There are two basic types of implants with various minor variations, silicone filled and saline(salt water) filled. he shell containing these fill substances are all silicone, just a longer polymer. Silicone gel implants come prefilled whereas saline implants are filled at the time of the operation. Silicone gel implants are preferred much more than saline, at least in my practice. This is inspite of the fact that gel implants are more expensive and require a slightly longer incision for placement. Silicone gel implants, in most patients, look and feel more natural. This is because the gel which fills the implant is manufactured to mimic the consistency of the normal breast. Now that the safety issues have been settled, patients are returning to the aesthetically superior gel models.
Saline breast implants are suitable in many patients, however. Where there is sizeable breast tissue and subcutaneous fat, the less viscous (more watery) consistency of saline can be well camouflaged. The greater the volume of native breast tissue and the smaller the saline implant, the less advantageous aesthetically silicone gel is over saline.
Implants can also have different profiles and may be preferentially “shaped”-teardrop. In general, these variations from the standard implants are used for unusual problems of anatomy. I use them only occasionally.
There are very good sizing systems available so nothing much will be left to chance when selecting the proper implant. At the Emory Aesthetic Center we have physical sizers as well as the Vectra computer simulator. Photos supplied by the patient may help in defining a range to begin more precise sizing. It is rare for a patient to be dissatisfied with the final size after employing our sizing systems.
I have been doing breast augmentations for many years. Almost all women, when asked a year or so later what they would have done differently, wish they had been made a little bit larger. Complaints the other way are almost never heard. This is usually because the patient has been modest or conservative when appraising the desired size. It is important to avoid the tendency to underestimate. Pick a range and lean towards the larger size of that range. Breasts that are somewhat ptotic (droopy) will be better dealt with by a larger prosthesis. The ptosis is not corrected, but is better masked.
There are three types of incisions with definite advantages and shortcomings. The inframammary incision is placed in the crease below the breast where the breast ends and the abdominal wall begins. The peri-areolar incision is located along the lower edge of the areola. The axillary incision is placed in the armpit. The most commonly used incision chosen by the patients in my practice is the inframammary. It is direct and requires no dissection through breast tissue. It is very well hidden especially when standing, the breast completely covers it. Generally, it is about 1 inch in length and results in a fine white line when wound remodeling is complete—6 months to 2 years.
Second in popularity is the periareolar incision. The incision is about an inch in length along the inferior border of the areola. The scar is highly acceptable. The incision does require dissection through breast tissue for placement of the implant. This has the theoretical disadvantage of exposing the wound to bacteria that exists naturally in the milk ducts. There is scarring in the breast tissue, as well. Nevertheless, there are really no long term disadvantages of consequence and this incision is highly acceptable.
The axillary incision is placed through the armpit and is generally 1.5 inches in length. The dissection of the pocket is more difficult and requires special instrumentation. This does not appreciably lengthen the operation, however. The glands in the axilla contain bacteria similar to breast tissue which poses the same theoretical problem. Again, there is no increase in infection noted. However, if an open capsulotomy is required for the treatment of capsular contracture at a later date, it cannot be performed through the axillary incision. Under these circumstances, a separate incision would be required.
In general, all of the incisions end up being highly satisfactory. Every effort is made to keep them as short as possible. Mother Nature is generally forgiving of these wounds so that they are nearly invisible when the healing process is complete.
There are advantages and disadvantages to both that must be understood for an intelligent decision to be made. First of all, as noted above, present day opinion (without scientific validation) favors a submuscular placement when considering the interpretation of mammograms. It is debatable that this is a major consideration. The placement of your implant will be determined during consultation with your doctor or physician.
If a breast is tubular in shape or if it is modestly ptotic (droopy), there is a definite aesthetic advantage to placing the implant above the muscle. The ultimate shape is more natural when the implant is in this subglandular position.
As a rule, since saline implants are filled with water and not thicker silicone gel, they feel more natural when more tissue covers the implant. Women who have some breast volume to begin with can expect a more natural feel to the breast.
Consequently, saline implants are preferred deep to the pectoralis muscle all other variables being equal. More tissue covers the implant (the pectoralis muscle is another layer of tissue) making them feel somewhat more like normal breast tissue. A submuscular implant may be distorted when the pectoralis muscle is being used. During certain strenuous chest exercises such as swimming or weight training, the implant may be temporarily misshapened as the pectoralis muscle is exercised.This is very subtle and seldom a problem for our patients. It is referred to as “animation deformity”.
