Dr. Tholen's Comprehensive Guide to Breast Augmentation (Part 2 of 2)

Richard H. Tholen, MD, FACS
Article by
Minneapolis Plastic Surgeon
Part 2 of 2
Tobacco use of any kind should be stopped completely two weeks before surgery to prevent post-operative coughing that can raise your blood pressure and increase the risk of bleeding or capsule formation, which can cause hard or painful breasts and require reoperation.  If you are having a breast lift, the incisions needed to shape and lift the breasts may cause reduced circulation and difficulty healing; smoking even one cigarette, using nicotine gum, or exposure to second-hand smoke may cause areas of the breast skin or areola to die because of lack of circulation.  Prolonged dressing changes, skin grafts, or additional surgery may be necessary if you continue even minimal tobacco or nicotine use or exposure.

On the day of surgery, wear loose-fitting clothes, preferably something with front zipper so that it can be put on and taken off without raising one's arms.  You must bring a driver as you should not drive a car for the first two days after surgery or while on pain medications.  Someone must also be with you the night of surgery, but this person does not need to be a nurse, just someone who can help with medications, ice bags, assist you to the bathroom, or answer the phone.
Anesthesia and the Operation
Minneapolis Plastic Surgery has employed the same certified registered nurse anesthesia (CRNA) provider group for the past 20 years.  Our team of CRNAs are the best of the best, and use state-of-the-art techniques and the most effective (not the least expensive) anesthetic medicines for your surgery, as well as  complete continuous monitoring of blood pressure, EKG, pulse, temperature, oxygen in your bloodstream, exhaled CO2, and fluids during surgery and your recovery.  Our CRNAs, recovery room RNs, and plastic surgeons are all ACLS-certified (advanced cardiac life support) as part of our surgery center accreditation process.

You are fully monitored during surgery, and most patients prefer a general anesthetic so they are completely unaware of any discomfort during surgery.  Anesthesia choices range from local anesthesia with sedation (“twilight anesthesia”) to general anesthesia; your surgeon and anesthesia provider will determine your exact anesthesia after discussion with you.

Since we utilize total intravenous anesthesia (TIVA) rather than inhalation anesthetics (gas and nitrous oxide) for virtually all cases, our post-operative nausea and vomiting (PONV) rate is significantly lower than the hospital and/or surgicenter rate of 7-28%.  We have tracked our own patients after surgery for the past decade, and our present PONV rate is between 1.5 and 3.5% (for all our surgeries, including complex and longer operations).  When you feel better, you do better, bruise less, have fewer bleeding concerns, less capsular contracture, and a much more comfortable experience—not to mention a softer and more natural breast augmentation result.

Saline implants arrive from the factory empty, allowing them to be “rolled up” and inserted into the breast pocket through a small(er) incision. They are then filled from a sterile IV bag so there is no exposure to the air, skin, or any source of bacteria. Proper implant filling is critical. As stated earlier, textured saline breast implants have been shown to have a somewhat higher leak or rupture rate than smooth saline implants. However, even smooth saline implants can leak or deflate, particularly if they are underfilled.  Underfilled saline breast implants can develop wrinkles or creases that flex and bend with each movement or breath, and eventually a tiny pinhole can develop, causing leakage or deflation. Proper saline implant fill volumes have been shown to be higher than the label on the manufacturer's box; a 300cc implant filled to 300cc has a higher likelihood of leakage than a 300cc implant filled to 330cc, which is closer to the optimal fill volume. Several studies have confirmed the validity of proper “over”-filling; each type of saline implant has its own optimal overfill volume which your plastic surgeon will then adjust according to your own anatomy and needs. Nationwide five-year leak rates have ranged from 6.8-9.7 percent; our own saline implant leak rates are substantially lower at two to three percent. If leakage or deflation occurs, a simple operation to open the incision, remove the deflated saline implant, and place a new one can be performed without the discomfort or recovery of your initial operation. The cost of the new implant is covered by the manufacturer.

