Health Creativ'

INTRODUCTION
The decision to have breast augmentation is an entirely individual and personal one. Few will understand how a woman feels and why she may wish it. Some reasons why women choose to increase the size of their breasts are: the size of their breasts is small in proportion to their body build, their breasts have become smaller after weight loss, breast feeding, pregnancy, age or they have asymmetrical breasts.

So, who is a candidate for breast augmentation?

Implant Location

http://www.plasticsurgery.org/patients_consumers/links_resources/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=8285

Breast implants may be placed on top of the muscle or under the muscle. When placed "on top of the muscle" they are placed between the pectoralis major muscle and the breast gland. When placed "under the muscle" they are placed under the pectoralis major muscle. There are actually several variations of being placed "under the muscle". One method is to attempt to obtain total muscle coverage (total submuscular) by attempting to recruit adjacent muscles to cover the implant. Another is to cover it with the pectoralis major without releasing it from the ribs near the bottom of the breast (partial submuscular). Another is to cover the implant with the pectoralis major muscle and release the lower portion from the ribs to allow a certain amount of interface between the implant and the breast gland (dual plane). The pros and cons of each method are shown below.

ABOVE MUSCLE

        * Advantages

         1. Better control of breast shape.

         2. May have less pain and faster recovery.

         3. No distortion with muscle contraction.

         4. Better control of the inframammary fold.

    * Disadvantages

         1. More likely to feel and see implant edge.

         2. More interference with mammogram.

         3. Increased risk of capsular contracture (firmness).

         4. More likely to see implant wrinkling.

         5. More likely to interfere with nipple sensation.

PARTIAL SUBMUSCULAR http://www.justbreastimplants.com/placement/partials.htm

     * Advantages

         1. Less likely to feel and see implant edge.

         2. Less interference with mammogram.

         3. Decreased risk of capsular contracture (firmness).

         4. Less likely to see implant wrinkling.

         5. Less likely to interfere with nipple sensation.

    * Disadvantages

         1. Eventually displaces towards the side, widening cleavage over time.

         2. Less fullness in upper inner breast.

         3. May have more pain and longer recovery.

         4. Distortion with muscle contraction.

         5. Less control of the inframammary fold.

 

TOTAL SUBMUSCULAR

     * Advantages

         1. Same as Partial Submuscular, plus:

         2. Possible temporary increased soft tissue coverage over lower outer breast.

    * Disadvantages

         1. Same as Partial Submuscular, plus:

         2. Increased risk of upper implant displacement.

         3. Longer surgery time.

         4. Most pain and longest recovery time.

         5. Least control of inframammary fold.

DUAL PLANE http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=12925857&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

    * Advantages

         1. Less likely to feel and see implant edge in upper and inner breast.

         2. Less interference with mammogram.

         3. Decreased risk of capsular contracture (firmness).

         4. Less likely to see implant wrinkling.

         5. Less likely to interfere with nipple sensation.

         6. Better control of lower breast shape.

         7. Less pain and faster recovery, identical to submuscular technique.

         8. Better control of the inframammary fold.

         9. Minimizes displacement towards the side, preserves cleavage.

        10. More fullness in upper inner breast than partial submuscular.

        11. Reduced distortion with muscle contraction.

        12. Less control of the inframammary fold.

        13. In my opinion, the most natural shape

    * Disadvantages

         1. More likely to feel implant at lower breast.

Scar Location

INFRAMAMMARY SCAR

* Advantages

         1. Fine line scar in crease below breast

         2. Less OR time (cost)

         3. Less risk of implant contamination

         4. Often used in secondary surgery

* Disadvantages

         1. Scar on breast

 

TRANSAXILLARY SCAR

 * Advantages

         1. Least visible scar, not on breast.

         2. Less risk of implant contamination.

* Disadvantages

         1. Very difficult to correct sagging (ptosis).

         2. Longer operating time (cost).

         3. Possible interference with sentinel node biopsy.

 