Submuscular placement does not involve cutting of any muscles and does not diminish muscular strength. Patients comment that post-operative pain is greater in the submuscular position. This generally equalizes with the subglandular placement in a few days, but is a consideration, nonetheless. After the appropriate convalescence, it is permissible to resume the normal range of activities. Most women are back to full athletic activity in 4 weeks.
Breasts can certainly be augmented in size by fat injections. It has been established that this treatment does not increase the risk of breast cancer or interfere with diagnosis. However, as appealing as it may sound, there are drawbacks. First, many women simply don’t have enough available fat to give them the size they want. Secondly fat grafting anywhere in the body and including the breasts has a certain amount of unpredictability. Not all fat that is injected remains so plastic surgeons generally overcorrect. This makes achieving symmetry of the 2 breasts a bit unprecise. Furthermore, these injections are not reversible whereas removing breast implants is quite easy.
Augmentations are performed on women of all ages. In my own practice, the age of the augmentation patient ranges from 17 to 60. The vast majority of women, however, fall into the 21 to 40 year old age bracket. Studies have been completed to evaluate the psychological profiles of the women who have breast enlargement. These studies show that the typical patient seeking augmentation is particular about appearance and has considered augrnentation for several years. Commonly, a friend has undergone the procedure with an enviable result. These women are found to be socially and professionally active with the operation chosen because it is perceived as a social or professional asset.
Most of the women we see have a very definite idea about the way they would like to look. Since the operation can come so very close to creating the desired breast size and shape, it is understandable that it remains popular. Some women consider breast augmentation as a means of appearance enhancement. Others have lost volume due to weight loss or previous pregnancy and simply want to re-achieve their native size.
Breast augmentation may be performed under general anesthesia or with a combination of intravenous sedation and local anesthesia. General anesthesia is almost always used in this operation, however. Both techniques are equally safe but differ in several important ways. An understanding of the differences will decide which anesthetic will be chosen.
General anesthesia is performed in a surgery center or hospital under the direction of an anesthesiologist or anesthesist. The technique requires insertion of a tube into the upper airway with ventilation controlled by a machine. There is no pain experienced during the operation, although an IV catheter must be inserted through the skin before anesthesia is begun. There is no recollection of any portion of the operation.
In “twilight anesthesia” no intubation is required, although supplemental oxygen is sometimes given by a mask. Intravenous pain medication and sedatives are given to relieve pain, control anxiety, and create temporary amnesia. Discomfort is perceived, but is well tolerated during the administration of the local anesthetic, which numbs the breast. It is generally not remembered after the operation. The operation itself is relatively painless because of the local anesthetic. Obviously, not every patient is suited for the intravenous technique. Patients who have their implants placed in the subpectoral position usually require general anesthesia. There is no significant safety advantage of one technique over another.
Anytime a foreign substance is placed in the body, it is recognized biologically as foreign. The body attempts to isolate the alien material and wall it off from the rest of the body. This happens with any foreign material–a piece of glass, a splinter, a bullet, a metal hip prosthesis, or a breast implant. The body accomplishes this by depositing a thin layer of collagen (scar tissue) around the prosthesis. This is probably a beneficial event. The prosthesis is effectively isolated from the body even though it is contained within it.
The capsule, however, has the ability to contract or “shrink” around the prosthesis. If this “shrinkage” is excessive, the capsule squeezes the prosthesis. This phenomenon leads to a breast that feels firm – a capsular contracture. This hardening is referred to by some colloqially as “capsules”.
Remember, however, that everyone with implants develops capsules. Most of the time they do not squeeze the prosthesis so as to create hardness. A better term to describe hardening of the breasts is “capsular contracture”.
Many variations to surgical techniques, implant materials, pre-operative and post-operative care have been suggested to decrease the chance of capsular contracture. In addition, medications of varying types and combinations have been advocated. Unfortunately, no combination of medication, activity, or implant type can prevent capsular contracture. Furthermore, it is not clear whether anything decreases the incidence of breast hardening due to capsule formation.
For a long time, it was generally accepted that an implant placed below the pectoralis muscle was less likely to suffer from hardening than one placed directly below the breast. Critical review of both groups of patients has shown that if there is a difference, it is minimal. Furthermore, one form of treatment of capsular contracture, the closed capsulotomy, is decidedly more difficult if the implant is below the muscle.
