Breast Augmentation Resources
Breasts as they occur naturally are not perfectly symmetrical i.e “twins, not identical twins.” Some balance can be achieved by differential filling and placement.
Women with implants who have pretty, big breasts are women who, without implants, had pretty little breasts.
Cleavage does not occur naturally, and attempts to place implants so close, as to achieve this may result in synmastia, (the touching of one breast prosthesis against another) which will result in an unnatural look.
Anatomy of Breast implant
- the shell (the outside layer, sometimes called the envelope or lumen)
- the filler (inserted into the shell)
- the patch (covers the hole where the filler is inserted into the shell)
Typically the shell is made of a single layer (“single lumen”), but some implants have a double layer—a shell within a shell (“double lumen”).Both silicone and saline implants have an outer shell made of silicone-rubber material. But when someone refers to a “silicone breast implant,” they mean the filler of the implant, not the shell.
The two types of implants used are:
- silicone gel-filled, silicone-rubber shell
- saline filled, silicone-rubber shell
Generally, the silicone-rubber shell is made of:
- Cured long strands of silicones
- Approximately 20 percent finely powdered silica
tightly bound to the silicone polymers
- Small amounts of other materials
Saline Filled Breast Implants:
Saline implants are filled with a sterile saline solution—the same type of salt water used in general surgery and for other internal purposes.There are several types of saline-filled breast implants. These types vary depending on whether saline is prefilled before breast surgery or is filled during surgery, and whether the volume of the implant is adjustable.
- Single lumen (“lumen” is the outside shell)—prefilled at the factory to a fixed volume. There are no valves for filling during surgery or for adjusting after surgery.
- Single lumen—filled with a fixed volume of saline during surgery through a valve. After surgery there are no adjustments to the implant volume.
- Single lumen—filled during surgery. After surgery, the volume of the implant can be adjusted by adding or extracting saline through a valve in the implant.
Silicone Gel-Filled Breast Implants:
The filler in silicone gel-filled breast implants is composed of silicone oil, cured large silicone, a small amount of uncured silicones, and other materials. Silicone is a very safe compound and has been widely used in a number of medical applications for many decades.
There are several types of silicone-filled breast implants:
- Single lumen—prefilled by the manufacturer to a specific volume of silicone gel.
- Double lumen—the inner lumen is prefilled by the manufacturer to a specific volume of silicone gel. The outer lumen is filled during the breast augmentation procedure with a fixed volume of silicone gel using a valve in the implant.
- Double lumen—the outer lumen is prefilled at the manufacturer with a fixed volume of silicone gel, while the inner lumen is filled during the procedure through a valve in the implant. This third type allows for adjustments to the filler volume after surgery.
- The fourth type of silicone implant may appear to have no shell—looks and feels like a semi-solid rubber gel.
Remember that breast augmentation is not permanent and breast implants do not last a lifetime. Eventually they may need to be removed and replaced with new implants. Data suggests that within ten years after surgery, up to 50 percent need to be replaced.
What type of implant is right for me?
Breast implants can be smooth or textured, saline or silicone, and round or shaped (previously called “anatomical” or “teardrop”). They each have their pros and cons, as follows:
Smooth vs. Textured
(+) PROS – As a rule, regardless of any other consideration, smooth implants wrinkle less than textured implants. Accordingly, if the implant is going to be placed above the muscle, you may be more inclined to choose smooth implants. Smooth implants also feel softer than textured implants unless they are overfilled. They have a “teardrop” profile when in the upright position, and they may also move somewhat with activity, much as a natural breast does. Smooth implants are always round.
(-) CONS – Smooth silicone implants have historically had a higher rate of capsular contracture than textured silicone implants (approximately 34% vs. 15% respectively, according to some earlier studies). In terms of saline implants, earlier studies have shown the rate of capsular contracture to be about the same (approximately 8% to 14%) regardless if the saline implant is smooth or textured. Capsular contracture is becoming increasingly rare now, with more recent studies reporting less than 5% for all types of implants.
(+) PROS – There has historically been a lower rate of capsular contracture for silicone, textured implants than for silicone, smooth implants.
(-) CONS – Textured implants are usually more firm than smooth implants, because the texturing requires a thicker shell.
Saline vs. Silicone
Since 1992, when silicone breast implants were taken off of the American market, the vast majority of breast implants have been saline (salt water). This saline fluid is exactly the same as you would be given through an I.V. if you were dehydrated, or going to have anesthesia, and is generally not going to be harmful to the body. Silicone has recently come back on the American market and is available to some patients, but only under certain circumstances. You may want to ask your doctor if you are a candidate for silicone gel.
