Breast augmentation enhances the size and shape of small or drooping breasts. An implant is placed behind, not in, the breast. There are numerous options regarding type and size of implant, position of the implant, position of the incision, and type and size of implant.
Most commonly breast augmentation is for women with:
- Genetically determined small breasts.
- Loss of breast volume and drooping after pregnancy
- Difference in breast size
- Absence of a breast following mastectomy for cancer.
Augmentation mammoplasty is usually an outpatient procedure with general anesthesia.
About silicone gel implants, risks and the FDA
The FDA banned the use of silicone implants filled with silicone gel in 1992 because of the possibility of silicone gel stimulating autoimmune disease (rheumatoid arthritis, lupus, and others). The FDA decided to further investigate implant safety and effectiveness. However, they allowed the use of saline-filled (salt water) implants. Since then, there have been hundreds of studies of the risk and as a separate trial managed directly by the FDA. A large study of women with and without breast implants conducted at the Mayo Clinic showed that autoimmune disease occurred with the same frequency in all women regardless of silicone implants. It is not known what causes autoimmune diseases, seen in middle-age women.
In 2003, the FDA advisory panel found that there was no medical correlation between diseases and gel implants. The FDA has approved the used of silicone gel implants and they are now available.
Types of implants
There are many choices of implant textures, shapes and sizes. Although the implant itself does influence the final outcome, the scar formation (capsule) around the implant has a profound effect on the shape, position and feel of the breast.
Sizes and shapes
Implants come in various shapes and sizes to fit the chest shape of each woman. The size of your augmented breasts depends on the implant volume as measured in cubic centimeters (cc). The bras size number (such as 32, 34 etc) represents the width of you back and not the size of the breast. Therefore augmentation changes cup size (A, B, C, D, E, etc.) but does not change that size number.
Cup Sizes
- One bra cup-size is approximately 200-225 cc. So you would use that volume if you want to go from an A cup to a B, or B cup to a C cup.
- If you want to go from a B to a D, you would need an implant of about 400- 450 cc. As the volume of the implant increases the cross-section diameter also increases.
- As the implants get bigger and project more for a larger cup size, they also get wider and may not fit a narrow chest. This variable is controlled by the implant shape as discussed below.
Implant shapes
Implants may be round with a high or low profile or teardrop-shaped (anatomical). In part, the choice depends on the size of your chest. However the shape of the implant does not determine the final shape of the breast. The shape is mainly determined by the tightness of the scar capsule that surrounds the breast.
- Anatomical (contoured) implants are sloped, resulting in a fuller lower area,
- Round implants result in more fullness of the upper part of the breast and have more width towards the cleavage.
- High profile implants are narrower for a given volume than a low profile implant. So that a high profile implant may better fit a narrow chest.
Realistic expectations of this procedure are important. Women often think of breast size in terms of bra cup size. If you are currently a size “A” and wish to be a size “C”, there must be adequate existing breast tissue coverage; otherwise you will be warned of visible or palpable implant edges and other possible risks.
Where is the implant located?
The position of the implant is either behind the breast tissue (subglandular) or under the pectoralis muscle (submuscular). Most patients have the implants placed behind the muscle, with the exception of women who have excessive drooping (ptosis) of the breast that is treated corrected with an implant alone. When a combination of a breast lift and implant is used, the implant must be placed behind the pectoralis muscle.
Subglandular
- Advantages
- Less postoperative pain
- Shorter recovery time
- More effective in lifting the drooping breast
- Disadvantages
- Higher probability of having a rounder breast
- Harder to examine the breast for lumps
- Harder to obtain mammogram x-rays
- Less tissue over the implant to hide the implant edges
Submuscular
- Advantages
- Higher probability of having a soft breast without scar capsule contracture.
- Easier to examine the breast for lumps
- Easier to obtain mammogram x-rays
- More tissue over the implant to hide the implant edges
- Disadvantages
- More postoperative pain and recovery time
- Longer recovery
- Not as effective in lifting the drooping breast
Placement of the incision
All incision sites give adequate access to the breast although the umbilical (naval) incision is most difficult and has no advantage. I do not use the umbilical incision. The choice is a matter of personal aesthetics as to where the scar is preferred. The incision can be made in three positions
- Under the breast (inframammary)
- Under the nipple (subareolar)
- Under the armpit (axillary)
- In the umbilicus (naval)
I find that most women prefer the subareolar incision and the second most commonly chosen is the inframammary incision. These are also my preferences.
We will review all of the above to help you decide which type and size implant is best for you.
Implant Surface textures
A breast implant is composed of an outer silicone shell filled with saline or gel. The outer surface of the implant is either smooth or textured.
Smooth implants
- Moves in the breast pocket and may feel more natural
- Slightly higher chance of getting a capsule scar and a firm breast
- Less chance of rupture
Textured implants
- May cause surface skin waviness, particularly if subglandular
- Slightly higher risk of spontaneous rupture
- Slightly lower chance of getting a firm breast (less capsule scar)
Post Operative Care
- You must have someone drive you home and stay with you for 24 hours after surgery
- I will see you 2 days after surgery to remove the drains (if used)
- You will experience pain for a few days and this is partially controlled with pain pills.
- Tightness in the breast area is also normal for weeks afterwards as your body adjusts to the implants. During this time I will instruct you on how to massage your breasts to soften the scar capsule around the implant
- Wear a bra at all times (except when showering) during the first 2 weeks following surgery.
- Avoid heavy lifting for 2-3 weeks. Do not do activities that involve extensive use of the arms and shoulders.
- Moderate exercise such as walking or stationary biking is allowed after the first week. Vigorous exercise such as jogging or aerobics may be resumed at 3-4 weeks.
- You will most likely be able to return to work after a week if your work does not involve upper body and arm activities.
- During recovery, the breasts will be somewhat swollen. Within a few months, the actual shape and size will be evident.
Potential complications
- Capsular contracture – The most common problem is a firm or hard breast (capsular contracture). Contracture is caused by the scar around the outside of the implant and not by hardening of the implant itself. 90% of women develop a soft pliable scar around the implant (like a piece of Saran wrap). In this case, the breast is soft and natural. 10% of women develop a hard stiff scar around the implant (like a piece of leather). In this case the breast will feel very firm, appeared more rounded and unnatural, and be at a high position on the chest wall. We cannot predict who will produce a heavy capsule scar. If this happens, it is possible to correct it with another operation to remove the capsule scar and “hope” that you will produce soft scars the second time. A good result occurs about ½ of the re-do surgeries.
- Thick scars are often the result of genetic tendencies and are more common in darker pigmented skin
- Change of nipple sensation. This can either be decreased sensation or irritable sensations.
- Rupture of the silicone bag and deflation of the salt water. In this case, the company warranty will cover most of the costs if the rupture occurs within 5 years of surgery. You also need to know that even a small hole in an implant can cause the saline to leak out, resulting in a “flat” implant and necessitating surgical replacement.
- Difficulty examining the breasts for lumps
- Tenderness of the scar and nipple rarely occur
- You may notice some asymmetry; however most breasts are naturally somewhat asymmetrical.
Conclusion
Augmentation mammoplasty is a safe procedure that has produced pleasing and satisfying results for most women. A preliminary consultation can help you determine whether breast augmentation is right for you. We will review all of the above to help you decide which type and size implant is best for you.