PERIAREOLAR SCAR

 * Advantages

         1. Well concealed at edge of nipple.

         2. Easier to contour breast if needed

* Disadvantages

         1. Requires a certain areola size and shape

         2. Higher risk of implant contamination (infection, capsular contracture).

         3. Greater risk to nipple sensation.

         4. Greatest risk of interfering with breast feeding.

         5. Possible interference with sentinel node biopsy.

 

UMBILICUS

 * Advantages

         1. Least visible scar, not on breast.

* Disadvantages

         1. Pocket developed blindly instead of under direct vision.

         2. May develop lumps or depressions in upper abdomen.

         3. More swelling, bruising, and pain.

         4. Longer recovery.

         5. Possible increased risk of bleeding.

         6. Few secondary operations can be done by this approach.

 

Implant Types

MANUFACTURERS
In United State of  America, currently there are only two manufacturers whose breast implants are FDA approved for use in the United States - Mentor and Inamed. Between the two of them they provide over 500 different styles and sizes of implants! .

OUTER SHELL
The outer shell of all implants currently available in the United States is made of silicone elastomer. The feel of the shell is similar to that of a zip-lock bag, only a little thicker.

FILLER
The implants may be filled with silicone gel or saline. Saline solution is simply salt water. It is the same solution often used when someone receives an IV for dehydration or surgery. The silicone gel is more cohesive with a more viscous consistency. The gel in earlier implants was more liquid (like honey), whereas now the tendency is to make the gel more cohesive (like gelatin). With today's implants, you can cut them in half and the gel doesn't just run out. It holds together more. Any candidate for breast augmentation may have saline implants. To get silicone gel implants a woman must meet certain study criteria and enroll in an FDA (Food and Drug Administration) study protocol.

SURFACE
The surface may be smooth or textured. The current texturing is the silicone elastomer surface, though other substances had been used in the past. The reason for texturing is that it was thought to reduce the incidence of capsular contracture (firmness). The texturing does help hold the implant in position so it is used for anatomic shaped implants. However almost all the deflations I have seen from the currently approved manufacturers in the United States have been textured implants. Therefore I only recommend a textured surface for use with anatomic implants.

SHAPE
The two basic shapes available for breast implants are round and anatomic. Round implants are recommanded for most applications but stay quite for comfortable placing anatomic implants. There are some instances in which I will highly recommend an anatomic implant. It may be easier to achieve a particular shape desired by the patient by using a particular shaped implant.

PROFILE
Implants now are available in low, medium and high profile. For a given volume, the low profile implant will have the widest diameter and the least projection. The high profile implant will have the narrowest diameter and the most projection. The medium profile implant is in between in terms of diameter and projection. An important concept to understand is that the center of the implant is centered in line with the nipple. Therefore as the implant profile increases, the diameter decreases and the space between the breasts becomes wider. High profile implants also give a more rounded upper breast.

FILL ISSUES
Saline implants come out of the box empty and are filled with saline at the time of surgery. The proper fill of an implant is very important. The less saline in an implant, the softer it feels but the more it wrinkles. The more saline in the implant, the firmer it feels but the less it wrinkles. The implants also come labeled for a particular volume - the nominal fill volume (i.e.: 300cc). The package insert will specify a normal fill range (300 - 325cc). Underfilling the implant in the example means filling it with less than 300cc. Overfilling would mean filling it with more than 325cc. Studies have shown that underfilled implants are more likely to deflate. I almost always fill implants at least to the upper end of the fill range and sometimes will overfill them. These fill issues will vary with different styles of implants as the current trend is to develop implants that require more volume for a given shell surface area.

SIZE SELECTION
A significant portion of the consultation is spent measuring the breast and determining implant size. For more information regarding size selection refer to section on Size Selection.