(+) PROS – Less perceived risks. No auto-immune disease controversy. Possible lower rate of capsular contracture than with silicone implants.
(-) CONS – Feel. No Saline implant will ever feel quite as nice as silicone gel. This is more important in thin women with minimal body fat and breast tissue to cover the implant.
(+) PROS – Feel. Silicone implants usually look and feel more natural than saline implants.
(-) CONS – Controversy regarding perceived risks of adverse reactions to silicone gel by the body. Possibly a higher rate of capsular contracture than with saline implants.
Bottom line: Silicone breast implants have been studied more intensively than any other medical device, and silicone has been definitively shown to be nontoxic. Worldwide, more than 90% of women choose silicone when they have that option available.
Round vs. Shaped
(+) PROS – Round implants consistently provide the most natural look and feel with the least potential complications.
(-) CONS – Some will say round implants offer less control over long-term superior pole (the upper portion of the breast) fullness.
(+) PROS – Anatomical implants were developed to provide a contour more like the natural shape of the breast itself. In long-chested women the implant may provide greater control of superior pole fullness.
(-) CONS – The implant must be textured so it will adhere to the breast tissue, and lessen the chances of having it rotate in the body. This concern with “directional orientation” results from the fact that if the implant does rotate, the upper portion of it could end up inappropriately positioned outward or inward. With round implants, all sides are the same by definition. Therefore, if a round implant does rotate, it does not matter. I put this information under (-) CONS shaped because it illustrates a shortcoming of the shaped implant. Of course, the shaped implant does have some indications, particularly for Reconstructive Surgery, and it is a favorite of some excellent surgeons.
Bottom line: Unless there was a compelling reason to choose otherwise, we would advise to choose round implants.
Standard vs. High-Profile vs. Low-Profile
The “profile” of the implant refers to the ratio of projection to base diameter; in other words, a low-profile implant is flatter and wider, whereas a high-profile implant has a narrow base and is more cone-shaped. The purpose of these various profiles is enable matching of the implant dimensions to the base diameter of the breast, while allowing for a variety of volume choices. They are available in both Saline and Silicone-filled and Textured and Smooth versions.
(+) PROS High-profile implants provide maximal volume on a small base and are particularly indicated for women who desire a great deal of fullness but have a narrow chest. Low-profile implants provide minimal volume while enhancing cleavage and can help avoid leaving a large space between the breasts.
(-) CONS High-profile implants may look more “fake” because they maximize projection, though this is more related to implant size (volume). Low profile implants may appear too flat in some cases
Incision & Scars
1)Videoendoscopic Transaxillary – (Through the armpit)
(+) PROS The benefits of this approach are that there is no scar on the breast (” scarless” breast augmentation). The scar is least noticeable, as it is placed in the arm pit. Using an endoscope (a pencil- sized rod with a fiber-optic camera on it’s tip) and special retractors the dissection of the pocket is done for theimplant to be placed above or below the muscle.
(-) CONS A potential drawback of axillary insertion is that if a visible scar does result, and you wear sleevelessdresses or bathing suits, the scar may be seen – especially when you raise your arms. No other breast implantincision is visible when clothed. Additionally, you can go through a previous periareolar or inframammary scartime and time again if another surgery is ever necessary. You generally cannot go back through an axillary scar,and thus a new incision (and perhaps scar) may result.
2)Inframammary – (In the fold beneath the breast)
(+) PROS This is arguably the most common approach for inserting breast implants. This approach is often used because it provides the surgeon with good visibility and accessibility for both sub-glandular and sub- muscular implant insertion. The first thing you want to be sure of is that once your implants are in, your breast will infact fold over, and thus cover, this scar. If so, this may be the best approach for you.
(-) CONS The scar tends to be slightly more noticeable and visible than in the Periarealor or Transaxillary approach because it is not “camouflaged” by the change in skin color. Also, due to gravitation-induced changes to the breast, the scar will tend to migrate upward and could become quite obvious on the breast itself. If a noticeable scar on your breast is your worst nightmare, then this approach is not for you.
3) Periarealor – (Along the areola complex), which is the pigmented skin surrounding the nipple. This sometimes erroneously called “through the nipple.”
(+) PROS Another common approach, because the scar often blends in less conspicuously where the darker skin of the nipple meets the lighter skin of the breast. Typically, the incision goes halfway around the areola.
(-) CONS Some early studies suggested that the periareolar incision increased the chances of sensory changes to the nipple, though more recent reports have refuted this assertion. Numbness, or partial sensory loss to the nipple, appears to occur with equal frequency with all of the incision sites used for breast implant placement. There is a higher risk of injury to the milk ducts through this approach as they lie right under the areola and thiscan be a major consideration for women who plan to start a family following the surgery. Some surgeons also believe there is a higher risk of infection with this approach, since bacteria in the milk ducts of the breast tissue might be exposed. However, this also remains unproven.
