Breast Augmentation surgery, or mammoplasty, involves using implants to revitalize breast volume and shape after pregnancy or weight loss. Augmentation is a popular option if you are unhappy with your breast size. By balancing your figure, increasing the wholeness and prominence of your breasts, a breast augmentation also improves your self-image and confidence.
The most common patient for this surgery is a woman in her 30’s, and has been considering this operation for many years. Many women in their 40’s and 50’s have undergone breast augmentation surgery with good results.
Pregnancy will change the size and shape of a woman’s breasts whether she has implants or not. These changes may adversely affect the cosmetic appearance of any augmented breast.
It is usually recommended that pregnancy be postponed until 6 months after the surgery. Breast-feeding with implants is still possible and has been shown to be safe for the baby and the mother.
Many women elect to have multiple plastic surgery procedure performed at once. There are many reasons for doing so. First, it costs less than having them performed separately. You will only incur one surgical center expense and only one anesthesia expense. You may also save money on pain medication, if needed. One of the most popular plastic surgery procedure combinations in recent years has been the Mommy Makeover. This procedure involves full body contouring and may be a combination of breast augmentation, tummy tuck (abdominoplasty), and liposuction. It restores youthfulness to the whole body, from your breasts down to your hips.
When deciding the type of surgical incision, it is important to remember that each patient’s body is different.
Incisions vary based on the type of implant, degree of enlargement desired, your particular anatomy, and patient-surgeon preference. They are made in inconspicuous areas to minimize visible scarring. You and your plastic surgeon will discuss which incision options are appropriate for your desired outcome. Implant type and size will be determined not just on your desired increase in size but more importantly on your breast anatomy, skin elasticity and body type.
This approach tends to be more direct and to allow greater control of the implant positioning. Seventy to eighty percent of breast augmentations are performed using this incision site. Since the incision is in the fold underneath the breast, the parts of the breast that make milk are less likely to be affected. This option also allows the surgeon to look directly where the implant will be placed and allows for better implant placement. In addition, if complications occur and additional surgeries are needed, the original incision can be used. Some of the other incision sites may not be ideal for treating complications.
This approach works well with patients who have already had children and are a little older, since age creates a small amount of natural sag in the breast. This minimal sag allows the incision to be well hidden in most women. For women who have yet to have children, who are thin, or who are younger, this surgical option may result in a more visible scar.
This incision is from the armpit, or the axilla. Fifteen to twenty percent of breast augmentations are done using this surgery. This incision site can be used for both submuscular and subglandular placement of the implant. One of the advantages to this site is placement of the scar in a less visible location. It also allows better access to place the implant in the submuscular position. Some surgeons will also use an endoscope, or a small fiber-optic camera, to help them in this surgery. This approach is often used for thin women where submuscular placement would allow more natural appearance to the breast. It is also used for women who are younger and have little to no breast sag, thus making an inframammary scar more visible.
A potential disadvantage to this approach is that proper implant positioning is somewhat more difficult, particularly if the procedure is performed without and endoscope. In addition, if the patient experiences scar thickening postoperatively, this scar may be visible when the patient wears a shirt or dress without sleeves. In addition, it may be visible when the patient wears a bathing suit and raises her arms.
The incision and scar in this newer approach is through the belly button or umbilicus. A fiber-optic camera (endoscope) is tunneled from the umbilicus to a pocket under the breast. The implant is inserted through this tunnel into the breast and is then inflated with saline. It is important to note that using this incision, only sub-glandular placement is possible. Advantages of the TUBA include a less visible scar, and a faster recovery time. Disadvantages of this approach include a slight increase in the likelihood of damage to the implant, and the possibility of tunneling under one of the chest muscles (pectoralis major) during placement. Furthermore, complications that require additional surgeries for treatment may require a new incision closer to the breast. In addition, implant manufacturers frequently will not honor the implant warranty if the implant is placed through this approach.
This is an incision around the nipple. The scar usually blends into the edge of the areola. However, since the incision lies closer to the parts of the breast that make milk, women with this type of breast augmentation often have more problems with breast feeding and nipple sensation following the surgery.
This is often one of the most difficult decisions, and for many reasons, has the most potential for disappointment. Breast implant volumes are often poorly understood by patients, who don’t realize all the variables (ribcage size, chest shape, existing breast volume) that will dictate what a given implant size will do for them. How big your breasts will be after surgery will depend on certain size issues:
For instance, women often come with a new bra size in mind. Since bra size depends on many factors, a better choice is to look at before and after pictures. By finding a women with a similar body shape in the “before” picture, and then with the results you want in the “after” picture – misconceptions on the final breast size can be avoided. In addition, we often have our patients wear implants under their bra to decide if this is the size they want.