Of course, if you choose silicone gel implants, there is no intra-operative filling, as the implants come completely filled, sealed, and in many different size gradations directly from the manufacturer. Even if the outer shell of the implant were to be damaged or opened, the silicone gel within the implant is cohesive and non-liquid in nature and cannot “leak” out.

Your surgical pocket will be created larger than the implant on each side, allowing some movement of the implants beneath the breast and muscle, so that when reclining the breasts will flatten, move upward and to the sides, and remain soft like natural breasts.  When the pocket is created exactly the same size as the implant, the surrounding scar will contract as it heals and matures, giving an unnaturally firm, round, high and tight appearance (the "coconut on the chest" look).  Capsular contracture around an implant can also cause a crease in the implant shell, which with repeated movement such as breathing, increases risk of eventual breakdown at the crease point and implant deflation (with saline implants).  Implant movement or displacement exercises (often erroneously called "massage") are recommended to keep your implant pocket open and larger than the implant itself, which can aid in reducing the incidence of capsular contracture, and maintain a soft, natural look.  Other surgeons prefer a tight bra or elastic bandage after breast enlargement surgery, likely to compress the breast area and surgical pocket in an effort to reduce bleeding, bruising, and resultant capsular contracture from this cause.  I believe careful surgery is preferable to a tight bra, bandage, and certainly a drainage tube!

The other side of the coin is excessive softness, thinness, or laxity of the overlying tissue, allowing saline implants to have wrinkles or ripples that can be felt, and sometimes seen.  Optimal fill (as discussed previously) and placement below the muscle can help to reduce, but will not always completely eliminate, this concern with saline implants.  If bothersome rippling does occur, I can discuss the options available to improve or correct this problem; switching to silicone gel implants solves this issue (or improves it significantly) in most patients.  Avoidance (or significantly reduced risk) of rippling that can be seen or felt can generally be achieved by the use of silicone gel implants in the first place.

I see each of my patients prior to surgery for preoperative measurements and markings.  Your preoperative photographs should have been taken during your consultation, or when you arrive for surgery, but before marking. You will meet with your anesthetist, and an intravenous (IV) line will be started.  A family member may be with you until you are taken into the operating room.   Breast augmentation surgery takes about an hour; recovery takes another hour or so.  A breast lift involves more incisions and surgical closure, and will require correspondingly longer operating time and cost.

Prescriptions will be provided to your chosen pharmacy prior to surgery, so you can pick up these required medications before surgery. This is particularly important if you use an out-of town pharmacy and are staying in Minneapolis the night after surgery. Written instructions and information about your prescriptions will be reviewed with your family member or responsible adult who will drive you home and stay with you the night of surgery.  A nurse from our office will call you the night of surgery to check on you and answer questions.  You may call the office at any time (763-545-0443) and speak to our staff or one of the plastic surgeons on call if there are any concerns.
How to Avoid Capsular Contracture
Breast implants do not become hard, ever.

When a breast enlargement patient has abnormally hard breasts, the problem is the scar capsule around the implants—for one reason or another, the capsule has thickened and contracted, squeezing the implant into a smaller space and causing the hard “feel” to develop. The human body creates a scar around any kind of foreign body, whether it is a pacemaker, a breast implant, or an artificial hip. Since every person forms scar tissue around any foreign body, every woman undergoing breast augmentation will have a capsule, but fortunately, only a few will develop capsular contracture to a problematic degree. If the scar capsule is thin, soft, and pliable around a breast implant, the augmented breast will feel soft. Since all scar tissue contracts, an excessively thick, nonpliable, and contracted scar capsule around a breast implant can make an augmented breast feel hard. Capsular contracture can be mild (Baker grade 2), moderate (Baker grade 3), or severe and visibly deforming (Baker grade 4).