4)Transumbilical – (That’s right, right through your belly-button)
(+) PROS The advantage is that you will likely have no visible scar.
(-) CONS The disadvantages are as follows:
- a) It is a somewhat “blind” surgery as it is very distant from where the implants are to be placed. While an endoscopic device (a tiny camera) is used, the correct placement of the implants is most difficult from here.
- b) Pre-filled breast implants may not be used, thus reducing your options for your best cosmetic look and feel.
- c) Few plastic surgeons use this approach because of the lack of control it allows, and because of poor long- term results caused by not getting the new folds of the breast to the same level.
- d) There is a chance of “tracks” being made in a line between the belly-button and the breast. These tracks form the shape of a “v”, coming together at the umbilicus, can be visible for a long time, and are not a pretty sight
We neither recommend nor practice this approach
There are advantages and disadvantages to every consideration in breast implant surgery, and there is no single best way for the surgery to be performed. Following are many of these considerations, and their trade-offs.
Should my implants be placed above the muscle or below the muscle?
In both cases the implant is behind the mammary glands and the breast tissue. The difference is that sometimes the implant is placed in front of the Pectoralis Major chest muscle (also known as ), and other times it is placed behind it (also known as submuscular or subpectoral).
|Normal Breast||Submammary or Subglandular||Submuscular or Subpectoral|
When the implant is behind the muscle, the muscle covers the upper 1/2 to 2/3 of the implant. This helps to conceal the implant and provide a smoother transition from the chest to the breast. Your individual body type, amount of existing breast tissue, and the look you desire will help you determine which position is best for you, as follows:
- If you have very little breast tissue…it is more likely you will want to “go behind the muscle”,for the following reasons: a) When the implant is in front of the muscle, there will not be much breast tissue to cover the implant, so more of the implant roundness will be visible. Clearly, if 1/2 to 2/3 or more of the implant is covered by muscle, it will be harder for you and others to see, feel and notice that an implant is there.
- If you have some breast tissue… If you have approximately 3 cm or greater of breast tissue, you will have more of a choice between above and below the muscle.At this point, new considerations need to be taken into account: a) If you exercise, the implant that is placed behind the muscle is more likely to displace, or move, when doing exercises that use the chest muscles. However, there are newer surgical techniques can minimize this. There is a slightly greater chance of capsular contracture, or implant hardening, when the implant is placed in front of the muscle.
- If you have some breast tissue and a “saggy” or “droopy” breast… There are different points of view on this, and it will of course depend on individual anatomy. Some favor placing the implant above the muscle for the following reason: Even though the breast (tissue and glands) itself has fallen, or drooped, down toward the abdomen, the chest muscles are still in the same place they have always been. So, if you were to put an implant behind the chest muscle, you would have the previous breast still in the same position it was before surgery (drooping low), but now you would have a breast implant protruding out from the chest wall a couple of inches above the rest of the breast… Not pretty. Having a droopy but larger breast is not ideal, however, because if the implant does not provide enough lift by “re-inflating” a saggy breast, an unfortunate “rock in a sock” look may result. Furthermore, the gravitational pull of the breast will be increased by the weight of the implant, which could result in the acceleration of further droopiness. This is a trade-off you must consider.
- The obvious solution… A breast lift, or mastopexy can be performed in conjunction with breast implants. This surgery can be performed in one or two stages. If performed in one stage, the implants will be implanted during the same surgery as the mastopexy is performed. Alternatively, the breast lift could be done on one day, with the implants implanted at a later date.
The logic behind this two-stage approach is as follows: Breast lifts require a relatively large incision which may better heal unchallenged. In some women, if there is a breast implant in the skin envelope that is pushing outward against the incision and stitches, it will be more difficult for the incision to heal, and can result in increased scarring. Your individual circumstances will help us determine which approach would be best for you. Also, silicone gel implants may be appropriate and indicated in this situation. We recommend that mastopexy and the implants be done at the same time.
It is important you are informed that, regardless of how performed, a mastopexy will leave scars on the breasts.
The extent of scarring will depend upon your own skin type, the skill of the surgeon, and your overall propensity to heal or scar. Not Smoking is critical to good wound healing after breast lift surgery because nicotine constricts blood vessels, thereby depriving the surgical area of oxygen. Also, ask your doctor i they recommend any homeopathic remedies that may be taken orally and/or applied to the skin before and after surgery to help to minimize scarring. Generally, breast lift scars will fade to a less conspicuous size and color, but they will remain visible for life.