New Breast = Implant + Your Breast

 The chest wall is the foundation upon which the breast sits. The chest may be tall and narrow or short and wide. The circumference of the chest may be a barrel shape or wide and flat due to the way the ribs are curved. The breastbone may be flat, depressed, or protrude.

 The quality of the skin over the breast may vary in appearance, pigmentation, and in how it heals. It may be thick or thin, and its elasticity will vary. It may have stretch marks. The layer of fat under the skin will vary in thickness from patient to patient and in different parts of the breast. It may vary from one side to the other. The amount and distribution of glandular tissue within the breast also varies. Pregnancy and breastfeeding will affect all of these elements.

 The nipple areola complex varies greatly in its size, shape, color, and position on the breast. The nipple may project more, less, or be inverted. It may be of large or small diameter. The position of the nipple relative to the inframammary crease is one of the factors that determines a need for a lift. They may be farther apart or close together.

Achieving symmetry is one of the goals of surgery. However no one starts out perfectly symmetrical, so it is impossible to have a perfectly symmetrical result. Some types of symmetry can be corrected but other are exaggerated by breast implants. On examining a patient I look at the shoulders first. In most patients the right shoulder sits lower than the left, the right nipple and inframammary crease are usually lower as well. Usually the left breast is slightly larger than the right. Volume differences may be corrected by implants. Although if you fill two particular size implants to different volumes, the one with more fluid will be firmer. If you use different size implants, then the implant diameters will differ and therefore another asymmetry is introduced. An even more difficult problem is having one nipple higher than the other. Implants often exaggerate this asymmetry. Another fairly common symmetry issue is the levels of the inframammary crease. The creases are usually at different levels. The bottom of the implant sits at the crease level; therefore the upper edges of the implants may sit at different levels.

 Also critical is the amount of soft tissue coverage over the implant. Soft tissue consists of skin, fat, breast, and muscle. The thickness of this tissue determines its strength and how well it will hold up the implant over time. It also determines whether there will be visible wrinkling and how easy it will be to feel the implant through the tissue. It also determines the final breast shape and how natural or unnatural it looks. One way to think of this is the ratio of breast tissue to implant. If the final result is 50% your tissue and 50% implant, it will look and feel very natural. If it is 90% implant and 10% your breast, then it will look and fell very unnatural. Some women prefer this unnatural, fake, or "Baywatch" look.

 Another implant to tissue relationship is the distance between the breasts, or the cleavage. If that distance is narrow before surgery it tends to stay narrow after surgery. If it is wide before surgery, it will tend to stay wide. One must be careful using a wider implant to narrow the cleavage as the inner edge of the implant may be under some very thin soft tissue. This may create visible wrinkling even with an implant under the muscle. Another limitation in narrowing the cleavage occurs when the nipples lie far apart. The center of the implant needs to sit under the vertical line of the nipple. This determines where the inner edge of the implant is and therefore the distance between the breasts. Though this could be improved by using wider diameter implants, an unacceptably large size may be required to achieve the desired distance between the breasts

Benefits of Breast Enhancement

Women seek breast enhancements for a variety of perceived benefits. Most simply want to look better in certain types of clothes or swimsuits, thus increasing her clothing options. Certainly when a woman believes she looks better, she feels better about herself. The woman will look and feel more feminine. It may very well increase her self confidence. We see this whether a woman never had a large enough breast to begin with, or if she is restoring her size after breast feeding, or if she is trying to achieve better symmetry of the breasts due to a developmental condition.

 Along with improving the shape and size of the breast, other goals are just as important. Every effort is made to maintain breast function, softness, and sensitivity. It is also critical to minimize interference with breast cancer detection. If a woman is planning on having more children then the procedure should be planned so that there is no interference with breast feeding.

 There is an extremely high satisfaction rate with breast enhancement surgery. However it is not for everybody. As with any cosmetic procedure patient selection is critical. The keys to success in this procedure are good health and realistic expectations on the part of the patient. When these goals have been met, many women tell us it's the best thing they ever did for themselves.