Many studies have been conducted over the years regarding capsular contracture, and how to control or minimize the likelihood that it will occur. With a surface skin cut or surgical incision, despite any surgeon's skill, best efforts, and technique, a few patients will heal with a thick, wide, or ugly scar. This occurs rarely, and is slightly more common in patients with darker skin. Vitamin E massage, scar pads, steroid tape or injections, or even scar revision plus any or all of the above can be used to reduce visible surface scars.

Radiation treatments have even been used for the most severe surface scars, known as keloids. Fortunately, these are uncommon. Similarly, internal scar contracture causing firmness or distortion of appearance is also uncommon, occurring in 5-10% of augmentation mammoplasty patients. If this occurs, surgical revision may be necessary, and contracture may in some cases recur despite careful re-operation.

Avoidance of most cases of capsular contracture is possible, in my opinion, by careful initial surgery and patient compliance with postoperative instructions. Any foreign body, such as talcum powder from the surgeon's gloves, cotton fibers from surgical sponges, dust or bacteria from the air of the operating room on the surface of the implant, and bacteria from the ducts of the breast, as well as postoperative bleeding or bruising, can cause an increase in scar formation. This is analogous to a grain of sand in an oyster; in humans, a pearl is not formed, just layers of scar tissue, in response to one or several of these irritants.

Every effort is taken to reduce these to an absolute minimum in order to minimize the likelihood of capsular contracture. I recently switched from a minimal-touch technique to an absolutely no-touch technique (facilitated by the Keller funnel) to place implants without ever touching them with my (gloved) hands, and without the implants ever touching the skin as they are inserted.  Prior to implant placement, there is very precise creation of the surgical pocket without blunt dissection, as well as pinpoint cautery control of capillary bleeding, antiseptic irrigation, and avoidance of sponges in the pocket.

I do not use drains for breast augmentation. Drains may allow blood or fluid out of the pocket, but of greater concern is that they can allow bacteria in, increasing the risk of contracture or infection severe enough to require implant removal. Even “normal” skin or breast duct bacteria can cause a biofilm on the surface of breast implants leading to capsular contracture, and bleeding can provide the “culture broth” for these bacteria! Meticulous surgical technique and control of all bleeding points is preferable to a drain, tight surgical bra, or elastic wrap after surgery! Intravenous antibiotics are used prior to surgery, and oral antibiotics are continued for several days post-operatively. 

Long-acting local anesthetic (Marcaine with epinephrine) is place in each implant pocket to provide immediate pain control that lasts for hours after surgery, and the epinephrine provides additional hemostasis by causing local vasoconstriction. You will also receive Exparel (extended-release Bupivicaine local anesthesia) as a 3-day comfort enhancer. This has been shown in our patients to reduce pain, narcotic use, nausea, vomiting (from narcotic), and improve recovery. Sure, you might feel like going out and dancing, but this is not recommended for optimal healing, it's just a marketing ply by other surgeons!

I recommend that all patients with implants take a dose of antibiotic the night before and two hours before dental work, including cleaning, to reduce the likelihood that bacteria from the mouth enter the bloodstream and sometimes cause capsular contracture.  This recommendation is similar to patients with heart murmurs, artificial heart valves, or other types of implants, who also take antibiotic prophylaxis when visiting the dentist.  We will be happy to prescribe these antibiotics—just call prior to your dental visit.  Some dentists and many plastic surgeons may tell you that antibiotics are not needed prior to dental work or cleanings, but experienced breast surgeons who do significant numbers of these operations and follow their patients for many years can attest to this being a wise precaution. (Also, if you do develop capsular contracture after dental work, I suspect you won’t be asking your dentist to do the corrective breast surgery!)

