Dr. Tholen's Comprehensive Guide to Breast Augmentation (Part 1 of 2)
Article by Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
For the past three years, breast enlargement (augmentation mammoplasty) has been the most common surgical cosmetic operation performed in the United States—over 318,000 women requested this operation in 2010, up 214 percent from 1997 [American Society for Aesthetic Plastic Surgeons Data]. For the past eight years, breast enlargement has been the most common operation performed at Minneapolis Plastic Surgery, Ltd.; every year several hundred patients undergo this one-hour outpatient operation in our nationally-accredited (AAAASF) office surgical facility. Superior anesthesia care, advanced surgical techniques, the care of my fantastic nursing and office staff, and over 20 years of experience allow my breast augmentation patients to return to everyday activities within 24 hours, and strenuous activities within several weeks.
If marketing hype and “snappy” trademarked names were important, perhaps we would call our procedure the “Overnight Recovery Augmentation,” the “24-hour Recovery Breast Enlargement,” or the “Flash Recovery Breast Augmentation,” as other doctors have. But for us, this is nothing new—this is the way we have been doing things all along!
Candidates for Breast Enlargement
Some women who choose breast enlargement do so to restore breast volume lost as a result of pregnancy, breastfeeding, weight loss, or aging. Others request this outpatient operation to improve symmetry in breasts that have never matched in size, and many women simply seek the improvement in self-image or clothing fit that fuller breast size gives them. For some women, breast lift surgery with or without implants may give a superior result. Examination and measurements will immediately tell us if breast lifting is necessary, or if excellent results can be obtained with implants alone.
Whatever the reason for requesting information about breast augmentation, you must understand that this operation is appropriate for you if and only if:
- You have realistic expectations regarding potential risks vs. benefits.
- Your breast development is complete (for younger women).
- You have decided to undergo this operation to feel better about yourself, not to live up to the expectations of anyone else.
- You are not pregnant or breastfeeding.
- Breast implants do not increase the risk of developing breast cancer.
- Mammography and breast self-examination can be performed on augmented breasts.
- Skillfully augmented breasts both look and feel normal in the majority of women.
- Breast implants do not harden, nor do they automatically need replacement after ten years.
- Nipple sensation and the ability to breast-feed are preserved in most patients.
- Breast implants (both silicone gel and saline) do not cause or increase the risk of developing arthritis, lupus, scleroderma, or connective tissue diseases.
- Saline implant leakage and deflation is uncommon and can be dealt with when it does occur.
- Since 2006, silicone gel implants are FDA-approved for use in first-time cosmetic breast enlargement patients. They are “cohesive” and cannot deflate.
Any patient considering breast enlargement with implants must have a personal consultation, during which she will discuss her individual cosmetic goals and concerns with Dr. Tholen. Many of our patients who do not live within driving distance of the Minneapolis/St. Paul area arrange for a consultation and surgical procedure during the same visit. Our staff can help you with arrangements for local lodging, postoperative care and assistance, if desired, and follow-up arrangements.
A complete medical and surgical history will be obtained from all patients, and should include information about allergies to any medications. You must inform your surgeon of all prescription or over-the-counter medications you take, including herbal, vitamin, nutritional supplements, and appetite suppressants. Some of these can interfere with proper blood clotting and increase the risk of bleeding after surgery. Breast enlargement patients must avoid aspirin or ibuprofen-containing products, Aleve™, additional vitamin E (the dose in a single daily multivitamin is acceptable), and any herbal remedies for a full two weeks before and after surgery.
Your pregnancy, breastfeeding, and mammographic history are important, as is physical examination of your breasts, nipple-areola position, measurements, and skin and muscle tone. Mild to moderate ptosis (breast droop or sagging of the skin caused by loss of breast volume after pregnancy or breastfeeding, and normal to slightly low nipple-areola position) can usually be corrected with implants alone (standard breast augmentation). If the ptosis is more severe, or if nipple position is below the inframammary crease, a breast lift (mastopexy) procedure will likely be necessary. After examination, I can determine the exact type of breast lift that is recommended and explain the additional incisions and resultant permanent scars that are involved. Breast lift surgery (with or without breast implants) requires additional operating time, incisions, and cost, but can correct more severe drooping or sagging of the breast skin, as well as raise nipple position. This is done without removal of the nipple-areola complex (though there is a scar around the areola to reposition it higher on the chest), which can preserve both sensation and ability to breast feed in about 85% of patients undergoing breast lift surgery.
Other conditions such as nipple inversion, tuberous breasts, significant asymmetry, Poland's syndrome, or problems from prior surgery, such as bottoming out, symmastia (uni-boob, or loss of cleavage), capsular contracture, or malposition can also be corrected or improved.
Choosing Your Breast Implants
The sheer number of implant variations available to patients and surgeons can lead to confusion; however, careful measurement, proper analysis of your anatomy, and experienced decision-making can help give you the best cosmetic result possible. Unfortunately, some choices are made on the basis of marketing, surgeon habit, a friend’s advice, or cost, rather than careful listening to the patient’s goals and concerns and utilizing the surgeon’s expertise to determine her best options. Since breast enhancement is done so frequently at Minneapolis Plastic Surgery, Ltd., we maintain an extensive on-site inventory of breast implants in virtually every size and profile, in both silicone and saline types. Your implants don’t have to be ordered in advance, you don’t have to worry about ordering the “right ones,” and on-time delivery is not an issue—they are already here!