- If you have very little breast tissue and a droopy breast…This is a situation where the combined mastopexy and augmentation will most likely be the best solution.A silicone implant would be likely to work in your favor in this situation as well, because when an implant has a very soft, natural feel and a very low incidence of wrinkling, you can greatly reduce the chance of being able to see, feel, or otherwise notice the implant.
This is probably a good time to mention that, as of late, there has been a trend in some parts of the country to want the implant to be somewhat visible, especially around the top portion (the superior pole). This is quite achievable in most any case. Just keep in mind that it is a trend, and trends change.
Risk & Complications
Although breast augmentations have been suspected of causing numerous systemic illnesses, the majority of these unfounded claims have been proven wrong. As a result, breast augmentation surgeries are on the rise.Approximately, 3,00,000 women underwent breast augmentation in the US last year.Women should be aware, however, that there are potential risks associated with breast augmentations, as are present with any other surgery. While no surgeon can guarantee a risk-free procedure, choosing an experienced, qualified, and board- certified breast surgeon can reduce many risks of breast augmentation.
By researching risks of breast augmentation before deciding on surgery, you can make more informed decision. Whether implant surgery is for the purpose of reconstruction or augmentation, breast implants are not considered to be lifetime devices. Chances are you will likely need additional surgeries and periodic visits to your surgeon in the future. Your implants might have to be eventually removed at which point you will have to decide whether or not to replace them.
Risks of breast augmentation are the same general risks as other surgical procedures. Some women with breast implants can experience some kind of trouble after the procedure. These risks of breast augmentation include:
Some degree of breast pain is common after breast augmentation surgery. With time and proper adherence to surgical care instructions, the breast pain that most women experience subsides, as do the swelling, bruising, and other initial side effects of breast augmentation surgery. Breast implant safety studies have indicated that between five and twenty percent of all breast augmentation patients experience breast pain three to five years after surgery. Breast pain is the number one reason that women seek breast implant removal or replacement after the original surgery.
There are several reasons why a person may experience breast pain after surgery. The improper size or placement of implants, an inappropriate surgical technique, capsular contracture all can cause significant breast pain.
Nipple and breast sensation changes after breast augmentation can cause an increase or decrease in sensitivity in the breast area. Nipple and breast sensation changes can vary from extreme sensitivity to no sensation at all. The physiological response to stimuli (sexual and non-sexual) and the ability to nurse a baby can be adversely affected by nipple and breast sensation changes after breast augmentation. These nipple and breast sensation changes may be temporary or permanent, depending upon the type of nerve damage or other injury caused during breast augmentation surgery.
Periareolar incision techniques pose a greater likelihood that the patient will experience nipple and breast sensation changes. However, nipple and breast sensation changes are possible with any type of incision when nerve damage is caused. Nipple and breast sensation changes also seem to be more common in patients who choose subglandular, rather than submuscular, placement of the breast.
Capsular contracture was a common complication associated with breast augmentation. Any time a foreign body, such as a breast implant, is placed in the body the natural physical response is to form a capsule of scar-like tissue around the unrecognized object. The current implants with their inert shells place the risk at 1 – 5 % .
While the development of the tissue capsule around the breast implants is expected and normal, capsular contracture is neither. The pocket that is made for the breast implant should remain open, allowing the implant to sit in the body with a natural look and feel. During capsular contracture the fibrous tissue surrounding the implant begins to squeeze in and apply pressure, causing the implant to feel hard and the breast to resemble a tennis ball in shape and density.
The exact cause of capsular contracture, beyond the presence of breast implants, is unknown. There are some factors, however, that are thought to increase the risk of capsular contracture. These risk factors include: germ or bacterial contamination of the implant shell, infection, seroma, hematoma, and other local complications. Capsular contracture may also be more common when the implants are placed in the subglandular position rather than under the muscle. Smoking can cause delayed healing after breast augmentation surgery, which might also increase the risk of capsular contracture.
When a breast augmentation patient develops capsular contracture there are medical techniques that can be employed to remedy the complication. Closed capsulotomy is when the surgeon will squeeze the implant hoping to “pop” open the scar capsule. This procedure is not recommended by implant manufacturers because it can cause the implant to rupture, bringing additional complications. For this reason, closed capsulotomy is not the preferred way to treat capsular contracture.
Open capsulotomy is a surgical corrective procedure, whereby the surgeon makes a periareolar or inframammary incision to enter into the pocket and make cuts into the scar tissue. These cuts, or scores, are made to release the tension around the implant caused by capsular contracture. The body will then form a new capsule around the implant. The most extreme surgical option to treat capsular contracture is to remove the implants altogether.
