The Breast Implant and Augmentation Procedure
Breast augmentation is a safe and effective procedure to enlarge the breasts and enhance their shape, fullness and your overall proportionality.
Under the Muscle vs. Over the Muscle
Incisions
Size
The Surgery
Possible Risks/Complications
The Implants
The implant in general use for breast augmentation in the United states have been predominantly saline in the last decade. However, in November of 2006, the FDA approved the use of silicone implants for women desiring breast implants. They concluded that the implants were safe and effective and deemed their use acceptable in women 22 or over.
Implants may be textured or smooth, but smooth are used more commonly. The implants currently in use are manufactured by Mentor Corporation or Inamed, a division of Allergan. I have found both implants comparable in price and performance. Round implants are used most often and may be selected in low, moderate or high profile, depending on the breast width, size goals, and how much projection is desired.
Under the Muscle vs. Over the Muscle
I prefer under the pectoral muscle implant placement. The reasons are as follows:
- Radiologists feel that a better mammogram may be obtained because more breast tissue can be visualized.
- More soft tissue is placed over the implant causing a more natural feel to the breast.
- The pressure of the muscle on the upper portion of the implant gives a more natural contour and lessens the round "half of a grapefruit" look, that makes the augmentation look so obvious in many actresses and men's magazine models.
- Under the muscle placement lessens the risk of visible wrinkling of the implant.
- There seems to be less incidence of capsular contracture by placing the implants beneath the muscle.
The saline implant shell comes highly sterile and empty. It is filled with sterile intravenous saline solution at the time of surgery using a closed system so contamination is very unlikely. It has a very reliable valve system that self seals after the filling tube is removed.
The silicone implant is prefilled and sealed at the factory.
Incisions
Periareolar – Incisions around the colored area around the nipple are usually very narrow and inconspicuous. It is a good incision for olive or brown skin tones as the scar would be less noticeable than in other locations. There does not seem to be any greater risks of sensory nerve injury with this approach compared to others.
Inframammary – the inframammary scar is located beneath the breast about ½" higher than the crease. This scar may be less noticeable in women with some ptosis (sagginess). It also avoids cutting through breast ducts or very much breast tissue. It can be as short as an inch long.
My patients are given an option as to which they prefer. Or, I may make a recommendation as to which would more suitable for the individual.
Other less commonly used incisions are via the axilla (armpit) and around the navel (endoscopic breast augmentation, or TUBA – this is NOT recommended).
The periumbilical incision approach is not allowed at all for silicone implants as it would damage the implant.
Size
Most women desire increased fullness with a size proportionate to their figure. This usually translates into going from an A or B cup to a C cup bra. Some women desire a very modest increase in size and still others would like to be as large as possible. The implant size and shape used to achieve this will be determined by the patient's aesthetic goals and her anatomy. For instance, has the breast skin been stretched by pregnancies, or previous weight gain? Has there been tissue loss or atrophy from breast feeding or aging? What are the hereditary characteristics of the skin thickness and elasticity, the breast envelope shape (round, or long and more tubular), and what is the shape of the chest wall (wide sternum, ribs forward or slanting back).
It may be helpful to look at your surgeon's before and after photos or cut out pictures in a magazine, if necessary, to help convey your idea of your aesthetic ideals. Your surgeon can get a better idea of your goals, but, you may not be able to fully achieve them depending on the factors listed above. For most women looking normal, natural and fuller, in a size proportionate to their height and frame, is a realistic goal.
The Surgery
The procedure takes about 1-2 hours. It is usually performed in the office O.R. setting as an outpatient. I use general anesthesia with a board certified M.D. anesthesiologist.
The blood loss is very minimal. After the procedure, a compressive dressing is placed.
Postoperative discomfort is treated with analgesics and antibiotics are given.
Most women take about one week off work and avoid driving for a week. You may slowly resume your activities over the next several weeks and return to full aerobic activity and heavy lifting by 5-6 weeks after surgery.