Recently, a new type of medication (in use since 1999 for the treatment of asthma) known as a leukotriene inhibitor has been shown to be helpful in possible prevention, reduction of severity, or even reversal of capsular contracture.  Though preliminary, the use of this medication (zafirlukast, trade name Accolate™, or a similar drug Singulair™) may be an alternative to re-operation for removal of capsular scar tissue, or may lessen the likelihood of capsular contracture recurring after surgery.  If you have liver disease, this may not be a choice for you, as this medication can have hepatic side effects in a small number of patients.
Recovery and Results
After an hour or so in the recovery room, you will be discharged to the care of another adult who needs to stay with you for the evening. You will need someone to bring you to your first postoperative recheck, since you should not drive a car for the first two days after breast enlargement surgery, or while taking pain medication. Virtually every patient can resume normal everyday activities within 24 hours after surgery, including showering, doing one’s hair or applying cosmetics, dressing, eating normal meals, and moving about the house. You should avoid stretching or repetitive activities that might raise your pulse or blood pressure, which can increase the risk of bleeding and re-operation.  Our superior anesthesia protocols, as well as careful, minimal-trauma surgery may allow most patients to feel well enough to go out for pizza on the way home from surgery, or to go to a party the next day.  But really, this makes no sense, since every patient having an operation must heal tissues and seal blood vessels.  The less strenuous activity you engage in, the less likelihood of bleeding, bruising, discomfort, capsular contracture, or re-operation.  Taking things easy, even if you feel great, is an investment in your final cosmetic result!

You should avoid exercising, lifting, or strenuous activity for a full two weeks following surgery, to limit the possibility of bleeding.  If you have bleeding, re-operation is necessary to remove the blood, cauterize or suture the source, and re-suture the incision.  Most patients prefer to reduce activities rather than risk re-operation and the higher rate of capsular contracture that may result if this occurs.  You should avoid anything that might increase your blood pressure or cause your pulse to elevate.  This generally means no exercise or other strenuous activity for the first two weeks.  Jogging, horseback riding, weightlifting (bench press, military press, curls, etc.), yoga, or any activities that bounce the breasts or stretch the chest muscles should be avoided for a full month.

 Some breast augmentation surgeons or websites state or imply that they utilize special techniques to minimize postoperative pain, swelling, or restriction of activities.  One website even emphasizes the implied “superiority” of their procedure by showing a photograph of a breast enlargement patient out dancing with her arms above her head shortly after surgery, or by showing testimonials by patients who go out to dinner the night after surgery. We also employ all of these “special” techniques, and in fact 98 percent of Minneapolis Plastic Surgery’s breast enhancement patients have NO nausea, NO vomiting, NO anesthetic hangover, and are able to eat normal food and be up and about the night after surgery. Do we encourage dancing and dining the night after surgery? Of course not; there still are the two percent of patients who will have some degree of nausea or more discomfort, and do best by minimizing the potential for raising the blood pressure that accompanies vomiting, and the risk of re-operation or capsular contracture that goes with elevating the blood pressure or pulse. Most of our breast enhancement patients are thrilled by their lack of post-operative pain, bruising, or swelling, not to mention the avoidance of nausea and vomiting our superior anesthesia techniques permit! But we want ALL of our patients to have a great result, so we recommend moderation in activities that might adversely impact your result (and our reputation).

Although limitation of strenuous activity requirements are simple, straightforward, and in your best interest, a few patients each year feel they can bypass this rule, think they are doing so well that this doesn't apply to them, or decide that they "got away with (an inappropriate activity) once, so it must be OK," and end up in the operating room again.  This is usually avoidable, but bleeding can still occur despite everyone's (patient and surgeon) best effort.  If this is the case, timely reoperation can remove the blood (usually only a few ounces), control the bleeding source, and avoid or limit any untoward effect on the final result.  If you have significant swelling on one or both sides postoperatively, notify your surgeon.

Infection is extremely rare in this operation; in fact, since 1985 when I began performing this surgery, I have not (yet) had an infection requiring implant removal.  It can occur, however, and you must take the prescribed antibiotics until gone to reduce this risk as much as humanly possible.  If an implant becomes infected, it must be removed (usually with the other implant, infected or not) and will need to be left out for several weeks to as long as a year, to allow all bacteria to be destroyed by antibiotic therapy and your own antibodies, as well as to allow scar tissue to soften enough to permit replacement of the implants. 