Vitamins, both pre- and post-op have never been shown to be of any benefit. Breast massage and other breast “exercises” similarly have been advocated by some but have never been shown to effect the softness of the breasts. It can even be argued that capsular contracture is increased by vigorous post-op manipulation. I do not recommend massage of the augmentated breast.
Antibiotics are given routinely to our patients to guard against infection.Some reports claim that a low grade infection may contribute to the development of breast hardening. The raw data to support this is lacking but the possibility does exist. All plastic surgeons employ meticulous sterile technique. In addition, it is my practice to irrigate the pocket during the operation with an antiseptic solution plus an antibiotic solution. Intravenous antibiotics are given during the case and post-operative antibiotics are taken for five days. These precautions may decrease the incidence of capsular contracture but do not eliminate the problem.
A biofilm is created when a colony of bacteria secrete a chemical that creates a protective barrier. A good example is plaque on your teeth that is removed by the dental hygienist. There is very good evidence (but not conclusive) that a biofilm forming on a breast implant may lead to capsular contracture. Much effort has been thrown at decreasing the risk of bacterial contamination at the time of breast implant placement which could lead to a biofilm
When choosing an incision (axillary, areolar, inframmary) theoretically biofilm formation is taken into consideration. When introducing an implant through the axilla or areola, breast tissue in encountered. Breast tissue normally harbors bacteria which could contaminate the implant as it passes past the breast tissue on its way to the surgically created pocket. For that reason I encourage my patients to consider the inframmary approach as it avoids breast tissue contact.
It is not known why capsular contractures occur. It does not seem to effect any particular ethnic group the way scarring problems do. It does not effect any specific age group more than another. It is unrelated to the type of incision used. It may involve one breast and not the other.
Capsular contracture is not an all or none phenomenon. That is, some breasts may be completely soft, others slightly firm yet still pleasing, others firm but attractive, and still others exceptionally firm and unnatural in appearance. About 5-15% of women will develop enough firmness to be labeled as having a capsular contracture. Fortunately, most firmness is modest and requires no treatment. I have had many patients tell me that their breasts were more attractive after they became slightly firm. Nevertheless, this is labeled a capsular contracture.
About 5-10% of all augmentations will develop enough firmness so that some sort of therapy will be required to soften them. The simplest treatment is called a closed capsulotomy (breaking up the capsule). This is a short office procedure that involves compressing the breast firmly in an attempt to break the capsule. It is easier to perform if the implant is subglandular (directly under the breast tissue).
If closed capsulotomy fails, an open capsulectomy (complete removal of the capsule) may be required. This is a formal operation that requires opening up the skin incision and surgically removing the capsule. The procedure is usually successful in softening the breast or breasts but a new capsule will form and a secondary capsular contracture may occur.
It is important to remember that a capsular contracture poses no health threat. It is a compromise to the aesthetic result only. Many women choose to keep a slightly firm breast rather than undergo an auxiliary procedure.
There has been an enormous amount of work done to answer these questions. It is impossible to say if the implant is completely safe. Clinical and experimental studies have examined relative risks of implants. The statements made henceforth reflect what is known about the safety of implants at the present time. The questions continue to be studied and new information may change the accuracy of these conclusions. Silicone is not only used in breast augmentation, but also in joint replacement, volume enhancement, and as a biological substitute for tendons and ligaments. It is now known that women with breast implants have a slightly lower incidence of breast cancer than women without. This is statistically significant meaning there is a slight, but measurable protective effect of the implant against cancer. The mechanism is unknown. This is certainly not a reason, of and by itself, to proceed with augmentation, but the patients who undergo the procedure may take comfort in the fact that they are not increasing the risk.
Breast implants do influence the interpretation of mammograms, the radiographic screening test for breast cancer. There is little question that interpretation of a mammogram is made more difficult with the presence of an implant- but not the accuracy. It is often heard that the interpretation is somewhat easier if the implant is below the pectoralis muscle rather than directly behind the breast (an arguable point). When a mammogram is obtained, the technician should be alerted to the presence of the breast implant if the breast has been augmented. This allows for special views which some radiologists request to better visualize the portion of the breast obscured by a breast implant.
Furthermore, all breast lumps must be treated as potential breast cancers even in the augmented patient. It is possible for the implant to create a breast lump. This judgment must be made by the plastic surgeon, however, and not the patient.