Types of Implants
Breast implants come in numerous sizes (100cc – 800cc, or about 3 to 27 ounces each), configurations or shapes (round, oval, or teardrop “anatomic”), surface characteristics (smooth or textured), and fill material. Most breast implants are filled with saline or silicone gel, and occasionally other materials.
Since the material inside breast implants is what gives them their “feel,” choice of filler material has generated much controversy and media interest, not to mention scientific debate. We can provide both the science and years of expertise to help you determine whether saline or silicone is best for you.
Until March 9th, 2012, only two companies produced breast implants FDA-approved for use in the United States (Mentor Corp., now part of Johnson and Johnson; and Inamed Corp., previously McGhan Medical, now owned by Allergan, Inc.). For the first time in 20 years in the United States, a third company (Sientra) has just received FDA approval to sell their Silimed brand of silicone and saline implants, including textured anatomic silicone gel implants.
Prior to the FDA restrictions of 1991-1992, numerous companies produced breast implants with different designs, surfaces, and filler materials, including polyurethane-coated silicone gel implants, silicone-saline double-lumen implants (the Becker implant), and PVP hydrogel filled implants designed to pass mammography X-rays and have a feel more like silicone than saline (the Bioplasty Misti-Gold implant). After the FDA restrictions, these implant options and companies were lost to USA patients, though some of these companies and options remain available in other countries.
In the United States, besides the presently-available Mentor, Allergan, and now Silimed implants, several companies have produced investigational implants such as the McGhan style 410 cohesive silicone gel “gummy bear” implant, Hutchison saline implants, Ideal saline implants, and others. These implants are not yet FDA-approved and are being implanted only by plastic surgeons associated with the FDA investigation/approval study process.
Silicone or saline?
Saline identical to intravenous fluid was the most common type of breast implant filler material used in the United States from 1992 until November 2006, when the FDA reapproved the use of silicone gel-filled implants for primary elective breast augmentation. Prior to the 1992 FDA restrictions, silicone gel implants were utilized in over 85% of all breast augmentations in this country, and remain the most commonly used implants worldwide. Other types of filler material have been evaluated over the years, and one or more problems are associated with these. Paraffin, sponges, and other unusual materials were used in early efforts to enlarge breasts; results were dismal until silicone came into use in the 1960’s. More recently, soybean oil-filled implants were studied extensively, and were used in many patients in Europe, as well as a few US patients in FDA studies. Breakdown of the oil, rancid smell, and other concerns ultimately led to withdrawal of this implant (Trilucent™) in the US and in Europe. Fat as implant fill material has the same concern, and is not used.
Fat graft injections of a patient's own liposuction fat (directly into or beneath the breasts) have been performed by some physicians. Among other names, this has been termed “natural breast augmentation” using one’s own fat tissue (and you have to pay for the liposuction used to obtain the fat)! The American College of Surgeons and the American Society of Plastic Surgeons are not yet endorsing this procedure because grafted fat that dies can cause microcalcifications and scar tissue within the breast that can interfere with the mammographic detection of breast cancer. A recent study confirms that fat cells removed via liposuction are mostly destroyed and non-living; improper freezing of the fat kills even more cells (ice crystals puncturing cell walls kill the fat cells), so this is worthless and potentially harmful. The same goes for fat harvested with SmartLipo (laser destroys the living fat cells) or ultrasonic liposuction (ultrasonic energy ruptures the living fat cells). Unless your surgeon uses a low-vacuum fat harvest technique, and transplants the fat globules in carefully-spaced tunnels with tiny fat grafts surrounded by abundant healthy tissue for blood supply, fat harvested by these liposuction techniques is not going to survive, and any augmentation achieved is lost as the dead fat is absorbed and carried away by the body.
The latest marketing “hype” around fat grafting for breast enlargement uses the term “stem cell breast augmentation.” This is the same procedure as fat grafting, but with the possible addition of centrifugation or addition of blood plasma to “concentrate” or “enrich” the “stem cells.” Until peer-reviewed scientific research validates fat grafting (or the even more “out-there” stem-cell breast enlargement), this should be considered a case of buck-naked Emperor’s clothes, snake-oil “cures,” or lakeside property sales in Death Valley!
Other implant materials are being studied, including a more firm, teardrop-shaped textured-surface cohesive silicone gel (the “gummy-bear” implant). This study implant retains its form and innate integrity even when its outer shell is punctured. This implant is more firm (like a “gummy bear” or silicone bathtub seal) than the softer “standard” cohesive silicone gel implant and requires a larger 2.5-inch incision for placement.
The latest types of silicone gel breast implants presently used (as part of the more general FDA study since 1992) are softer but also cohesive. These 5th generation implants do not leak if the shell is cut or punctured. These silicone gel implants can be inserted via a 1½-inch incision. Cutting one of this latest generation of breast implants is like cutting Jell-O—you get two solid intact parts and leakage does not occur.
With silicone gel or saline implants, microscopic silicone molecules can still enter a patient's body, just as liquid silicone does in the patient who has an injection with a needle lubricated with liquid silicone. No scientific study to date has provided credible evidence that silicone has any cause-and-effect relationship with autoimmune diseases or conditions such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant illnesses." With these studies in mind, silicone gel breast implants were FDA-approved in November 2006 for elective first-time cosmetic breast enlargement in women over the age of 22. Use of silicone gel implants in women under age 22 would be considered “off-label” use. I support the right of properly-informed women between the ages of 18 and 22 to consent and request the implants of their choice.
