Things to know about breast augmentation
Breast augmentation is probably one of the first things most people think of when they think of plastic surgery. Although it is the most commonly performed cosmetic surgery most people don’t understand all the nuances of it. It is estimated that in 2009 alone 289000 women had a breast augmentation in the United States. The modern silicone breast implant hit the market in 1962. These implants came off the market in the U.S. in 1992 and after careful studying were returned in 2006. Fifth (and 6th) generation implants are now available as more and more innovations are occurring.
The first thing one needs to know is why an augmentation. Many women will tell me at their initial consultation that this is “something I’ve always wanted”. It’s important to determine that this is something that the patient wants and not simply something they are pressured into doing for their significant other or to improve their position at work. Women with inadequate (and this is up to personal interpretation) breast volume have a negative body image feelings of inadequacy and low self-esteem. These things may affect the woman’s interpersonal relationships sexual fulfillment and quality of life. The motivation whatever it is needs to be personal and not coercive.
Hypomastia (small breast size) can be due to initial underdevelopment or occur later in life (involutional). Developmental hypomastia may occur by itself or it may be related to problems with the chest wall such as Poland’s syndrome. Poland’s syndrome can affect males or females (although much more dramatic in females) and typically involves the pectoralis muscle and possibly even the ribs. Involutional hypomastia happens in the post-partum period with significant weight loss or at menopause when the breast becomes deflated and loses some of the dense glandular tissue. Developmental hypomastia can often be treated just with an implant. In more severe cases such as Poland’s syndrome where a portion of the chest wall fails to form fat grafting or “flaps” may be required to restore an acceptable appearance. These severe syndromic cases are reconstructive. In involutional hypomastia an implant is often needed to restore fullness but there is often laxity or sagging (ptosis) that may require a mastopexy (lift) to restore youthful appearance.
The next question is what to use for the augmentation. Although many materials have been used in the past this typically now involves either a saline or silicone implant. Saline implants are essentially silicone shells (bags) filled with sterile saline solution. An advantage is that there is often a range of fill volumes so it is easier to match differences in sizes between breasts. If a rupture occurs the saline is reabsorbed by the body. The other major option is a silicone implant. These implants are only FDA approved for age 22 and above. They consist of a silicone shell filled with cohesive gel silicone (“gummy bear” or 4th generation). The newer cohesive gels replace the older fluid silicone which was more of the consistency of syrup or honey. This newer silicone is also form stable and does not flow out like the older silicone if the shell is ruptured. In the last few years 5th generation “shaped” implants (teardrop) have started to become popular. The 6th generation is the higher cohesive/overfilled round implant that allows for more projection with less supposed rippling (essentially a round version of the form-stable 5th generation implant).
Another important question is where to place the incision. Wherever the incision is placed it is typically 3 to 5 cm indiscrete and in most cases will fade to be nearly imperceptible. The most common placement is in the inframammary fold (under the breast). Placement here allows the best control of the tissues and implant placement and in my mind the safest. I almost exclusively offer this incision for revision cases and offer it to most of my primary cases. Periareolar incisions (around the areola) allow for a slightly more discrete incision in some cases but often this can widen or distort the junction or the areola and skin. This incision is limited to women with large areolas unless a saline implant is used. This incision also may cause changes in sensation to the nipple more problems with lactation and may expose the implant to bacteria contained within the breast ducts. A tranaxillary (through the armpit) incision may allow placement of most sizes of implants but places the incision in a place where it can be visible in tank tops and bikinis. It may also expose the implant to bacteria lurking in the armpit and does not provide (even with an endoscope) as much precision in implant placement. The last incision type is the TUBA (trans-umbilical breast augmentation) which places the implant through the belly button. This incision may sound good but is only useful for saline implants lacks any accuracy or control and may actually void the warranty of the implant – so beware.
A final question is where to place the implant. The two main options are above (subglandular) or below the pectoralis major muscle (submuscular). Above the muscle is typically less painful and more anatomic since the implant sits just under the breast tissue. Since the implant is closer to the surface it may be more visible and cause rippling to be apparent. The alternative is below the muscle which allows the implant to be hidden and protects it from exposure should there be a problem with the incision. In most cases I recommend a submuscular placement however in women that competitively lift weights or have had previous issues I will recommend subglandular placement.
A new technology that may become available everywhere is the BRAVA™ system. This is an external vacuum system that may provide some mild improvement of the breast though tissue expansion but can be cumbersome to use and apply. This system when combined with fat grafting (transfer of fat cells from the belly or thighs) has been demonstrated to make significant improvements in breast size and has been used to completely reconstruct a breast following mastectomy. This requires the BRAVA to be worn continuously for 2 to 3 weeks prior to the fat grafting session to create spaces for the grafted cells to be deposited. Augmentation of a cup or more can be done in one session and complete reconstructions (even after radiation) have been reported over 4 sessions spaced over a year. This allows a breast composed solely of your own fat cells without an implant. The downside is that this system is NOT FDA approved (yet) and only available as an investigational study. It is currently approved in Europe Canada Taiwan Australia Singapore and Argentina.
Although simple breast augmentation is relatively straight-forward and could be performed with little to no formal surgical training there are many nuances that require years of experience to master. It is important to know the credentials of your breast surgeon and not just “bargain shop.” There are many complications that can occur with breast augmentation (see future post) and it is important to know that your surgeon is capable of dealing with any of these problems. If your surgeon doesn’t have a frank and thorough conversation with you about what to expect then seek a second opinion – the FDA actually requires the manufactures to provide patient handouts (that the patient must sign).