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Procedure: FAQ Breast Augmentation

FAQ Breast Augmentation

1. Some of my friends have fake-looking breasts. How do you avoid that?

One must understand that many factors can contribute to the fake look. One reason is if a patient sports too large a bust line for her frame-(Think about it...How many very few slender, 0- 2 sized women naturally have DD-cup breasts?). Therefore, no matter how natural-looking the actual breast itself is, the total balance of the woman's body will appear unnatural and top-heavy. Another reason is to have an implant above the muscle, especially in patients with little breast tissue and body fat. Ripples and, often times, the edges of the implant will become visible in these cases. The implants may appear "stuck on". Finally, in order for the breast to fall and feel natural, the pocket in which they are placed needs to be somewhat larger than the implant itself, otherwise, the implant will not move properly and may ride up too high on the chest wall. This situation can occur if the surgeon doesn't create an appropriate pocket or space in the first place or if the pocket shrinks down by itself. This latter situation is called encapsulation.

2. What approach do you use to put in the implants?

I almost always use the submuscular periareolar approach (or "through the nipple") since in my hands, it affords the greatest visibility for the surgeon during surgery. As a result, I can see every millimeter of pocket creation that I perform before placing the implants within that space while enabling me to stop any bleeding that is encountered. This is in contrast to approaches through the axilla (armpit) and umbilicus (belly button-TUBA technique) which are basically "blind" procedures because the surgeon can only feel if he is creating symmetrical pockets and cannot actually visually verify the symmetry. As a result, these "blind " procedures result in more breast implant asymmetries, "high-riding" implants, encapsulations ("hardening") and hematomas (the latter two from uncontrolled bleeding). Patients are understandably concerned over the scarring along the areolar border with the normal breast skin as well as loss of sensation. I have found that the scarring associated with the periareolar technique of breast augmentation is almost invariably better and invisible as compared with the other approaches, including the axillary one. Loss of sensation with the periareolar incision has been found to be no different than with other methods. This is because the nerves that supply the nipple don't run along the skin (where they can be interrupted by an incision) , but attach themselves to the nipple from its undersurface (like the roots of a tree). However, changes of nipple sensitivity are more common when larger implants are utilized.

By employing the submuscular or "below the muscle"(pectoralis major muscle) approach, one benefits from 5 ways:

  1. The breast tends to look better as long as the surgeon knows what they are doing by going under the muscle;
  2. There is less long-term sag under the muscle;
  3. There is less chance of seeing ripples and the edge of the implant (the latter imparting the "stuck-on" look) by going under the muscle;
  4. There is less interference with mammography and , finally,
  5. There is less chance of encapsulation (refer to 7. And 8. below).

3. When do you use silicone implants? What are the "gummy bear"/Cohesive Gel implants?

One must understand that there is no perfect implant which will satisfy the unique needs of every single patient. For some, saline implants are the best choice, while for others silicone may be preferable. Silicone does feel softer and more natural than saline even though it is associated with a slightly higher risk of capsular contracture (albeit by a very small amount). For the same volume, moderate profile silicone gel implants are flatter and wider while saline tends to stand taller, but with a narrower footprint. For example, a 500 cc gel implant is more like the Pentagon while a saline implant tends to be tall and narrow like a skyscraper. The choice of implant would have particular implications in patients who have a long vertical distance between their collarbones and the top of their breasts (such as after nursing). A flatter silicone implant will tend to gracefully fill this empty vertical distance lending a natural youthful appearance to the bustline without giving too much obvious forward projection, which may make a woman feel too "top-heavy". Additionally, silicone is associated with less annoying rippling than saline.

Despite the hype about less complications associated with the solid silicone "gummy bear" implants, I have removed a number of them because of hardening/encapsulation and , even in the best of circumstances, they feel "rubbery" and more unnatural than the best regular gel implants. One must also remember that the silicone gel implants that I utilize are Mentor's "Memory Gel" variety, which if ruptured, do not spill and yet retain their shape despite the softer consistency of the contained silicone as compared with the Cohesive Gel implants.

4. When do you use textured versus smooth implants? Do you use the "tear drop" shaped implants?

I rarely use textured implants. I find the evidence suggesting less incidence of capsular contracture associated with textured implants non-compelling, since none of the comparison studies address all other variables affecting rates of capsular contraction. For example, no study compares capsular contraction of textured implants against smooth implants implanted with the vertical submuscular megapocket technique (the one I employ) with vigorous postoperative implant- displacement massage routines. I used to use the "tear drop" implant back in 1994-1996, but have since abandoned them because the results were not consistently natural, cleavages were too far apart and the implants could rotate on themselves. My goal is to give everyone of my patients a completely natural "tear drop" shaped breast, but plastic surgeons have found that "tear drop" shaped implants tend to produce the opposite.