Smooth or textured? Above or below the muscle?
The surface of breast implants can be smooth or textured, regardless of the filler material—silicone gel or saline. When silicone gel implants were used prior to the FDA restrictions of 1992, placement above the muscle was also the preferred implant position for many plastic surgeons. Texturing the surface of the silicone gel implant reduced the incidence of capsular contracture in this position (above the muscle and just below the breast tissue). However, after the FDA restriction on silicone gel implants and the switch to saline-filled implants, placement above the muscle led to unacceptable wrinkling that could sometimes be felt or seen. This led to most surgeons switching to placement of saline breast implants below the muscle to increase tissue coverage and reduce these concerns. Even placement of saline-filled implants below the muscle will not always eliminate implant wrinkles or ripples, particularly in thin patients and/or patients with very little overlying breast tissue. Now that silicone gel implants are again available, more patients will be able to avoid the “water-balloon” feel and visible or palpable rippling seen in some saline implant patients.
Based on the choice of saline or silicone, textured or smooth, and the patient's unique body type, appropriate surgical placement will be determined. Using textured breast implants below the muscle can cause unnatural adherence to the chest and restricted natural movement of the breast, and is not recommended. In addition, the lack of gel to act as a lubricant inside the implant (saline is a poor lubricant) can allow flexing and creasing of the implant shell surface with each movement or breath of the patient, ultimately leading to a higher risk of failure at one of the low spots in the textured surface, with leakage and deflation of the saline implant. The textured implant shell is also thicker and more palpable. Submuscular placement already reduces the incidence of capsular contracture, so smooth breast implants in this location are preferable to adherent textured-surface implants. The smooth-shell saline-filled implant placed below the muscle is soft, less palpable, and less likely to deflate (if properly filled), and has low rates of capsular contracture formation. It also moves with the patient's position and is therefore more natural and breast-like.
However, smooth-shell silicone-gel-filled implants are even more homogeneous with breast tissue and provide the softest, most breast-like, and most natural “feel” of any implant. Since the newest generation of silicone gel implants is also cohesive, they cannot leak. While the vast majority of patients are again choosing submuscular silicone implants for their breast enhancement surgery, I believe that the best and most experienced breast surgeons offer their patients a choice of either silicone or saline breast implants. With careful evaluation of the patient’s individual requests and needs, and detailed discussion of the pros and cons of the two surface textures available, we can help you choose not only the implant but the location and proper profile for your anatomy.
Anatomic (teardrop-shaped) or Round Breast Implants?
Breast implants come in round or teardrop ("anatomic") shapes. While some plastic surgeons prefer the teardrop-shaped implants in some situations, the smooth round implants are generally the softest, most natural in appearance (upright and lying down), least likely to be felt externally, and (for saline implants) least likely to leak.
Textured surface implants have a thicker shell, are more likely to be felt externally, and have a somewhat higher leak rate (saline implants) because of the thinner or weaker areas in the tiny peaks and valleys of the shell surface. Since teardrop-shaped implants must have proper positioning and must stay in that position (sloped part up, rounded part down) to take advantage of their innate shape, by necessity they are textured so that the body's tissues can adhere to and maintain the proper position of the implants. Thus, teardrop or “gummy-bear” implants cannot and do not move as the patient changes from a standing to a reclining position. Also, the teardrop implant remains teardrop-shaped when the patient is lying down, whereas the natural breast flattens out and assumes a round appearance. Teardrop or “gummy-bear” implants are also more costly than round smooth implants. The smooth round implant does just what a natural breast does: it is teardrop-shaped when the patient is upright, and flattens and drops slightly to the side when the patient reclines. Thus, the round implant is actually more "anatomic" than the teardrop, “gummy-bear,” or so-called anatomic implant.
It has been suggested that the “anatomic” or teardrop implant has a more natural look than the round implant, and much advertising and marketing has been used to promote “anatomic” implants to the public. The implant is a perfectly good device, but it is more expensive than the smooth, round implant, and whether or not it is truly more "anatomic" is questionable (see above). A recent study compared actual women with smooth, round implants to women with textured, teardrop-shaped implants. Mammograms were performed in upright and supine (lying-down) positions, and digital tracings computerized and compared. Both the round and teardrop-shaped implants had a sloped, teardrop shape when the women were upright. In fact, in upright patients, teardrop and round implants were indistinguishable on X-ray. But when a woman is lying down, the natural non-augmented breast flattens, drops to the side of the chest, and assumes a round shape, as does the round smooth implant. The teardrop-shaped implant stays teardrop-shaped in the lying-down position, which makes this actually less anatomic than the round implant! Still, in rare situations, the textured or teardrop-shaped implant may be an appropriate choice.
Moderate, moderate plus, or high profile? (and now there’s ultra-high!)
Both saline and silicone gel breast implants come in three standard profiles: moderate “classic,” moderate plus, and high profile. For example, a 400cc (Mentor style 7000) moderate profile silicone gel implant has a base diameter of 14.5cm and a projection (height) of 3.2cm. The 400cc (Mentor style 1000) moderate plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.0cm. The 400cc (Mentor style 4000) high profile silicone gel implant has a base diameter of 12.2cm and a projection of 5.0cm. Mentor now also makes an ultra high profile (style 5000) implant with a base of 10.6cm and projection of 5.4cm for the 400cc size. Thus, various dimensions are available to help best match the desired size of implant to the patient’s breast dimensions.
