KNOWING YOU LOOK YOUR BEST?

The first reported breast augmentation was performed by Czerny in 1895 using the patient’s own fat. He actually used fat that he had removed from a fatty tumor called a lipoma. In the early part of the century synthetic injections were attempted by Gersuny in 1899 (paraffin) and by Pangman in 1951 (synthetic polyvinyl alcohol and formaldehyde polymer). In 1963, two United States physicians named Cronin and Gerow introduced the popular silicone implants that are used today.

In 1991, a moratorium was placed by the F.D.A. for the use of silicone implants. This decision was based on a concern from numerous women across the country who felt that their implants were responsible for development of immune disorders and breast cancers. Although the move to halt all silicone implants was controversial, the physicians agreed that further testing should be performed to determine the safety of silicone implants. Over a decade of studies has shown that, in fact, silicone implants have no relation to development of immune disorders and that women who have silicone implants are less likely to develop breast cancer. In March of 2007, the F.D.A. re-approved the use of silicone implants in all women aged 22 years and older.

Prior to March 2007, silicone implants could only be placed in women who needed replacement of their implants (saline or silicone), in women who had sagging of the breast requiring a breast lift, in women who had chest wall deformities, in women who had breast asymmetry, and in women who needed breast reconstruction for breast cancer. For all other patients considering breast augmentation for the first time, only saline implants are allowed. As of March 2007, the F.D.A. has approved the use of silicone implants in all women aged 22 years and older.

Most women who desire enlargement of their breasts are good candidates for breast augmentation surgery.  In general, it is safer to place implants in patients who have not previously had breast symptoms such as: breast tenderness, breast lumps, nipple areola discharge, and breast infection. In addition, if the patient has had a family history of breast cancer, this can be concerning because it may increase the likelihood of breast cancer in the patient. If you have experienced any of the above concerns, a mammogram is recommended so that any breast abnormality can be detected prior to breast augmentation surgery.

Indications for having breast augmentation include inadequate breast volume and  developmental delays in breast growth. Additionally, breast augmentation has proven to benefit psychological conditions such as: low self esteem, lack of self-confidence, or sexual inhibition. Finally, small degrees of breast droop (up to 2 cm) can be corrected with a breast implant placement.

The surgery involves placement of accurate preoperative markings including: the midline of the chest, the incision line (determined by the approach used), the inframammary crease (fold under the breast), as well as the pocket that is going to be dissected to fit the implant. The pocket size is determined by the implant size selected.

Following placement of the implants, the patient is sat upright so that breast symmetry can be confirmed. If there are asymmetries, the patient is placed back down and either pocket dissection or implant volumes are adjusted until symmetry is achieved.

Finally, the incision is closed in multiple layers and using plastic surgery closure techniques to ensure protection of the implant and an aesthetically pleasing incision line.

 The various approaches to breast augmentation include:

a) inframammary crease(in the breast fold): this approach provides the surgeon the best visualization of the breast pocket that he/she is dissecting thus ensuring breast symmetry following breast augmentation surgery. The most important advantage of this approach is that it provides the most direct access to the surgical pocket in the event that revision surgery is required.

b) periareolar (around the areola): when this incision heals well, can be very well camouflaged. However, this incision is associated with several disadvantages including: surgical trauma to the breast glands, increased potential for nipple numbness, and poor scarring in the event revision surgery is required. Since the incision is circular, if opened a second time, it tends to contract into a straight line when healed thus distorting the areola.

c) transaxillary (in the armpit): This incision tends to hide well as long as you don’t have to raise your arms as part of your occupation. However, it has several disadvantages including: more difficult dissection resulting in more difficulty obtaining symmetrical pockets, potential for arm numbness, potential for damaging large veins to the arm which if damaged could result in prolonged arm swelling, and a necessity to convert to another incision if a revision is necessary (revisions may include correcting  asymmetry or to remove a thickened capsule scar). Breast implants using the armpit technique are usually placed under the pectoralis muscle.

On your initial visit, your surgeon will evaluate your health status by obtaining blood work. If you are 40 years or older or if you have had a history of breast symptoms (tenderness, lumps, nipple discharge) you will have to obtain a mammogram. If you are a smoker, you should quit for 1 month prior to your breast augmentation surgery to minimize the risks of implant infection. In addition, it is prudent to quit smoking for 6 weeks following surgery to ensure a well-healed surgical incision line. Finally, you will need to arrange for a friend or a spouse to care for any small children who may need to be lifted since you will be sore for the first couple days following surgery.

Since your surgery will require general anesthesia and/or intravenous sedation, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated into your lungs during induction of anesthesia. Since, you will have anesthetic medications administered throughout the case, you will remain groggy for several hours and will require a ride to and from the surgery center. You should choose a caretaker who is conscientious and who can spend the first night with you.

Patients who undergo breast augmentation surgery are extremely satisfied with their surgery and will notice immediate improvement in their breast to body silhouette. A thorough preoperative assessment, safe intraoperative course, and close monitoring with frequent postoperative visits ensures that patients experience a speedy recovery and a return to a more productive and rewarding life. Patients are extremely pleased with breast augmentation surgery and radiate increased physical and mental confidence

Since breast augmentation surgery will require general anesthesia, it must be performed in an operating room that is part of a hospital institution or outpatient surgery center. Less frequently, patients may be operated on in an in-house office based operating room, but it is of utmost importance for patients to make sure that the office facility is  accredited by a surgical accreditation body such as AAAASF.

For the routine breast augmentation, the implants are placed in a submuscular plane which will require general anesthesia. For certain individuals, a subglandular (over the muscle) plane is recommended for which conscious sedation (sedation through intravenous medications only) will suffice.