 

Risks of Breast Augmentation

Although breast augmentation is a very common operation with a high level of success, it is incumbent upon every patient to understand the natural course of events and potential complications for any breast that has an implant placed under it. Patient understanding of limitations, tradeoffs, and complications is critical. Complications can be due to a number of factors. There are complications due to the patient's underlying health, complications of anesthesia, complications due to surgical trauma, and complications due to the implants. There is often a fine line between what is considered a side effect of surgery and what a true complication is.

 One of the limitations of breast augmentation is that stretch marks on the breast will not be eliminated by implants. Also, the skin may be too tight to accommodate a very large implant. If there is severe sagging of the breast a lift may be required either at the same time or at a later date. Breast implants do not prevent the natural aging of the breast. Many asymmetries may persist and actually be aggravated by breast implants.

 A breast augmentation patient will also have to accept certain tradeoffs. Where incisions are made there is always a scar. Every effort will be made to make this scar as inconspicuous as possible. Most of the time, the patient will be able to feel the implant under the skin. The less breast tissue you have the more likely you are to feel the implant. A saline breast implant is also slightly firmer than natural breast tissue, though many women actually prefer the firmer feel. One of the most important tradeoffs is the anticipation of future operation. Breast implants are not lifetime devices.

 Most complications due to poor underlying health can be avoided by restricting the operation to healthy patients. Likewise many of the potential anesthetic problems can be avoided by operating only on healthy women.

Possibilities of Surgical complication

 Breast implants are not considered lifetime devices. You should anticipate additional surgery and doctor visits over the course of your life. Even though the implants are covered by a lifetime replacement policy, you should anticipate additional expenses related to future implant surgery.

DEFLATION
Breast implants deflate when the saline solution leaks out of the implant due to the development of a defect in the implant shell. It may deflate rapidly or progressively over the course of several days and is noticed by a loss of size and shape of the implant. The rupture rate is less than 4% in the first seven years. They may deflate due to some type of trauma but usually they just wear out over time and deflate. Deflated implants require additional surgery to replace the implant.

CAPSULAR CONTRACTURE
The scar tissue or capsule that normally forms around the implant may tighten and squeeze the implant and is called capsular contracture. Capsular contracture is more common following infection, hematoma, and seroma. It is also more common with placement above the muscle. Symptoms range from firmness and mild discomfort, to pain, distortion, palpability of the implant, and/or displacement of the implant. Additional surgery is needed in cases where pain and firmness are severe. My recommended treatment of capsular contracture is implant removal with removal of the scar tissue, followed by re-augmentation 3 months later. Capsular contracture may happen again after these additional surgeries. Capsular contracture may occur on one or both sides.

PAIN
Pain of varying intensity and duration may occur and persist following any surgery. In addition, excessively large size, improper placement, surgical technique, or capsular contracture may result in pain associated with nerve entrapment or interference with muscle motion.

DISSATISFACTION WITH COSMETIC RESULTS
Dissatisfying results such as wrinkling, implant displacement (shifting), incorrect size, unanticipated shape, implant palpability, scar deformity, or hypertrophic (irregular, raised scar) scarring may occur. Asymmetry in implant position, nipple location, or size may occur. Unsatisfactory surgical scar location may occur. Results of surgery are unpredictable for any individual patient. You may be disappointed with the results of your surgery.

REOPERATIONS
Some complications may require additional surgery or other treatment to correct them and will result in additional expense to you. In rare cases, a satisfactory solution may not be possible.

INFECTION
Infection can occur with any surgery. Infection may occur even though special precautions are taken, and despite the administration of antibiotics. Most infections resulting from surgery appear within a few days to weeks after the operation. However, infection is possible at any time after surgery. Infections with an implant present are harder to treat than infections in normal body tissues. If an infection does not respond to antibiotics, the implant must be removed. Another implant may be placed 6 months after the infection is resolved.