Allergan Natrelle® implants also come in a total of four silicone gel profiles: moderate, moderate-plus, high, and extra-high profiles. To use similar examples, a 390cc (Natrelle style 10) moderate profile silicone gel implant has a base diameter of 13.6cm and projection (height) of 3.8cm. The 397cc (Natrelle style 15) moderate-plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.2cm. The 400cc (Natrelle style 20) high profile silicone gel implant has a base diameter of 11.9cm and a projection of 5.0cm. As you can see by comparing these two manufacturers’ implant dimensions, near-equal volumes and profile implants from each company have nearly identical measurements. Allergan also makes an extra-high profile silicone gel implant (Natrelle style 45) with an 11.2cm base and 5.1cm projection for the 400cc size.
I believe it is important to first measure the patient’s breast dimensions, including base diameter, nipple to crease distance, nipple-to-nipple distance (cleavage diameter) and overall chest circumference, determine what final breast size she wants to achieve, and then see if a properly-chosen implant volume and profile can be surgically combined with her own breast tissues and skin brassiere to yield the desired results. Most of the time it can! In other cases, there may need to be compromises to achieve a good result, or additional skin shaping and tailoring (via breast lift) may be necessary.
Any surgeon who “always uses” high-profile implants, for example, “because I like the look of those the best” is selling some of his patients short. A narrow-chest small-frame petite woman who wants large breasts (but has virtually no breast tissue of her own), may require high profile breast implants to achieve the look she wants. But a tall, wide-breast base, large frame woman who only wants a modest enlargement (or has a fair amount of her own breast tissue), will not be served well by high profile implants—she needs moderate profile implants to get as much base diameter as possible for the small(er) size she has selected, in order to accurately fill her own breast base. Otherwise, she would have a narrow-diameter implant “sliding around” in a large-diameter breast pocket.
Thus, implant profile is based on each individual patient’s anatomy, pre-operative breast measurements, and requests, not on a particular surgeon’s “habit” or “routine.” It is, in my opinion, not the surgeon’s job to decide what a patient should have, but rather to listen to the patient’s requests, examine and carefully measure the patient’s individual anatomy, and then use our experience and expertise to determine how to best achieve her goals, or at least come as close as the anatomy and details allow! One profile does NOT fit all!
What is the Right Size for You?
Choosing breast implant size can be done in a number of ways; using as many of them as possible only increases the information I utilize to most accurately achieve the “look” each patient desires.
Of course, patients often have input from friends who have undergone this operation, have a "great result," and have ____cc implants. "Get those!" she tells you. But you probably don’t know what proportion of her present size is her natural breast tissue, and how much is implant. Unless your breasts exactly match your friend's pre-operative breast size (doubtful), and the rest of your chest wall, breast base, and anatomy are the same (impossible, unless she is your identical twin sister), you will need different implants added to your own tissue to get similar results. Determining what size is best for you is even more difficult if you rely on friends who advise to “not go too large” or you will “look fat,” be top-heavy, or have a "porn-star look." Compared to whom? Or is she just a bit jealous? I have seen entertainers, models, and everyday women with breasts of all sizes and shapes--many of whom ask me to give them something different: bigger, smaller, higher, or with an improved shape. What is best for one is definitely not best for all.
Breast augmentation is a personal choice, and while a friend’s input can be helpful, you should choose a size that makes you feel good about yourself. For MOST women, the size you choose is not only possible, but perfect for you! Remember, you should never have surgery to please someone else, or to try to conform to someone else's opinion.
Plastic surgeons that perform lots of breast enlargements have extensive experience in helping our patients choose implant sizes that are compatible with individual anatomy. Every one of us does this slightly differently, and some surgeons even decide for their patient. But what about the patient's wishes? Every patient has a "perfect size" in her mind's eye, and all we need to do is figure out what that size is, and whether or not it will match appropriately with the patient's chest and breast base dimensions, skin and muscle capacity, position of the nipple-areola complex, as well as a host of individual anatomic factors. I start with breast examination, careful measurements (everyone is asymmetrical), and ask you what your goals are. Based on these factors, I can determine if your requests can be achieved. For most patients, the answer is YES! If not, I will tell you, and we try to figure out what CAN work, and how to best get CLOSE to your ideals.
One of the best techniques for choosing implant size is for the patient to bring photographs of models with the desired (final) breast size to their consultation, or at the time of surgery. The proper size implant to most closely achieve this appearance is then chosen in the operating room. (Since we stock all sizes and profiles of saline and silicone gel breast implants in our surgical center, we do not have to “order in advance” and can change based on your choices right up to the time of surgery). Photographic examples have proven to be much more accurate than the patient requesting a letter cup size, or trying to find a similar person via internet search whose anatomy and/or results approximate your goals. Don't try to match your height, weight, or preoperative breast appearance to the photos, and don't use a stated implant size as a guideline for choosing your implant size—just find an “AFTER” photo you like.