Patients will awaken from general anesthesia to find their breasts wrapped with Ace Wraps as well as a breast band. The Ace wraps are to support the implants in their newly created pocket. The breast band is to prevent the implants moving up on the chest wall. Although this is not intuitive, for the first three weeks following surgery, breast implants tend to want to move up on the chest wall against gravity. The band counters this movement and ensures that the breast implant stay in the desired position. Patients will feel sore throughout the first 2 to 3 postoperative days. By placing long lasting local anesthetic solution in the breast pockets prior to closing the incisions, this soreness is minimized . Patients are asked to avoid lifting of weights greater than 15 pounds for the first two weeks. Incision lines will be sealed with special tape (steri-strips) for the first 36 hours so showering is delayed until the 2^nd day following surgery. Finally, exercise should be limited for the first 4 weeks until the incisions and the breast pocket have completely healed.

Patients can expect to return to work at the earliest at 4 to 5 days following surgery if they have a sitting job. In general, patients are recommended to take 1 week off if their work permits. Weight restrictions are set at 15 pounds for the first two weeks to guide patients who may have more physical jobs.

There are several side effects that have been associated with breast augmentation surgery and these include:

1. a) High riding implants: Patient’s frequently notice high riding implants in the early postoperative period. The implants will drop into their desired, aesthetically pleasing position within 2 to 4 weeks. The tendency for the implants to sit high is countered by wearing of a breast band which will be provided by your plastic surgeon. The breast band will be worn for approximately 2 to 4 weeks until the implants fall into their desired space.
2. b) Numbness: Numbness can occur when sensory nerves are inadvertently traumatized during the surgery which requires creating a pocket for the implant to sit in. Since these nerves are extremely small, they are not apparent to the naked eye and so unavoidable. Clinically, the periareolar incision has been associated with increased incidence of numbness since the dissection is closer to the nerves. Fortunately, numbness is an infrequent event and when present resolves itself over 2 to 3 months.
3. c) Capsule formation: Capsule formation refers to the phenomenon of the body forming a scar around the implant. This is a natural event that occurs as the body tries to wall itself from a foreign body; this occurs when you get a splinter the body forms a scar around it that eventually helps the body spit it out. Usually, the capsule around the implant is thin and soft, and does not cause any problems. However, if the capsule does thicken it can lead to breast distortion and is referred to as capsular contracture. Capsular contracture is an infrequent event that occurs most commonly with silicone implants. The good news is that capsular contracture is rarely observed with saline implants and to be limited with the new generation silicone implants. Since capsular contracture tends to occur years after implant placement, time will tell if the new generation silicone implants prevent the development of capsular contracture.
4. d) Hypertrophic scar: Hypertrophic scar refers to the development of a thick scar in the skin. Since, most plastic surgeons use a similar technique for closure of their skin incisions, whether or not you are at risk for this depends on the healing capacity of your body. Contrary to common knowledge, the better healer you are
5. e) Mild asymmetry of breast size: Asymmetry of the breasts is considered a side effect only for the mere fact that most women have some degree of asymmetry. The surgeon must do his/her best to improve on any asymmetry by utilizing different sized implants. Thus, any preoperative asymmetry should be improved upon; as a rule of thumb, the surgeon should be able to get the breasts to a similar size with a less than 5 % difference in size.

f) Deflation: Deflation of the implants can occur and in gen at 1% per implant per year. So in 10 years there is a 10% chance of the implants deflating. Deflation is felt to occur when the shell (or cover) of the implant rubs against itself. In saline implants, this occurs when the implant is under-filled. For example, if you chose a 360 cc implant, then this implant is usually overfilled to 380cc so that there are no creases in the implant. Detection of deflation in saline implants is easy since they deflate like a flat tire. Detection of deflation in silicone implants is more difficult since the silicone implants tend to ooze and minimally deflate. Often a ultrasound or MRI is needed to confirm a break in the silicone implant shell.

1. 1. Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period which pools into a pocket. When less than 10 % of the breast volume, the hematoma is left to resolve on its own. When larger than 10 % most surgeons will recommend a trip back to the operating room so that this hematoma can be removed. There are two reasons why the hematoma must be removed. First, the hematoma is a perfect medium for harboring growth of bacteria. So if you have an infection anywhere in your body, the bacteria will travel through the blood stream and grow in the hematoma; this can lead to an infection of your implant(covered below). Second, the presence of a hematoma is felt to promote capsule formation (covered above).
   2. Infection: An infection is probably the worst complication that can occur following breast augmentation surgery. An infection will require you to remove the implant and get on 1 month of antibiotics. You will have to wait approximately three months before having your implants replaced. This 3 month interim can be quite discomforting for you since you will have to wear a falsy(bra) to make your breasts symmetric.
   3. Pneumothorax: A pneumothorax refers to the inadvertent puncturing of the lining that covers your lungs. This is a rare event but can occur since most implants are placed under the pectoralis muscle. Once you are dissecting under the muscle, there is only a few millimeters of tissue between your pocket and the lung lining. Regardless, if this does occur, then the surgery is more complicated as you might assume. The surgeon has to place a catheter into the lung, has to seal the hole created, and then pull the catheter after the case following an X-Ray to confirm proper placement. This will probably mean a trip to the hospital for the X-Ray and an overnight stay.
   4. Assymetry of breast shape: Assymetry in shape is very different than asymmetry of size (described above) and occurs when the implant pockets have not been dissected accurately. This is why preoperative marking is so critical (see below). In fact, if the breast pockets are dissected too medially, this can lead to the breast pockets connecting together leading to a condition called symmastia. This can be a difficult complication to fix and will require revision surgery.