may be very good overall with saline there probably is some advantage to silicone gel in this regard, particularly in someone who has relatively small amounts of natural tissue.
Silicone implants have undergone immense study and review prior to their returned availability on the market. They now represent a very safe and desirable alternative. Silicone gel is ideal in terms of feel, softness, and reduced rippling tendency. It represents an ideal choice in a thin individual with little natural tissue. The risk of leakage has been dramatically reduced and the silicone is a very thick gel rather than the more liquid prior implants which limit the problems even in the unlikely case of leakage.
Minor disadvantages include the need for a somewhat larger incision although very new techniques have in fact minimized this concern. Silicone implants are available to individuals who are 22 or older and do add somewhat to the overall price.
Overall there is no "perfect" implant at this time and it is important to discuss the options with Dr. Allegra.
What is the right size? Many factors will play a roll in decision making. It is very inaccurate to think of size by bra cup size as one manufacturer's "C" may well be another's "D". It is better to think of the degree of volume to be added in CC's. During your consultation we will try various sizers and try to narrow down the appropriate implant and style. At home one can fill a large zip lock bag with rice and using a sports bra see the volume desired. The rice can then be measured in a cup measure to determine volume. It is also helpful if you bring pictures of someone who you think looks good to you and would be similar to the desired outcome- men's magazines may be a good source for pictures.
Once we have decided on a size with the external sizer we would generally recommend increasing the implant size by about 100cc if they are to be placed under muscle in order to match the external sizers.
It is rare for patients to be dissatisfied with size after the decision making process as noted above. In fact the most common complaint is that the size could have been larger. It is possible to adjust up or down although this would be at additional cost.
No one has perfect symmetry and it virtually impossible to achieve perfect symmetry with any form of breast surgery. However, symmetry is usually very good within the parameters of what is possible given the basic anatomy.
The degree of cleavage that can be obtained is highly individual and is generally dictated by the basic position of the nipples and natural breast tissue . The chest contour also plays a significant roll. Implants need to be centered with the nipple to look normal and not result in a "walleye" or "cross-eyed" breast configuration. This is the greatest factor in how much cleavage is possible. A larger implant may allow for more cleavage within limits. If there is need to correct the nipple position there is also the opportunity to improve the positioning for better cleavage.
There are four choices of incisions for placement of implants.
The transaxillary (armpit) incision is popular for basic breast augmentation and is the most common approach we use. It generally results in a small incision that tends to be well hidden. For saline implants it is often ideal allowing a very small incision. Larger gel implants are more challenging and require a larger incision. The very newest techniques now allow us to minimize this with gels even in larger sizes.
This incision is placed in the crease of the breast fold and is well hidden. It offers excellent access to placement of implants and may be very small with saline implants. It may be a necessary incision if there is need for implant removal or treatment of capsule problems even if the implant was originally placed through the armpit.
This incision is made at the margins of the areola and allows good access for implants as well as other possible corrective surgery. It can be very well hidden in the majority of individuals.
This is the approach to implant placement via a belly button incision. It is limited to saline implants only but results in a minimal scar for most individuals. We do not offer this approach as we feel that the limitations tend to outweigh any benefits of consequence.
Implant Placement Locations
There are four choices for implant placement divided in two categories-above and below muscle. The above muscle option is "sub mammary" or "sub fascial"; the below muscle options are "sub pectoral" or "total sub muscular".
Placement above the muscle would be most useful for an individual who has a modest amount of natural tissue and perhaps has a small amount of droopiness. The above muscle placement will tend to result in somewhat greater appearance of a lift effect. Larger implants will however become droopy over time. This approach is also useful for someone who is a body builder as placement under muscle could result in a sig flexion deformity problem (creasing of the breast appearance with flexing of the chest muscles).
Placement below the muscle is generally the preferred location as there is an added layer of tissue that helps to create a natural appearance and feel.
Risks and Complications of Breast Augmentation
Breast augmentation is generally a very safe and satisfying procedure; however, as with all surgical procedures there are some risks you need to be informed about. These fall into two basic categories: short term and long term.
Short Term Risks
Post Operative Bleeding Resulting in a Hematoma
This is a rare problem and is one of the specific reasons we will plan on seeing you the following day. If there is a hematoma it will likely need to be drained and might require implant removal and replacement at that time. If there has been a hematoma there is a somewhat increased risk for capsule contracture in the future.
Post operative infection is very rare but potentially serious and needs to be treated by removal of the implant and antibiotic therapy. Once resolved the implant can be replaced generally after 3 months. We treat all our patients with antibiotics to help minimize this possibility.
There is a possibility of a temporary decrease in nipple sensation - this generally improves over a period of several weeks to months. A significant permanent decrease is rare.
Long Term Complications
There is a normal and necessary capsule that will form around an implant. In some cases this capsule becomes thickened and contracted in an adverse fashion. The degree of problem varies considerably from the minor which may not need much treatment to the major that will need to be treated. Signs of significant contracture may include firmness, distortion, displacement ,and occasionally some pain.
The risk of contracture is approximately 1% per year and probably peaks at 10%. There is evidence to suggest that implants placed under muscle may be somewhat less prone to contracture. Repair of contracture may require release or removal of the capsule and then replacement of the implant possibly in a different pocket. Unfortunately there may still be the return of a capsule contraction despite this.
The risk of leakage is considerably reduced in newer implants but may still occur. In the saline implant there may be a rare problem of sudden deflation which is not harmful as the implant contains saline. If this occurs it is generally quite easy to simply replace the implant-this may often be covered by the manufacturer. Some slow leakage may occur with saline implants and is estimated to be 1% per year. If there is evidence of some slow volume loss then the implant can be changed.
Leakage of silicone implants is now much less of a problem than with the earlier implants and due to the thicker gel consistency is less troublesome. Older leaking or "bleeding" implants are best removed and will require a capsulectomy (removal of the capsule) and then replacement with a modern implant. The FDA does recommend but does not require that an MRI scan be performed to look for non-symptomatic leaks 3 years after the surgery and every 2 years thereafter.
Rippling of the implant where there may be visible scalloping of the contour is a risk that is affected greatly by one's individual anatomy and by the size, style ,and placement of the implant. A large saline implant placed above muscle in someone who has little natural tissue is likely to show some rippling particularly if one leans forward. In general the least rippling will be with a gel implant placed under muscle in someone who has a moderate amount of natural breast tissue. Saline also will do well in this position particularly if it is "over filled" to the maximum parameters. If one has moderate natural tissue it may be reasonable to consider an above muscle placement particularly with gel.
It may be impossible to completely eliminate rippling in a very thin individual given the implants currently available. The form stabilized implants hopefully available soon may offer a way to eliminate rippling effects.
The "double bubble" is a crease like deformity along the lower aspect of the breast that results when the natural lower crease of the breast needs to be lowered due to excessive height, very tight tissue, or the size of implant to be placed. It may be difficult to avoid or eliminate in some individuals due to the nature of the breast tissue.
Some individuals may note a temporary shape change of the breast with flexion of the pectoral muscles when the implant has been placed under muscle. This is not harmful and of course instantly disappears when one stops flexing. This generally does not become cause for concern unless on is a body builder and certainly if one is performing in this capacity. Implants above the muscle would generally be effective at eliminating this problem.