Also, if your breast sizes don’t match (most women have some degree of asymmetry), we can choose different implant sizes and/or profiles to achieve as much symmetry as possible. In more severe cases, we can recommend appropriate procedures (such as breast reduction, breast lift, or other surgical options) to optimize size, shape, and position between mismatched breasts. Implant choices can be made to help camouflage chest wall or other skeletal asymmetries caused by scoliosis, pectus excavatum, or certain genetic syndromes.
Trying on implants in a brassiere is another excellent way to provide some idea of desired final breast size and the implant volume needed to achieve that size; however, it is essential not to become overly attached to a specific bra cup size (B, C, D, etc.) or implant volume (400cc, etc.), since the implant size you like in a bra or top will always look smaller when it is under your own breast tissues and chest muscle. Typically, a woman who chooses a specific cc volume implant that she feels looks good in her bra will be disappointed (too small) after surgery if that exact volume implant is used in her body. A good general rule of thumb is to add 50 to 100cc to the implant volume you feel looks good if you choose to size in a brassiere. In other words, if you like how a 400cc implant looks in a bra, it will take a 450-500cc implant to look about the same size in your body.
In general, for an “average” height and weight woman, 250cc equals about one bra cup size. A 12 ounce can of soda = 360cc. Most patients cannot even see a difference of 50cc (3 tablespoons and 1 teaspoon). Thus, 400cc implants will cause an increase of about 1½ cup sizes to whatever breast volume the patient started with!
Since what this surgery accomplishes is volume increase, your own skin brassiere (pre-surgery breast shape) will determine your final breast shape after implants increase your breast size. Size will also determine just how much breast mass extends to the side of the chest (armpit area), or into the cleavage region, since proper implant positioning is determined by the position of your nipple areola complex.
For instance, a woman with widely spaced nipples will need to have her breast implants positioned more laterally (towards the armpit area), since the implant pocket and final breast mound must be properly centered beneath the nipple areola complex. If the implants were simply placed close together in the center to give the full cleavage look, each nipple areola complex would then be positioned too far laterally, giving a "wall-eyed" appearance.
Similarly, a woman who has more medial nipple position would have a "cross-eyed" appearance if she requested lateral fullness and her implants were placed towards the armpits without taking into account the nipple position atop the new breast mound.
Clearly, not only size, but also the exact position of your breast implants, is critical to your final result. Your own anatomy determines shape (unless you also need a breast lift, where incisions are made to lift or otherwise shape your breast skin, or reposition too-low nipple/areola complexes).
Most breast implant patients will notice that implant position tends to drop as time goes by after surgery. If you look “perfect” in the first few days after surgery, I believe that even wearing a surgical bra 24/7 may not prevent implant position from dropping to an unattractive “too-low” appearance (“bottoming out”) in a majority of patients after several months. (This also makes the scar position too high above the crease.) I endeavor to take this into account surgically, placing the implant position slightly higher than I anticipate the desired final position to be. I will have you use an elastic bandeau at night, and go braless during the day (when upright), to allow the implants to settle, drop, and soften as time goes by. The elastic bandeau also helps me adjust any differences between breasts, since each side will swell, bruise, scar, and heal slightly differently, and drop into position at its own individual rate! I firmly believe that looking a bit “high and tight” right after surgery ensures a better final result, and a lower likelihood of re-operation to adjust position. In those few patients that do not drop into “perfect” position, it is a much more simple (and successful) re-operation to open the pocket slightly lower than to try to raise the crease and keep it “high enough.” This is especially true if we are successful at creating a thin, soft, pliable capsule around your implants; to try to raise the pocket we must sew to that capsule and get our sutures to remain secure and not “tear through.”
I also make the surgical pockets larger than your chosen implants, and will show you how to do implant movement exercises, often inaccurately called implant massage, to keep the pockets open and larger than the implants so that the final breasts are soft, natural, and drop slightly to the side when you recline (which is what naturally larger breasts do), rather than remaining hard and immobile on your chest.
Most women requesting this surgery emphasize that they do not wish to be "too large" after augmentation. There is a natural hesitancy to make a change that is so dramatic that "everyone will know" or that might embarrass you at the health club, swimming pool, relative's home, or church meeting. Most patients have these concerns, and many verbalize this. However, 6-12 months after surgery, when these concerns evaporate, and the social settings where "someone might notice" are successfully overcome, a surprisingly large number of patients admit they now wish they had chosen larger implants. Some even undergo another operation to place new, larger implants. Fortunately, when size change is requested, the surgical pocket for the implant is already healed, and recovery is easier.
Although size choice is entirely up to each individual patient (with some anatomic limitations), choosing just slightly larger than what you consider to be optimal preoperatively will help you to avoid reoperation for size change, including the cost of new implants, operating room, and anesthesia.
Are Silicone Breast Implants Safe? A Brief History
The modern era in breast augmentation began with the development and surgical implantation of silicone gel breast implants in a woman in 1963. In the 30 years that followed, plastic surgeons worldwide used silicone-gel-filled breast implants for both breast reconstruction and elective breast enlargement in well over one million women. Saline-filled breast implants were also used during this time, but in only about 15% of all patients receiving implants.
Breast implants were developed and utilized for more than a decade before the FDA began regulating medical devices in 1976; the safe and effective use of silicone in these and other medical products such as pacemaker insulation, lubrication for insulin needles, chemotherapy tubing, and artificial joints was well-established before the FDA could evaluate all of them. Because silicone breast implants and many other silicone medical devices were already in use prior to 1976, the ongoing use of these products was “grandfathered” by the FDA without formal evaluation and approval. None of these other silicone medical devices has been made unavailable to patients, but lack of formal FDA evaluation and approval of breast implants came into public awareness in the early 1990s.