5. How do you figure out the size of the implants I will need to get the results I am expecting?

The most reliable to do this is to have you, the patient, collect photographs of breasts and shoulders that you like. The internet, "Playboy", "Perfect 10" magazine, etc. are sources of these materials. I can then get a visual idea of what you desire-what is too big and conversely, what is too small. With these photos as a guide in the Operating Room, I then place "sizers" within the cavity I have created and sit you up (you are asleep of course). My nurses and I then judge how closely your breasts (with the sizers in ) match the pictures you identify with and make any adjustments as deemed necessary. After I make my determination, then I substitute the sizers for the "real" implants, again, verifying symmetry and natural hang. This protocol eliminates guesswork enabling me to best match your goals.

6. What happens if the implant ruptures?

If a saline implant ruptures, one will soon notice an obvious change in the symmetry of one's breasts (one breast will suddenly get smaller). The saline will be harmlessly absorbed by your body. On the other hand, if a gel ruptures, one may not notice any size change and indeed, the rupture may be "silent". Only an MRI will have the best chance of non-invasively detecting if a silicone implant has ruptured. If this does occur, most of the time the gel will remain within the pocket bounded by the capsule without any health consequences. Rupture rates for Mentor gel implants have been reported to be as low as 0.5% at 3 years.
I utilize Mentor implants because I prefer their texture and safety profile and all are guaranteed for life. Therefore, if one should break during the lifetime of a patient, the implant company will replace the implant free-of-charge. They will also cover the costs of surgery should an implant rupture during the first 3-5 years after the original augmentation.

7. What are the main risks of breast implants?

  1. 8-14% Nipple sensitivity changes (either less or more, irrespective of whether the initial incision is made around the areola or under the breast or through the umbilicus or through the axilla). Sensory changes become more prevalent when larger implants are utilized.
  2. 1-2% Hematoma (a blood collection that may develop in the pocket generally within 24 hours after surgery). Should this happen, surgical drainage is all that is needed.
  3. 1-2% Infection. Unfortunately, if the implant becomes infected, antibiotics will not work and removal of the implant for 3 months is indicated. This may be a psychological burden to the patient (and the surgeon), but before you know it 3 months have gone by and another implant will be in place. Fortunately, my rate of infection at The Beverly Hills Surgical Center, Inc in The Haworth Institute is only 0.5%.
  4. 15-20% is the national rate of encapsulation for implants placed under the muscle while it approaches 25-50% above the muscle (depending on which study you read). My rate for under-the-muscle augmentation is roughly 10%. When I create the pocket under the muscle during surgery, I deliberately form a space that is vertically larger than the height of the implant when sitting on its end. This maneuver allows the implant to move up and down in conjunction with the patient's overlying breast tissue in accordance to their posture. Hence, the implants will not be "affixed" in an immobile manner to the chest wall. Within a few days after surgery, the patient's body forms a collagen-lining of the pocket that is slick to the touch. Encapsulation occurs when this pocket-lining contacts thus shrinking the pocket that I created down to the point that it is compressing and distorting the implant in a cocoon-like process. This results in an externally deformed and hardened breast. If you are unfortunate to experience an encapsulation, fortunately chances are that only one breast will be affected while the other will remain beautifully soft. This scenario indicates that something unique happened to that one affected breast pocket, otherwise both pockets would show encapsulation at the same time. The most likely event that would cause encapsulation of only one pocket would be a small amount of bleeding stemming from when a patient overexerts herself too soon after the surgery (while the tissues are fresh and still healing). That is why it is imperative to avoid all upper body exercise (including yoga and pilates and weights) for 10 weeks after breast augmentation.

8. What are my options if my breasts encapsulate?

Read 7. before reading this FAQ. Conservative treatment is started early (usually more vigorous massage and Accolate™) which helps about 50% of patients. If this doesn't completely work, then a simple operation called a Capsulectomy is performed which corrects the encapsulation for the long-term in 90% of cases. Most encapsulations occur within the first 3-4 months after the original augmentation. Therefore, as a commitment to my patients (and an acknowledgement that encapsulation is a shared risk), if anyone manifests encapsulation within the first year of surgery then my professional surgeon's fee is waved, leaving the patient responsible the operating room and anesthesia costs. The capsulectomy is generally associated with very little pain and takes about 45 minutes to perform.

9. Is Breast augmentation painful?

The pain from going "under the muscle" has been vastly diminished ever since I started instilling a long-acting local anesthetic (lasting about 3 days) into the pocket before waking the patient up. I have been performing this maneuver for over 10 years now with unparalleled success.

10. Do you do other procedures, such as a breast lift, at the same time as augmentation?

Yes, but only if they are indicated and deemed safe to perform simultaneously.

11. Can I breast feed after breast augmentation?

In the vast majority of cases, yes.

12. Should I wait to have my kids before breast augmentation?

If you are planning to have children in the next couple of years, than it would be prudent to wait till you are finished doing so. However, if the answer to your questions is "Yes, sometimes in the future, but I'm not sure when" or "When I get married" or "Not for at least 4-5 years", then there would be no compelling reason to wait unless medical issues are a concern.