The lay press has stated that silicone (at least in breast implants) can cause a number of auto-immune physical problems. The complaints fall medically under a group of problems called ” collagen-vascular” diseases. There has been a general acceptance by the public that breast implants and these conditions are linked. This misconception was further reinforced when the FDA asked for a voluntary moratorium on women seeking breast augmentation for the first time in the 1990’s.
In fact, none of this happens to be true. There are now a number of studies demonstrating that there is no relationship between silicone filled breast implants and systemic diseases. Silicone gel-filled implants are now available to any women interested in augmentation.
Plastic surgeons and implant manufacturers remain vigilant to safety issues. Patients choosing silicone gel implants are immediately enrolled in an ongoing study to establish data over long periods of time. This includes the harvesting of data regarding overall health issues and specific aesthetic issues such has hardening or misshaping of the implants.
In the past few years a small number of patients who had undergone previous breast augmentation developed a type of cancer around the breast implant called anaplastic large cell lymphoma. This is a very rare illness and to date has never been observed when the breast implant is smooth walled. That is, occurs exclusively in implants that have a rough surface (texturized). Manufacturers texturize the surface of the breast implant in different ways. There is one particular method of texturizing that predominates this discussion (Biocell by Allergan)
The onset of the problem is heralded by the formation of a seroma (a collection of fluid) around the breast implant. When this occurs that fluid is sampled and sent of analysis. The diagnosis is made from studies performed on that fluid.
Initial treatment involves removing the breast implant and the capsule that formed around it. Most of the time this is all the treatment needed. If the disease is more extensive that additional treatment may be indicated.
The question for patients is whether or not they should remove texturized implants prophylactically. At the moment, the recommendation by the FDA is “no” as the incidence is extremely low and all operations carry some risk. This may change as the risks of contracting this disease may change. Patients with texturized implants should discuss their particular situation with the plastic surgeon. For now, patients with smooth surface implants do not need to worry about ALCL.
Complications are very uncommon after breast augmentation. When they do occur, they are treatable best if they are recognized and addressed immediately. The complications that may occur after the operation and before the first office visit are infection, wound separation, or hematoma (this is an abnormal collection of blood in the implant pocket).
The following observations require an immediate call to the office:
1. Excessive drainage, especially if it is foul smelling.
2. Fever and chills.
3. An excessively swollen or tight breast especially when compared with the opposite side.
4. Severe pain not responding to the prescribed pain medication.
Obviously some pain is to be expected. It should get better, not worse, with each day.
Other observations may be made that are not listed here. This does not mean that they are not important. If anything causes concern, please do not hesitate to contact the office.
Rest and leave the dressings in place for first 24 hours after the operation. After the first 24 hours, you may remove the support bra (provided to you at the end of the operation) and dressings.You may shower if you wish but try to keep the steri-strips covering the wound dry. Place small pads over the incisions and allow the support bra to hold these dressings in place. (The incisions should not be immersed in water while sutures are in place.)
Allow the steri-strips to remain in place until they begin to come detached by themselves. Many times they will remain adherent until the first post-op visit. At other times, they may detach themselves. If this happens, you may remove them. New steri-strips need not be applied.
A small amount of drainage is expected for several days after the operation. Large amounts of drainage that soak the dressing should be reported to Dr. Zubowicz.
Other than when showering, the support bra should be worn at all times, including sleeping. After one week, you may use a sports bra or another bra that is supportive, but no underwire bras for 6 weeks.
Shampoo your hair only with assistance for several days. The patient should not lift their arms over the head until the pain has subsided. Furthermore, lathering in hard to reach areas should be done by an assistant.
After the first 24 hours, light activity is permitted if it is comfortable. This would include walking, riding in a car, or any activity that is not strenuous and does not involve use of the arms. Driving may commence when the pain has gone.
(Light exercise may begin in one week after procedure if the pain has subsided and the arms will not be used.) Tennis, swimming, running and golf are not permitted. Furthermore, any exercise that involves excess movement of the breasts is to be avoided. Walking is a superb exercise, as is riding an exercise bicycle. Four weeks after the operation, most patients can resume their normal lifestyle and exercise habits. You will be seen in the office at this time and receive a medical clearance. It is advisable to work into your exercise routine over several days.
Work may resume if it does not involve strenuous physical activity or use of the arms and there is no pain. Most patients can return to desk-type jobs in 4-5 days. If the pain increases or excess fatigue occurs upon work, go home and rest.
Sleep on your back as much as possible. Sleeping on the stomach will put pressure on the chest, while sleeping on the side requires extension of the arms. You may put pillows at your sides for comfort.