The lay media has been responsible for spreading a great deal of information and misinformation regarding breast enlargement in the past decade and a half. Many women remember tabloid and TV talk shows' focus on the supposed problems claimed to be associated with silicone gel implants. Despite a lack of scientific data supporting these concerns, in 1992 the FDA restricted the use of silicone gel breast implants in women requesting elective breast augmentation.
At no point have silicone gel implants ever been “taken off the market,” but until November 2006 their use required enrollment in the FDA study that allowed only eligible patients and plastic surgeons access to them under strict guidelines. Since the FDA restrictions in 1992, numerous scientific studies (over 30 in the past decade) have continued to show NO cause-and-effect relationship between silicone gel breast implants and autoimmune-type illnesses (such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant" diseases). Since 1992, silicone gel implants have been used by plastic surgeons (including both Dr. Tholen and Dr. Gervais) involved in FDA-approved studies for patients undergoing breast reconstruction, breast augmentation revision (in certain patients), breast lift, and for those patients with congenital breast deformities.
After exhaustive review of the past nearly four decades of use, the FDA approved the use of saline-filled implants in May 2000.
Late in 2003, the FDA reviewed all of the available scientific data about silicone gel implants, including very detailed information from implant patients over the past decade, and heard testimony from patients, physicians, and researchers. The expert physician advisory panel to the FDA voted to recommend that the FDA approve the use of silicone breast implants for primary elective breast augmentation. However, the FDA deferred its decision, requesting “additional information” before granting approval.
In spring 2005, the FDA again revisited the request by both of the existing implant manufacturers for approval of general use of silicone gel implants; the expert physician advisory panel recommended approval for Mentor Corporation’s gel implants. Late in 2005, Both Mentor and INAMED® received letters of “[gel implant] product approvable” from the FDA.
On November 17, 2006 the FDA approved the use of silicone gel implants from both companies in patients over the age of 22, with certain restrictions, including involvement in the FDA study that has been ongoing for the past several years.
Opponents of silicone gel implants continue to claim that they cause autoimmune illness or are unsafe, but peer-reviewed scientific studies by many researchers and institutions have shown them to be safe and effective for their intended use. The controversy about silicone gel implants has made them one of the most intensely studied products in the entire medical marketplace.
As part of the 2006 FDA reapproval of silicone gel implant use, each company has an informed consent booklet that you will be asked to read (and sign). The FDA has made a controversial recommendation that patients with silicone gel implants undergo a MRI (magnetic resonance imaging, a non-X-ray study similar to a CAT scan) every two to three years to evaluate their implants (for leakage or rupture). Studies have shown that MRI evaluation of silicone implants has 79% effectiveness in detecting implant rupture or “leak.” Thus, if you have no identifiable problem or concern with your implants and choose to follow this recommendation, you will require an unnecessary reoperation (for entirely normal non-ruptured) implants 21% of the time! The FDA makes this recommendation because physician examination has been shown to be unreliable in detecting silicone implant rupture. Yet, since present silicone implants are cohesive and cannot “leak,” this is a nonsensical recommendation, in my opinion. If you are not having any kind of problem or concern with your implants, it is ridiculous to perform a costly (may not be covered by your insurance) and often-inaccurate test that would require an operation (erroneously) over 20% of the time. Rather, I believe that if you have any issue at all with your implants (size, shape, position, firmness, or concern about possible rupture), return to our office for evaluation. I can then do whatever corrective surgery is needed, where I will be able to examine, and replace if necessary, the implants under direct vision. I can offer better than 79% accuracy with direct implant examination!
Implants and Breast Cancer; Mammography
Numerous scientific studies have shown that augmentation mammoplasty does not increase the risk of developing breast cancer. Even without a family history of breast cancer, a woman has an 11% risk of developing a breast cancer in her lifetime. If there is a family history of breast cancer, these risks are higher. It is important to realize that while breast enlargement does not increase the risk of developing breast cancer, it also does not reduce the risk, so every woman must continue breast self-examination, physician examination, and mammography, regardless of whether or not she has breast implants. If you have any concern whatsoever regarding your breasts, I would be happy to perform breast examination and answer any questions; there is never a charge for consultation or recheck for any reason.
In early 2011, the FDA requested that health care professionals report confirmed cases of anaplastic large cell lymphoma (ALCL) in women who have breast implants. This FDA request was part of an investigation of a possible association between breast implants (saline and silicone) and ALCL. The FDA reported that the scientific literature from January 1997 through May 2010 showed 34 unique cases of anaplastic large cell lymphoma (ALCL) in up to an estimated 10 million women with saline and silicone breast implants. This equates to 1 case per 294,118 women (over 13.3 years), or 0.00033%. These cases were most common in patients undergoing revision for late onset, persistent seroma for which treatment may consist of implant and adjacent capsule removal.
ALCL is lymphoma, NOT breast cancer, and some researchers have suggested that breast implant-associated ALCL may represent a new clinical entity with less aggressive behavior (Li, 2010; Miranda et al, 2009; Thompson et al, 2010). Because of the extremely small number of cases and short median duration of follow-up, the FDA states that it is premature to draw conclusions regarding prognosis of ALCL in women with breast implants.