The implant can be placed in one of two areas:
Advantages exist for both sites depending on the shape of the breast before surgery:
If you have little breast tissue, partial submuscular breast implant placement or fully submuscular breast implant placement is likely to reduce the chances of visible rippling of the breast implant. This is because the implant is partially or fully covered by muscle, in addition to breast tissue. The extra padding created by using the muscle to partially or completely cover the implant hides potential rippling beneath a thicker layer of tissue.
Many plastic surgeons contend that over the muscle breast implant placement is more likely to lead to sagging as you age. In a complete submuscular placement or a partial submuscular placement, the breast implant may be better supported resulting in less sagging of the augmented breast over the long term.
Saline implants are filled with sterile salt water. They can be filled with varying amounts of saline which can affect the shape, firmness and feel of the breast. Should the implant shell leak, a saline implant will collapse and the saline will be absorbed and naturally expelled by the body.
Silicone implants are filled with an elastic gel. The gel feels and moves much like natural breast tissue. If the implant leaks, the gel may remain within the implant shell, or may escape into the breast implant pocket.
The method for inserting and positioning implants depends on the type of implant, degree of enlargement desired, your body type, and your surgeon’s recommendations. Incisions are closed with layered sutures in the breast tissue and with sutures, skin adhesive or surgical tape to close the skin. Over time the incision lines will fade. The results of breast augmentation are immediately visible. Over time, post-surgical swelling will resolve and incision lines will fade. Satisfaction with your new image should continue to grow as you recover and realize the fulfillment of your goal for fuller breasts.
You will be given specific instructions on how to prepare for your surgery. A pre-operative information packet will be provided that explains everything you should do and know before your surgery date. Your surgeon will instruct you on how to prepare for surgery, including guidelines on eating and drinking, smoking, and which vitamins and medications should be taken or avoided. You should arrange for someone to drive you home after your surgery, whether your surgery is done on an outpatient or inpatient basis. You may also want to make arrangements for someone to help you out for a day or two after you leave the hospital.
Depending on the type of breast augmentation chosen (where the incision in made) the surgery will usually last 1-2 hours.
Implant Surface – Two implant surface types exist: smooth and textured. The textured surface means the outside of the implant has lots of tiny microscopic bumps. This was developed to decrease a complication called contracture after surgery (discussed in risk section below.) Some studies show a decrease in this complication when using textured implants. In reality, however, many surgeons have excellent results with the smooth implants. Smooth implants also have a softer more natural feel. Since options exist on what type of implant is used, it is important to discuss at your consultation.
See post-operative instructions for information about what to expect during your recovery. It is very important that you follow your surgeon’s instructions. This will promote healing and improve progress towards your new physical appearance. Also, it is important that you attend all scheduled follow-up appointments so that your surgeon can assess your long-term results and answer any questions or concerns you may have.
Implant Surface – Two implant surface types exist: smooth and textured. The textured surface means the outside of the implant has lots of tiny microscopic bumps. This was developed to decrease a complication called contracture after surgery (discussed in risk section below.) Some studies show a decrease in this complication when using textured implants. In reality, however, many surgeons have excellent results with the smooth implants. Smooth implants also have a softer more natural feel. Since options exist on what type of implant is used, it is important to discuss at your consultation.
Patient satisfaction for breast augmentation surgery is high. Even women who experience complications after surgery are often satisfied with the way they look. How “natural” post-implanted breasts look will depend on the size of the implant AND the patient. For example, women who have small breasts before surgery and are receiving large implants are less likely to have “natural” appearing breasts, compared with women receiving smaller implants (i.e. more modest enlargement.)
Not all patients are happy with this surgery. Understanding the potential risks for this surgery as well as having realistic expectations will help ensure a good result.
Most women will have loss of some feeling or sensation following breast augmentation surgery. For most of them, this lasts 6-12 months before returning to normal. Approximately 15% of women, however, have alterations in nipple sensation.
This is one of the most frequently asked questions by women considering this surgery. Many studies have shown that women who get implants are not at an increased risk for getting breast cancer. In addition, implants do not delay the detection of breast cancer. Numerous studies, as well as evidence from the National Cancer Institute, show that having implants does not hinder the patient or their physician in finding breast tumors. Finally, breast implant patients who do get breast cancer have the same chance of obtaining remission, or being free of cancer for 5 years, as women without implants
For the first few days after surgery, you will be in pain, and you will be sore. These symptoms are common and shouldn’t cause alarm:
Dr. Roesner will typically write prescriptions for related medications prior to surgery. Get them filled in advance and take them as prescribed to keep pain and swelling down. Don’t skip or delay doses because they can take up to 30 minutes to kick in – if you wait until it hurts, you will be in pain.
Some patients experience nausea or a “hangover” response to anesthesia. One way to overcome that is by limiting your movement. Keep a bucket and a moist towel or baby wipes nearby in case you feel sick. That way, you won’t have to make a painful dash for the bathroom.
