AUGMENTATION MAMMOPLASTYTHE GOAL: to enlarge or reshape the breasts and enhance cleavage to those unhappy with small breasts or those whose breasts have lost volume due to aging, pregnancy, nursing or changes in weight.
Breast Augmentation Terminology Notes
Breast augmentation uses one of two kinds implants:
- Silicone implants filled with a safe FDA-approved medical-grade silicone gel that achieves the most natural-feeling results
- Saline implants filled with a safe viscous salt-water solution Dr. Haworth will choose an appropriate incision site so that scars will fade to nearly invisible.
Candidates & Expectations
Candidates for AugmentationThe most appropriate candidates for augmentation mammoplasty are:
- A woman who wishes to have larger breasts and WITH a more pronounced cleavage and more appealing shape
- A patient wanting to replace lost volume (especially in the upper pole of the breast) after pregnancy, nursing or notable weight loss
- A patient needing to balance a difference in breast size (either from congenital problems such as Poland’s syndrome or minor natural asymmetries)
- A patient requiring reconstruction following breast cancer surgery
- Lift existing sagging breasts more that a breast lift can. It can rotate nipples that point slightly downwards up to a small degree.
- Prevent sagging over time due to gravity, weight gain or unprotected sun exposure
OLD THINKING VS. NEW TECHNIQUESBreast augmentation has become significantly more sophisticated than in generations past, resulting in a far more natural outcome than ever before. These breakthroughs include:
- No-Touch Technique: By minimizing contact with the actual breast tissue when the surgeon is inserting the implant into created pocket, bacterial contamination is avoided as well as the risk of capsular contraction.
- More Natural Muscle Draping: Placing the implant under the muscle eliminates the telltale signs and ‘frisbee rim’ sign of implants. Dr Haworth can manipulate the pectoralis muscle in different ways when placing the implants “under the muscle” to maximize a natural look individually for each patient.
- Pocket Placement: The art of pocket making is real proof of a surgeon’s skill. It is vitally important that all dimensions of the pocket are controlled within millimeters to maximally ensure good cleavage, perfect symmetry, beautiful shape and proper implant placement.
The two site options for implant placement (both of which are centered appropriately under your nipples) are:
A. Underneath the pectoral is muscle, offering the advantage of looking more natural with less sag, healing with less capsular contraction and making future mammograms easier to read. However, this site may also be more uncomfortable during recovery and require a bit more healing time. However, discomfort is dramatically lessened by approximately 85% because Dr. Haworth instills a long-acting local anesthetic into the breast pocket before closing the incision. B. Directly behind existing breast tissue but above the muscle. Dr. Haworth rarely uses this technique due to the aforecited reasons.
The 4 options for incision sites are: 1. Under the breast (inframammary) where the crease meets the wall. No scar ever disappears entirely and this one is no exception. It often gets darker (hyperpigments) and is located in potentially quite a visible area especially with the arms outstretched while lying on a beach. I will use this approach if a scar already exists in this location or if other approaches are imprudent.
2. Around the nipple’s areola. This happens to be the most versatile of incisions since it offers the surgeon the most visibility and therefore control during the surgery while healing to a near invisible scar in the majority of patients. Besides, this is a hidden scar, only visible to your partner or pet! All other scar locations are public ones, possibly leading to embarrassing excuses.
3. In the arm pit (axilla). Again, this often hyperpigments (especially in olive-skinned patients) and results in a higher frequency of misplaced implants and asymmetry. 4. In the navel (umbilicus). This results often in implant malposition. This is not available with silicone gel implants.
Pre-Operative ConsultationThe pre-operative consultation is where you meet with Dr. Haworth and our staff to review your health, work out the details of your procedures, order appropriate tests, prescribe medications, discuss your aftercare and answer any questions you may have. All patients are required to be medically-cleared along with routine blood tests before surgery. For those over 35 or those younger with a family history of breast cancer an up to date mammogram is required. For patients over 45, we may also require a recent chest X-Ray and EKG. We can arrange this for you or, alternatively, you may ask your private English-speaking medical doctor to assist you with this requirement. Our office will facilitate you along the way. To the consultation, we ask if you could bring photos of your breasts when you were younger and/or before bearing children, and Photos of breasts you like and don’t (Playboy magazine and the internet can be a good place for source material).
CRITICAL PRE-OP CAUTIONARY NOTEIt is absolutely essential that that you avoid all aspirin, aspirin-related, ibuprofen or blood-thinning medications for 2 full weeks prior to your surgery. In your pre-op consultation, we will give you a complete list of these drugs. For our patients, we also provide a password-protected link allowing you to download the list onto your computer. If in doubt about a specific medication, do not take it, call the office first and ask if it is on the forbidden list
Operation and Recovery LogisticsSURGERY DURATION: 1 to 2 hours ANESTHESIA: General. Dr. Haworth places a long-acting numbing agent within the breast pocket to minimize any post operative pain in your breast. As you wake up from surgery, you’re likely to feel tired and slightly sore (particularly in the back). However, we will give you prescription painkillers which will easily control the discomfort. There will be tape for support over the sutured incision sites and gauze dressings over your breasts. The day after surgery, we will remove the dressings and may provide you an appropriate bra that you should wear continuously for 4 to 12 weeks. Rarely do sutures need to be removed since Dr Haworth employs specific closure techniques with absorbable sutures.