The FDA also states that because the risk of ALCL appears very small, the totality of evidence continues to support a reasonable assurance that FDA-approved breast implants are safe and effective when used as labeled. The FDA further states that "There is no need for women with breast implants to change their routine medical care and follow-up."
Mammography can still be done successfully in women who have undergone breast enlargement surgery. Most radiologists feel that they can adequately view 99% of a woman's breast tissue even with implants in place, though special techniques and additional views may be necessary to accomplish this.
Although there is a slight chance that mammography might cause leak or rupture of a saline breast implant, this is less likely with a soft, non-contracted breast, with smooth implants, and with submuscular placement. (The present generation of silicone implants is cohesive and cannot leak.) Improperly-performed mammograms can forcibly compress and rupture the scar capsule around any kind of breast implant, so it is important to let the radiologist and technician know that you have breast implants. A radiographic method called the Ecklund technique (also known as the displacement technique) compresses the breast tissue in front of the implant, and not only increases the visibility of breast tissue in the mammogram, but also reduces pressure on the implant. We do recommend a baseline mammogram one year after augmentation, so that any scar tissue or calcium deposits within the breast are documented and available for comparison with any subsequent mammogram.
Timing of Surgery
Many women wonder if they should wait until their family is complete before undergoing breast augmentation. Certainly, pregnancy and breast-feeding change the breast skin, shape, and size; these are common reasons many women choose to have this surgery. Should a woman who has never had a child (and plans to in the future), or a woman who wishes to have more children later, undergo augmentation mammoplasty?
Since breast implants are in most cases placed beneath the chest (pectoralis major) muscle, and in all cases beneath the breast itself, the presence of implants does not interfere with the function of the breasts. Whatever breast tissue a woman has prior to breast enlargement surgery will swell and respond to the normal hormonal changes of pregnancy and later breast-feeding. The degree of enlargement, skin stretch, and later droop or sagging is as individual as each woman. A patient who had breast augmentation prior to pregnancy may choose to undergo a breast lift when her family is complete, just as the woman without breast implants. Others may simply choose a slightly larger implant to further fill the stretched skin brassiere. Or, you can indeed wait until your family is complete, and then undergo augmentation to obtain desired breast size, or augmentation plus mastopexy if a lift is needed in addition to restoring volume.
What you need to know is that it is safe and appropriate to choose either way, whichever is best for you.
Breast augmentation does not generally affect the ability to breast feed. One study shows that about 54% of women without implants reported problems nursing. 93% of breast augmentation patients had their children before undergoing the procedure, so nursing was not an issue. Of the 7% who had children and nursed them after augmentation, 50% reported problems, essentially the same number as those without implants.
Some surgeons have postulated that if a periareolar (around the dark part of the nipple) incision is chosen, a smaller percentage of women will preserve the ability to breast feed. If you have never breast-fed and undergo augmentation (regardless of incision chosen), you will, in the majority of cases, retain whatever breastfeeding capability you had prior to surgery. Most women who have breast-fed prior to undergoing breast augmentation have successfully been able to nurse again after augmentation mammoplasty. However, as noted in the study above, many women are not capable of breast-feeding (irrespective of breast size), and these patients will still be unable to nurse a baby after augmentation mammoplasty, regardless of incision placement.
If you have fibrocystic mastitis (this is not a "disease" since about half of all women have fibrocystic changes in their breasts) you may note tenderness or swelling in your breasts prior to your menstrual cycle. Augmentation mammoplasty does not change this for the better or worse in most cases, but it is advantageous for all breast augmentation patients to consider a surgery date that is a week after your period rather than just before, in order to reduce pain, swelling, or bleeding tendency with your surgery.
Choice of Incision
There are four types of incisions used for augmentation mammoplasty: axillary (armpit), periareolar (around the areola – the dark skin surrounding the nipple), umbilical (belly button), and inframammary (in the skin crease under the breasts). Each of these choices has pros and cons; some surgeons use some or all of these options, whereas others have a preference based on training, experience, or habit.
The armpit (axillary) incision is often thought to create a "hidden" scar because the scar is not visible on the breast itself. However, the armpit scar can be visible when the arm is raised while the patient is wearing a swimsuit, sleeveless top, or strap-type blouse, and this scar may be wider or more visible than other areas because of its presence in a warm, wet, bacteria-rich environment which is constantly being stretched with every arm movement.
In addition, dissection from the armpit incision requires that the arm be elevated during surgery, raising the position of the breast and potentially causing malposition of the implant with relation to the crease. A higher proportion of high nipple, "bottoming-out" augmentations are caused by improper pocket creation that results from this incision raising the breast during surgery.
One final consideration with the axillary incision is that dissection from this vantage point is somewhat more likely to cause nipple sensation loss, since the (lateral fourth intercostal) nerve to the nipple runs along this dissection route on the side of the chest wall.
- The periareolar incision is generally made from the three o'clock to nine o'clock position at the junction between the normal breast skin and the darker adjacent areolar skin. Usually, this scar can be minimally visible when healed; however, this scar is visible when unclothed and can occasionally be unsightly, wide, thick, or irregular and it can produce a sharply visible line in an area where the areola color normally undergoes a gradual transition from dark to light. In addition, this incision requires cutting through ducts that end at the nipple, as well as the breast tissue itself, in order to create the implant pocket. This can cause internal breast scarring and/or calcification, which can make mammograms more difficult to read. Since the nerve branches to the nipple area are partially cut by this incision, a somewhat higher likelihood of nipple-areola numbness is present. Ductal bacteria may also increase the possibility of capsular contracture, so cutting through breast ducts is inadvisable, in my opinion.