Mammary asymmetry can result from breast augmentation surgery when one of the breasts is higher than the other or when one or both are placed too medially or laterally on the chest. This is most often caused by incorrect placement of the implants during surgery. Mammary asymmetry can also be caused by poor or improper healing of the breasts after cosmetic surgery. There are four different incision locations that can be used during breast augmentation surgery to insert the implants: the further away the incision site from the breasts, the greater risk of surgical error leading to mammary asymmetry.
When mammary asymmetry occurs after breast augmentation, additional surgery is typically required. This additional surgery will involve repositioning the implants to achieve more balance and symmetry in the breast area.
The surgical process to correct mammary asymmetry can be relatively simple or more complex, depending on the nature of the complication.
When a patient experiences significant complications after breast augmentation, immediate removal of the implants is often recommended. Because no implant lasts forever, removal will be necessary at some point in the patient’s life. Removal of the implants can be recommended or necessary a few months to several years after the original breast augmentation surgery.
In some cases, the patient will wish to have her implants replaced after removal of the original implants. Others will just have the implants removed. There are several reasons that breast implant removal would be desirable or necessary. The reason for removal may be aesthetic dissatisfaction with the results of breast augmentation. This can include unsatisfactory size or shape of the breasts, implant malposition, breast asymmetry, wrinklin, dimpling, rippling, and the like.
Local complications after breast augmentation are also likely to require removal or re-operation. These complications can include: breast pain, implant calcification, capsular contracture, extrusion, granuloma, hematoma, seroma, infection, inflammation, tissue death, implant palpability or visibility, and more.
Rupture/deflation is a serious complication that can occur after breast augmentation. When there is a break in the shell of the breast implants or an unsealed or damaged valve leaks, the result is rupture/deflation. Rupture/deflation has different characteristics depending on whether it occurs with saline or silicone implants. This serious complication can occur just a few months after the breast augmentation surgery or it may occur after ten or so years of having implants. The current implants used are cohesive gel implants which do not “bleed” following the rupture.
There are certain activities that are contraindicated, or not recommended, because they can cause rupture/deflation. These include: a procedure to treat capsular contracture called closed capsulotomy, placing any substance besides saline into saline implants, injecting through the implant shell, altering the implants in any way, and placing more than one implant into the pocket created during breast augmentation surgery.
There are several possible reasons that rupture/deflation occurs. Over-handling of the implants during surgery, particularly the TUBA technique, can compromise the implants and increase the risk of rupture/deflation. Surgical instruments may also damage the implants during breast augmentation surgery. Over or under filling of the saline breast implants may also lead to rupture/deflation. During the life of the implants, capsular contracture, physical pressure or trauma, compression during a mammogram, and damage related to other medical procedures like a biopsy or fluid drainage can also cause rupture/deflation.
Rupture/deflation in saline implants usually happens immediately or may take a few days to occur. When saline implants rupture or deflate it is noticeable to the woman. Her breast will look “deflated” and/or the size and shape of her breast will change. Silent ruptures, without any symptoms, are more common with silicone implants. When a silicone rupture/deflation occurs, the gel may stay within the capsule or may slowly leak to surrounding areas such as the chest wall, armpit, and even make its way to organs like the liver. Without symptoms, the only way to tell that a silicone implant has ruptured is to have an MRI performed.
Though uncommon, scarring is a possible complication of breast augmentation. All breast augmentation techniques will leave a permanent scar behind, which is meant to be as inconspicuous as possible after healing.
There are two kinds of scarring that make a scar look more severe and counter the aesthetic appearance of the breast implants. Keloid scars are red and raised and typically extend beyond the area of the original incision. These are the result of too much collagen production during the healing process. Keloid scars tend to be more common in people with darker skin tones. Hypertrophic scars are those that grow too thick, though they are limited to the confines of the wound area.
There are many ways that a breast augmentation patient can reduce the risk of excessive scarring in the surgical area. In some cases, however, excessive scarring is the result of genetics, specific medical conditions, and overall health. These factors are difficult to prevent, but can be identified prior to surgery. Smoking before and after breast augmentation, as with virtually every surgical procedure, reduces the body’s ability to heal properly and quickly, so patients who smoke are encouraged to quit smoking before the procedure at least until the wound has fully healed.
To prevent unwanted scarring, it is crucial to follow all postsurgical care instructions provided by your cosmetic surgeon. When severe scarring does occur after breast augmentation there are medical interventions that can reduce or diminish the appearance of the scars. However, in some cases, excision of the scars may be the best option. This removes the actual scar tissue and allows the skin another chance to heal properly.