Possible Risks/Complications
There are risks involved with undergoing any surgical procedure , but fortunately a healthy individual undergoing breast augmentation can expect a very low level of risk.
Always verify that you are seeing a well-qualified board certified Plastic Surgeon and having your surgery in an accredited ambulatory surgery facility. Our office O.R. is a state-of-the-art fully accredited facility by AAAASF (American Association of Accredited Ambulatory Surgery Facilities). To check out your surgeon's credentials, you may contact the American Society of Plastic and Reconstructive Surgeons www.plasticsurgery.org , the American Board of Medical Specialties, and the Board of Medical Quality Assurance.
The risk percentages below reflect numbers quoted by research studies. Dr. Sardo's risk rates over the past 20 years are significantly less.
The manufacturer's 4 year risk rates for primary augmentation are approximately
- reoperation 23%
- capsular contracture 13%
- breast pain 8%
- implant malposition 4%
- hematoma 1.6%
- nipple complications 5%
- deflation of saline implant about 4%
Bleeding – blood loss in this surgery is minimal. It is important after surgery, especially in the first 2 weeks, to avoid exercise and raising your heart rate and blood pressure. Also avoid aspirin, ibuprofen and many other medications that may affect your ability to clot your blood. I supply a list of these medications and herbal preparations, which should be discontinued about 2 weeks prior and 4 weeks following surgery. Significant bleeding requiring reoperation occurs <1%.
Infection – the implant is filled with sterile saline using a closed system. Antibiotics are given IV during surgery and orally after surgery. Infection risk is less than 1%.
Deflation – The risk of deflation is about 4-12% over 7 years. It has been noted that the smooth implants generally have a lower deflation rate. If deflation occurs, the saline will be safely absorbed and the breast volume will decrease. There is no particular time frame when deflation is likely to occur. Under filling of the implant below the manufacturers recommended fill volume of saline may cause a higher rate. The Mentor and Inamed implant companies provides a lifetime replacement of implant policy. For an additional $100, they will cover replacement expenses for 10 years. The implant can be exchanged in a relatively simple procedure and optimally should be done fairly soon after the deflation is noticed.
The FDA recommends obtaining an MRI to check for silicone rupture beginning 3 years after implantation and every 2 years thereafter. Most ruptures are "silent", but it is possible that a ruptured implant can cause discomfort, capsular contracture or benign granulomatous lumps.
Capsular contracture – It is a normal process for the body to cover the implant with a thin layer of scar tissue. Occasionally, an excessive amount of scar is formed and it contracts or shrinks around the implant making it feel unacceptably firm. If mild, the breast or breasts are moderately firm. If severe, the breasts can appear distorted and be hard and uncomfortable. This can be treated by a surgery to remove the scar tissue and replace the implants. It may or may not occur again. The risk of this occurring using textured implants under the muscle is less than 5%.
Nipple numbness – Numbness may occur temporarily or permanently from traumatizing sensory nerves in the breast during the procedure. The risk has been reported as high as 15%, but is less than 1% for many surgeons. Nipple numbness is typically less than 1% but may be higher in the periareolar approach.
Breast feeding – Having breast implants may cause inability to breast feed. This is a very low risk and many have successfully breast fed after having implants placed. It does seem that the periareolar approach is more likely to cause this problem than the inframammary approach.
Insurance consideration – It is possible that your medical insurance company may deny coverage or limit coverage in women who have had cosmetic breast augmentation. They may also deny coverage for complications resulting from this surgery.
There may be other very rare or less likely risks that your surgeon will discuss with you.
Dr. Marialyn Sardo, MD, FACS
Tel: 858-452-6226
Toll Free: 866 DR SARDO
(866-377-2736)
Fax: 858-452-6235
9850 Genesee Avenue,
Suite 380
La Jolla, CA 92037
Email Dr. Sardo
– Breast Augmentation Patient
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