How much breast, suture or incision pain is normal or ok? Proper healing is a key component in successful breast implant surgery. The worst of your breast augmentation recovery pain should subside a few days after surgery, but plan to spend weeks adjusting to the growing pains associated with breast implants – breast tightness, back pain.
Women recovering from breast augmentation surgery often describe feeling a certain amount of discomfort, pain and tenderness across their breasts and along suture and incision line.
Dealing with sutures and incisions can be one of the most difficult aspects of recovery. When you feel the itch, you know your body’s healing, but don’t scratch. Excessive itchiness is not good. Ask you the office or Dr. Roesner for tips in handling excessive itchiness – should it occur.
At your consult, you will discuss your health and lifestyle, review your medical history and determine your breast implant needs. At this time, Dr. Roesner can roughly estimate recovery time.
Your implants will need time to settle into their final position. The American Society for Aesthetic Plastic Surgery sets the following general time table for implant settling:
In the interim, it may appear as if one breast implant is settling in more slowly or quickly than the other – or as if they’re both still sitting relatively high. Give them time, and don’t be alarmed. Initial asymmetry typically corrects itself with time.
Signs you may not be recovering appropriately:
1. Hypertrophic Scarring – This is a very thick, raised, red scar that develops after surgery. Hypertrophic scarring occurs in 2%-5% of patients and may require treatment with additional operations or steroid injections into the scar.
2. Hematoma – A hematoma is a pocket of blood inside the wound. It occurs in 1%-6% of patients and is usually occurs within 2-3 days after surgery. Hematoma symptoms are swelling of the breast and severe pain that does not respond to pain pills. Treatment includes putting a tube in the breast to drain the blood. This procedure often requires a trip back to the operating room. Sometimes, if the collection of blood is small, no treatment is required and the body is able to clear the hematoma on its own.
3. Seroma – In the days or weeks following the surgery, fluid can collect around the implant, causing pain or swelling. This can be thought of as “blister fluid.” Just like a hematoma, it can leak from vessels damaged during the surgery and form a collection. Removal of larger seromas is recommended since they can become infected. Usually, the fluid can be removed carefully by a needle and does not require additional surgery. However, this technique of draining the seroma with a needle also may create a hole in the implant leading to implant deflation.
4. Wound Separation (Dehiscence) – A relatively rare complication within the first 2 weeks where the edges of the wound separate resulting in an open wound or possibly exposure of the implant. This can be solved by using Steristrips to close the incision, or may require additional surgery.
5. Infection (Cellulitis) – This complication occurs in 2%-4% of patients, and is usually from bacteria that normally live on the skin. Most surgeons will give a single dose of antibiotics before the surgery, and use an antibiotic solution in the wound before implant placement to help reduce the chance of infection. Symptoms of infection include pain, redness, swelling, and fever. Doctors may treat this complication with antibiotic pills, or if the infection is severe, by having the patient go to the hospital for intravenous antibiotics until the swelling and redness go away. After leaving the hospital, antibiotics pills are taken for 1-2 weeks. For infections of the implant itself, surgery to remove the implant is often the only option. Though some surgeons will attempt to save the implant from being removed by reopening the pocket and washing out the wound, this may not be effective. Infected implants put the patient at additional risks including: scar contracture, wound separation, and (in very rare cases) a severe illness called Toxic Shock Syndrome. After removal, healing and softening of the breast need to take place before the implant can be replaced – which often takes several months.
6. Mondor’s Disease – This is an inflammation of the blood vessels that run under the surface of the breast and it occurs in about 1% of patients. Fortunately, this condition requires no additional treatment and will go away on its own.
1. Asymmetry (difference in size or shape between breasts) – Most breast are asymmetric before breast augmentation, and all breasts remain (at least to some degree) asymmetric after the operation. Usually, the differences between the breasts can be improved during surgery, but occasionally the breast can become even more asymmetric after the operation and additional surgery may be required to improve this problem. For problems with sinking implants or implants placed off center, the wound is opened and the implant is moved. Sometimes if the first procedure is done in a subglandular approach, fixing the asymmetry can be done with submuscular implant placement.
2. Contour problems – These may be seen before or after breast augmentation. Although implants usually improve breast shape, contour irregularities may persist or worsen after the operation requiring additional surgery to correct them.