Post-Operative CareIn person and in your post-op information packet, we shall explain everything you need to know for your aftercare at home. RECOVERY You will need to keep your activities to a minimum for at least 3 to 5 days. Gradually, you will be able to resume to your normal activities:
- 2-3 DAYS – long walks, no impact
- 3 WEEKS – gentle no-impact exercise (NO Pilates, NO Yoga and NO upper body weights)
- 8-10 WEEKS – light weight training, yoga
- Bruising around the incision and lower pole of the breast usually reaches its peak during the first week, and generally takes about 2 weeks to a month to completely fade away.
- Either a numb or a burning sensation in your nipples for about 2 weeks. This is perfectly normal and should subside as your bruising fades.
- Small patches of numbness near the incisions. These usually disappear over time, but may be permanent in some patients.
- Breast sensitivity for 2 to 3 weeks, so you might want to keep contact to a minimum.
- Mild soreness, similar to a hard workout, up to 3 to 4 weeks after surgery.
- Milk leaking from your nipples if have nursed an infant within a year of your augmentation. Should this occur, we can prescribe a medication to treat this.
- Following all post-op instructions to the letter
- Where the surgical bra as recommended
- Avoiding pulling and tension
- Sleeping on your back (which keeps pressure off the implants)
- Leaving Steristrips on for 2-3 months or silicone scar strips if you develop an allergy to the former
- Avoiding all sun exposure on your neck, breasts and decolletage or at the very least using a strong physical and SPF sunblock on exposed areas
Risks & Challenges
Risks and ChallengesConditions that make augmentation mammoplasty more of a challenge and may require additional skills and surgical techniques include:
- Previous breast enhancement surgery. Surgical options may range from simply replacing the implants and removing scar tissue (capsulectomy) to complicated pocket modification (capsulorraphy) to modify how the actual implant lies under the breast. Whatever is needed, the final appearance of the breast will be rendered more natural and pleasing to both sight and touch.
- Previous breast cancer surgery and reconstruction.
- Still nursing or milky discharge. Dr Haworth delays any implant surgery for at least six months from the time lactation stops.
- Capsular contracture where the scar around the implant starts to shrink tight resulting in noticeable hardness and distortion of the breast. We can treat this with conservative methods or by removing the scar tissue and, in extreme cases, by replacing the implant itself. Note that while the national average for capsular contraction is 25% to 40% for implants placed above the muscle, it is less than 15% when the implant is below the muscle. Dr. Haworth’s record is far superior to this being at 6%.
- Excessive bleeding to the extent that it causes swelling and pain. Should this continue, you may need another surgery to control the bleeding and remove the accumulated blood (very rare).
- Infection around the implant, usually within a 10-14 days of the surgery. In severe cases resistant to oral medication, the doctor may need to remove the implant for several months until the infection clears and he can insert a new one (very rare).
- Change in nipple sensitivity, including numbness or over-sensitivity of the nipples
- Hematoma (blood collection within the pocket, which is also rare)
- Implant rupture, breakage or leakage
Dr Haworth favors the newer “Memory Gel” silicone implants produced by Mentor corporation, since they combine unparalled softness with an impressive track-record of safety and reliability. They are now FDA approved for all patients except for those under 22 years old for some questionable reason. Indeed, Dr Haworth finds it puzzling that women over 18 can legally fight in war, participate in adult films, drive while those over 21 can drink alcohol, but are considered too immature to opt for silicone breast implants! Over 90% of his patients opt for this implant choice upon weighing all the “pros and cons” and the vast majority are glad they did so. (A break in the older type of silicone implant, on the other hand, was more serious because the implant was filled with a more runny or liquid type of silicone. The thin gel tended to pool in the breast and possibly migrate to nearby lymph nodes.) A break in either a silicone or saline-filled implant requires another surgery to exchange the implant and possibly remove scar tissue and any gel from the pocket. In some cases, it may not be possible to locate and remove all of the escaped silicone gel.
Several years ago, a number of women who had had silicone gel breast augmentation reported symptoms consistent with auto immune connective tissue disorders such as scleroderma and other arthritis-like conditions. However, numerous clinical trails conducted by the FDA concluded that there is no clear link between silicone breast implants and autoimmune disorders. The silicone implant has been the most extensively studied “device” in the whole history of medicine. Breast implants should not affect fertility, pregnancy, or your ability to nurse.
FAQs1. 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:
- The breast tends to look better as long as the surgeon knows what they are doing by going under the muscle;
- There is less long-term sag under the muscle;
- 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;
- There is less interference with mammography and , finally,
- There is less chance of encapsulation (refer to 7. And 8. below).