You can also reduce the risk of infection by showering rather than bathing, and you should absolutely stay out of the lake, Jacuzzi, pool, hot tub, or sauna for three weeks after surgery.  Close contact with animals or household pets (especially cats) should be limited as well during this time.  Taking your antibiotics as prescribed does not eliminate the need to follow these recommendations!

You will also receive prescriptions for muscle relaxants, antibiotics, and anti-inflammatory medications before you leave our Clinic (these are now e-prescribed and can be picked up prior to surgery so you don’t have to stop on the way home after surgery! Narcotic prescriptions must be hand-signed and cannot be e-scribed in advance, called-in, or refilled by phone--new FDA rules.) Take your medications as advised to reduce nausea, vomiting, and the resultant increase of blood pressure that might start bleeding. Your breasts will not have drains (they are not necessary with our minimal-trauma surgical technique and careful control of bleeding points), but you will have a long-acting local anesthetic placed in your implant pocket to minimize immediate post-operative discomfort, as well as the extended-release local anesthetic Exparel noted previously. This multi-pronged approach is why the vast majority of our breast enlargement patients do so well.

Keep fluid intake up and walk, move around, and flex your calf muscles to reduce the risk of blood clots.  This is important to reduce the risk of heart attack, stroke, pulmonary embolism or sudden death.  Do not take aspirin, ibuprofen, Aleve™, etc. during the two weeks after surgery.  Resume other medications as advised by your doctor.  Return to work based on the activity levels required at your job, and resume exercise or strenuous activity gradually, no sooner than the two weeks discussed above.  Jogging, horseback riding, weightlifting, vigorous sexual activity, or similar strenuous exertion should be avoided for four weeks to decrease the risk of bleeding, reoperation, and/or capsular contracture

Your bleeding risk is actually highest 10 to 27 days AFTER surgery, as pain and soreness resolve, and activities naturally increase. 
I have really had a patient bleed 27 days after surgery; please realize that this patient thought she was doing fine and following instructions. Healing tissues are not durable and supple enough for vigorous stretching or strenuous muscular contraction until one month from surgery, and then only if started gradually.  This information is meant to help you avoid reoperation for bleeding!

Following these recommendations will make the likelihood of a successful outcome as high as possible, and the risk of complications low.Your final appearance will take some time to be achieved, as your muscle, breast tissue, and skin must heal, stretch, soften, and settle over time. Some patients look fabulous days after surgery; most take somewhat longer! Most patients are sent home with a Velcro bandeau placed on the upper part of the breasts. This will be worn at night, and in most cases, patients will be asked to remain braless during the day. This will allow your breast implants to drop into the proper position over time. The amount of time necessary is different for each patient. Do not judge your recovery by the yardstick of a friend's or relative's experience; every patient is unique, and every recovery and result is also unique. I will guide you as time goes by and advise you on how to enhance your result. I offer our patients a lifetime of no-charge rechecks and will keep you apprised of the best advice I am capable of giving.

Most patients look good in clothing within days after surgery; unclothed, a soft, natural appearance will take longer to develop. Final softening, settling, and the return of sensation can take several months to as long as a year or so. During this time, or at least as long as your scars are pink, you must avoid tanning booths or any source of ultraviolet exposure in order to reduce the chance of permanently darkening the scars. Vitamin E oil or ointment massage of the scars after three week's time can help to soften and fade them; you should not begin this prior to three weeks after surgery in order to avoid the risk of prematurely softening and stretching the scars. If you have a tendency to form thick or heavy scars, I can instruct you in the use of scar pads or other scar-treatment remedies as other ways of helping to reduce this concern.

All in all, breast enlargement is a straightforward procedure with a very high satisfaction rate. This information and these recommendations are not intended to be complete or all-inclusive. Postoperative rechecks are important and are designed to monitor your progress, make appropriate recommendations, and address any specific concerns or questions. Following the guidelines above will help you to achieve the best result that I am capable of obtaining for you.
copyright 12-2014  Richard H. Tholen, MD, FACS