HEMATOMA / SEROMA
Hematoma is a collection of blood inside a body cavity, and a seroma is a collection of fluid. Hematoma and seroma may contribute to infection and/or capsular contracture. Swelling, pain, and bruising may result. If a hematoma occurs, it will usually be soon after surgery. However, it can also occur at any time after injury to the breast. Seroma may occur soon after surgery or, rarely, years later. While the body absorbs small hematomas and seromas, large ones will require surgery for proper healing.

CHANGES IN NIPPLE AND BREAST SENSATION
Feeling in the nipple and breast can increase or decrease after implant surgery. The range of changes varies from intense sensitivity to no feeling in the nipple or breast following surgery. Changes in feeling can be temporary or permanent and may affect sexual response or the ability to nurse a baby.

BREAST FEEDING
At this time it is not known if a small amount of silicone may diffuse (pass through) from the saline filled breast implant silicone shell and may find its way into breast milk. If this occurs, it is not known what effect it may have on the nursing infant. Although there are no current methods for detecting silicone levels in breast milk, a study measuring silicon (one component in silicone) levels did not indicate higher levels in breast milk from women with silicone-filled gel implants when compared to women without implants. (Most modern day pacifiers and baby bottle nipples are made from silicone.) The periareolar incision site may significantly reduce the ability to successfully breast feed.

ASYMMETRY
No one has perfectly symmetrical breasts. Implants can correct volume asymmetry but may make nipple asymmetry more obvious. The breasts usually heal at different rates and some degree of asymmetry is expected during healing. If the implants heal in asymmetric positions (too high, too low), a second surgery may be needed.

WRINKLING
Visible and palpable wrinkling of implants can occur. Some wrinkling is normal and expected. This may be more pronounced in patients who have saline-filled implants with textured surfaces or thin breast tissue. It may be possible to feel the implant fill valve. Some patients may find palpable valve and wrinkles cosmetically undesirable. Palpable valve, wrinkling and/or folds may be confused with palpable tumors and questionable cases must be investigated.

SYNMASTIA
This can develop with implants above or below the muscle. The skin over the breastbone can pull away and the implants can slide closer together, reducing or eliminating cleavage. The degree can vary from mild to severe. Secondary surgery may be required and correction may be extremely difficult to accomplish.

DISSATISFACTION WITH SIZE
Every effort is made to help the patient select an appropriate size implant. We never guarantee a particular cup size as there is too much variability among bra manufacturers.

BREAST TISSUE ATROPHY/CHEST WALL DEFORMITY
The pressure of the breast implant may cause the breast tissue or chest wall tissue behind the implant to thin and shrink. This can occur while implants are still in place or following implant removal without replacement. This is more likely to occur with high profile implants.

CONNECTIVE TISSUE DISEASE
Concern over the association of breast implants to the development of autoimmune or connective tissue diseases, such as lupus, scleroderma, or rheumatoid arthritis, was raised because of cases reported in the literature of small numbers of women with implants. A review of several large epidemiological studies of women with and without implants indicates that these diseases are no more common in women with implants than those in women without implants. The effects of breast implants in individuals with pre-existing immune system and connective-tissue disorders are unknown. There is the possibility of unknown risks associated with silicone breast implants and tissue expanders.

SECOND GENERATION EFFECTS
There have been concerns raised regarding potential damaging effects on children born of mothers with implants. A review of the published literature on this issue suggests that the information is insufficient to draw definitive conclusions.

REMOVAL / REPLACEMENT OF BREAST IMPLANTS
Future revision, removal, or replacement of breast implants and the surrounding scar tissue envelope involves surgical procedures with risks and potential complications. There may be an unacceptable appearance of the breasts following removal of the implant.

LONG TERM RESULTS
Subsequent alterations in breast shape will occur as the result of aging, weight loss or gain, pregnancy, or other circumstances not related to augmentation mammoplasty. Sagging of the breast may normally occur.