- Some surgeons may advocate the use of a periareolar incision along the top edge of the areola, excising a small crescent of skin above the nipple/areola complex in order to achieve a “crescent lift” for small degrees of breast droop or lower- positioned nipples. The amount of “lift” with this procedure is minimal to none, and because of this, I believe this should be considered a “scam” (in some cases) designed to charge higher “mini-lift” prices for what is a standard augmentation incision choice if a surgeon utilizes this approach anyway. If the cost is identical to augmentation alone, then in rare cases, this may be a reasonable recommendation.
- The umbilical incision involves use of an endoscope (a lighted tube commonly used to perform tubal ligations, appendectomies, gallbladder removals, and visual evaluations of the stomach or colon) to create a pocket beneath the breast or chest muscle for the implant. Only saline implants can be placed with this incision. The implant pocket is created by blunt dissection with a temporary tissue expander or the implant itself. Bleeding or inframammary crease malposition can require an additional incision on the breast, which negates the main advantage of using the umbilical approach (no visible breast scar). Very few plastic surgeons utilize this incision for breast augmentation, and the learning curve is difficult, but acceptable results have been produced by reputable, board-certified plastic surgeons, so consideration of all options is reasonable. Silicone gel breast implants cannot be placed via this incision.
- The inframammary incision (beneath the breast in the crease) is the most common incision used for breast enlargement with implants. I believe this incision provides the best exposure for creating an implant pocket with the least amount of bleeding (and the highest likelihood of controlling this bleeding should it occur), avoids the course of the nerve to the nipple in most cases, does not cut through breast tissue and/or ducts (avoiding the mammographic concerns), and leaves a short scar that is not visible clothed or unclothed unless one lifts the breast or looks from beneath. When the patient is reclining, the breast falls to the side and up, and the crease (inframammary) scar can be visible; in most cases it is nearly imperceptible. I use dissolving stitches beneath the skin surface—no cross-hatch or railroad-type marks, no sutures to be removed, and just a thin-line scar hidden in the natural inframammary crease.
Skin and Nipple Sensation after Surgery
Regardless of incision choice, creation of the surgical pocket for the implant will unavoidably cut some of the tiny sensory nerves to the breast skin, and skin sensation will be diminished or absent in the areas these nerves supply. Over time, sensation will generally recover as nerves heal, but may not return to 100% of preoperative sensation. Note that this has nothing to do with nipple erectility (response to cold or stimulation), as different nerves are responsible for this response.
In a few cases, depending on your own particular anatomy, the nerve or nerve branches to the nipple-areola region may also be cut during the surgical pocket creation, and you will permanently lose sensation to the nipple-areola complex on that side. About 5-10% of women will lose nipple-areola sensation with augmentation alone, and about 15% will lose nipple-areola sensation if a breast lift is necessary. Again, incision choice can affect these statistics: a higher number of women may lose nipple sensation with a periareolar or axillary (armpit) incision.
Getting Ready for Surgery
You will need to see your own primary care physician for a preoperative physical within 10 days prior to your scheduled breast augmentation surgery at our AAAASF-accredited surgical facility, just as you would at a hospital. This is necessary to ensure you are in good medical condition for an anesthetic and operation. All surgeries and types of anesthesia have some risk; every effort is made to reduce risk wherever possible, particularly since this is elective surgery that you, the patient, request to be performed for you. A preoperative physical is an essential part of this process, just as a pilot's checklist is before takeoff.
Besides being in good health prior to surgery, you must avoid aspirin-containing products (Bayer™, Excedrin™, Anacin™, Bufferin™, Ecotrin™, and many multi-symptom medications--anything with acetylsalicylic acid [ASA, or aspirin]), ibuprofen-containing products (Advil™, Nuprin™, Mediprin™, Motrin™, and similar multi-symptom medicines containing ibuprofen), Aleve™ (naprosyn), or high-dose vitamin E (this interferes with vitamin K absorption, which is necessary for proper blood clotting). The dose of vitamin E in a daily multivitamin (usually 400 units) is not a problem, and a multivitamin in the weeks before surgery is a good idea. Except for the daily vitamin, all of the above medications should be avoided two weeks before and after surgery, since even one dose can interfere with proper clotting. Even a single baby aspirin or ibuprofen tablet can increase the risk of bleeding, capsular contracture, and reoperation.
You must also discontinue all herbal preparations you may be taking, as many of these remedies contain blood-thinning agents that can cause bleeding and require reoperation. Even over-the-counter appetite suppressants or “natural” diuretics can cause increased risk for anesthesia, and must be stopped a full two weeks before surgery.
If you have the Factor V Leiden gene, or other genetic bleeding/clotting disorders, you may need additional consultation with a Hematologist to minimize bleeding or clotting with this elective surgery. Oral contraceptive use, particularly in smokers, increases the potential for developing blood clots with any surgical procedure. Staying well-hydrated and flexing the calf muscles regularly (walking does this also) will help reduce the risk of blood clots.
Continued in part 2