3. Capsular Contracture –
o Definition – Once an implant has been placed, cells called fibroblasts make scar tissue to surround the surface of the implant. This occurs around every implant in the body, including artificial joints, pacemakers, or shunts. The scar tissue that forms around the implant is called “connective tissue” or the “fibrous capsule” and is responsible for keeping the implant in place. This capsule, for reasons which are poorly understood, can sometimes thicken and contract. This squeezing of the implant can cause shape changes, hardening, or pain.
o Preventing Contracture – A number of factors may reduce the occurrence of capsular contracture. These include submuscular implant location, use of textured implants, and prevention of post-operative infection or bleeding. Sometimes doctors will also ask patients to start massaging the breast 5 days after surgery to reduce hardening of the capsule surrounding the implant. It should be noted, however, that massaging with textured implants is discouraged.
o Treatment For Capsulars Contracture – For severe capsular contractures, the treatment of choice is re-operation. During this procedure, scar tissue lining the implant pocket is removed. Subglandular implants may be moved to a submuscular position.
4. Altered Sensation or Feeling – Most women have some decrease of breast/nipple feeling or sensation following surgery. For women with these changes, feeling often returns after 6-12 months. Unfortunately, 15% of patients have loss of nipple sensation in at least one of their breasts. Loss of feeling to areas besides the nipple is common as well, though within a year most patients return to normal. Rarely, symptoms such as itching and tingling occur, but like the others, these normally end in 6 months.
5. Deflation or Rupture – The rate of deflation was published in one large, well-controlled study at 8.3%, though in the past this has often been a largely debated number. Implants that are placed in the subglandular position and implants larger than 450cc are at greatest risk for deflation. If this complication occurs, additional surgery is required to replace the implant. The cost of replacement usually is the responsibility of the patient.
It may be recommended that you perform breast implant massage or compression exercises.
In general, these exercises involve pushing the implant to the outermost corners of the pocket several times in succession. You move the implant up, down, to the right, and to the left. Hold your implant in each position for a few seconds. These exercises may help decrease your risk of developing capsular contracture (scar tissue around the implant).
You may be asked to start the exercises about a week after your breast implant surgery. ONLY perform massage exercises if instructed.
We recommend
Anatomical Implants: Implants that are shaped like a breast.
Anesthesia: Local anesthesia numbs just a certain area of the body. General anesthesia puts you to sleep.
Areola: Nipple
Armpit Incision: Also called trans-axillary incision. This approach can be used for both submuscular and subglandular placement of the implant.
Biocompatible: The ability or something to be put into a person without causing your body to attack or reject it.
Breast Augmentation: A surgical procedure that enlarges the breast through implantation of a prosthesis.
Capsular Contraction: A tightening of the scar tissue surrounding an implant. This is a serious complication that may result in removing the implant.
Dehiscence: Separation of a wound or scar. Patients are more likely to have this if the incision is in the abdomen. In addition, factors like obesity, dehydration, malnourishment, smoking, and coughing can cause this as well.
Fibrous Cysts: Fluid filled masses in the breast that 25-30% of women experience at one time in their lives. Some women develop more cysts than others and this might affect the decision to get breast implants.
Glandular: Relating to a gland or a part of the body that makes fluid. For example-a sweat glad, or salivary gland. Glands are the area of the breast that make milk.
Hematoma: A pocket of blood, or a clot, in the body. Following surgery, larger hematomas need to be removed since they can become infected.
Hemorrhage: Bleeding. This can be inside or outside the body.
Incision: A cut on the body.
Inpatient Surgery: A surgery in which the patient is required to stay overnight in a hospital.
Keloids: More common in African-Americans, this is an expansion of the scar beyond normal boundaries from the wound site. Frequently found on the ears and on the chest.
Milk Ducts: Tubes that allow milk to run to the nipple.
Mondors Disease: A surface breast vein that has become clotted or inflamed.
Necrosis: Tissue death. This can cause inflammation.
Outpatient Surgery: A surgical procedure in which the patient is not required to stay overnight in a hospital.
Pectoralis Major: A muscle located in the upper chest, which provides support for the breasts and is necessary for arm movements.
Ptosis: Sagging or drooping.
Ripples: This comes from having a large implant or not having enough natural tissue to cover the implant.
Saline: A mixture of water and a little salt. Very similar to ocean water and can be safely absorbed by the body.
Sepsis: Bacteria, or other small organisms, in the blood. Can also be caused by the small substances produced by bacteria.
Silicone: A material, taken from sand, which is generally accepted by the body and can be shaped.
Subgaldular: An area underneath a gland. For Breast Augmentation surgery, this is an area under the breast tissue, but above the chest muscles.
Subpectoral: Under the pectoralis muscle. This is also referred to as submuscular breast augmentation.
Textured Implants: The surface of the implant is covered with very small bumps in order to help the body accept the implant. This is believed to help prevent contracture.
Toxic Shock Syndrome: This is a severe, and potentially fatal response by the body to a bacterial substance called a toxin.
Thrombosis: The formation or development of a blood clot.
(TUBA)-Trans-Umbilical Breast Augmentation: A bellybutton incision with a faster recovery than some other approaches. This technique only allows sub-glandular placement of the implant and also needs additional incisions to treat serious complication
