Procedures::Breast
Breast Augmentation
The breast augmentation is performed to improve the size of the breast to make the patient happy. Some patients have no breast tissue at all and are very happy with a B cup breast. Others may come with a C cup and want to be larger. Therefore, there is not an ideal size that everyone should recommend. I feel that I always have to establish a balance between what the patient wants and what they can aesthetically have, because there are dimensional requirement that one has to adhere to in order to get good and stable results.
Many things influence the decision, including:
- The dimension of the chest
- The distance between the nipple and the notch of the sternum
- The distance between the nipples and the fold under the breast
- The position of the fold
- The tightness of the fold
- The width of the breasts
- The distance between the breasts
- The quality of the skin
- The consistency and elasticity of the breast tissue
- The patient’s size and weight
- Asymmetry in the shape and size of the breasts
- Asymmetry in the position of the folds under the breasts
- The degree of breast ptosis (droopiness)
- The patient’s overall appearance including their waist, hip and shoulder dimensions
Some of this is documented by measurement and the rest by preoperative photographs.
The most important thing to understand is that the difference in the quality of the final results of breast augmentation is more dependent on the above factors than on the type of implants and which plane they are placed in.
The above factors determine the success and longevity of the results. It is a matter of judgment and experience to be able to advise the patient to do the right thing. The most common implant used is a smooth, round, moderate profile implant. We occasionally may use a textured implant, which is anatomic in shape. There are only two manufacturers in the US, Mentor and Allergan. Both are similar in quality. The implants are typically placed in the sub-muscular pocket, but in some rare cases I may decide to place them under breast tissue for special indications.
The most common incision is under the breasts, but it could be around the areola or in the armpit. We normally discuss all these approaches and go through the pros and cons of each. Now let’s talk about what fills the implants. All breast implants are made of a silicone shell. This shell or membrane can be filled with saline, which makes a saline implant, or with gel, which makes a silicone gel implant. I have been in practice long enough to have exclusively used gel for breast augmentation, and then exclusively saline when the gels were forbidden by the FDA for breast augmentation. Today I use them both. They both have advantages and disadvantages. The gel implants offer a more tissue like feel, but they require an incision twice the size of what is required to put a saline implant in. They are also twice the price of a saline implant (just the implant cost). The other important difference is that the manufacturers demand that an MRI be done every two to three years to rule out a leak. This is also an FDA requirement. The insurance may or may not cover the cost of the MRI, and it is an expensive test. With the saline implant, there is less of a concern about the leakage because if it leaks, the saline gets absorbed in the system and the patient simply notices a deflation. There is no harm to the patient except that an exchange of implants is necessary.
When I see a patient for a cosmetic breast consult, I listen to the patient’s history. I ask them why they want the breast augmentation. After all the measurements, photographs and after considering everything else, I recommend a range of safe sizes. The patients choose the size within that range. If there are issues with asymmetry and nipple position, they are discussed at length. In some cases, it is necessary to do an additional procedure to lift or symmetrize the breasts. These procedures and additional scarring is discussed. I try to accommodate what the patient wants, but if I think what they are asking me to do is not safe, I would let them know.
The operation is done as an outpatient. A surgical bra acts as the initial dressing. Antibiotics and pain medications are prescribed. The pain is not so bad because I leave a long-acting local anesthetic in the area before closing. I check the patient in the office three to five days later. A bra of choice could be worn at that time. There could be some swelling or bruising at this time.
The complications are rare. The immediate concern is bleeding. If significant bleeding causes the breast to become very swollen and painful, it should be evacuated in the operating room. The long term problems are usually about capsular contraction and implant displacement. All of these potential problems are discussed and an informed consent is signed by the patient before any surgery.
