Dr. Tholen's Comprehensive Guide to Breast Augmentation: Part 2


Go to Articles for Part 1 of Dr. Tholen's Guide to Breast Augmentation. This begins Part 2:

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. Since submuscular placement reduces the risk for capsular contracture, this position also makes mammography and breast examination easier and more accurate. (Soft, natural breasts are a cosmetic “plus!”)

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. Digital mammography has now enabled radiologists to better visualize the augmented breast, while also reducing the need for additional views or displacement mammograms. I 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?   

If your breast development is complete and you have had breast enlargement surgery, and then later become pregnant and breast-feed, your breasts will indeed change in appearance, just as in a woman who has larger breasts naturally, becomes pregnant, and nurses her baby.  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. This is because as many as half of the ducts to the nipple (and some branches of the sensory nerve to the nipple area) are severed by this incision.  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 breast augmentation surgery, 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. This, in turn, can reduce the risks of re-operation for bleeding or developing capsular contracture in certain patients.

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. Contamination of the implant with sweat gland bacteria may increase the risk of capsular contracture. 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.

Since silicone gel implants are pre-filled at the factory, implants larger than about 400cc are not able to be inserted via this incision. Saline implants of a larger size can be inserted and filled once in place, but may still have rippling issues that gel implants do not.

Re-operation (for bleeding, malposition, capsular contracture, or other reason) will often require an inframammary incision, resulting in 4 scars, not 2, and eliminating the “advantage” of the no-scar-on-the-breast axillary choice.

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) sensory 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 lower edge of the darker areolar skin where it meets the lighter normal breast 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 most cases) designed to charge higher “mini-lift” prices for what is a standard augmentation incision choice if a surgeon utilizes this incisional approach anyway. If the cost is identical to augmentation alone, then in rare cases, this may be a reasonable recommendation, but only if the “lift” desired is minimal to none.

  • 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.  With a belly button incision, no scars are placed on the breasts or armpits, but 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 accurate-sized implant pockets 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 (minimizing the bacterial, mammographic, breast-feeding, and sensation concerns), is associated with the least likelihood for development of capsular contracture, 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 only 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 or slightly above the natural inframammary crease. I also place the scar medially beneath the full part of the breast (rather than laterally where I see many other surgeon place their scars), as it is less visible here, as well as providing optimal access to all areas of the submuscular pocket for careful control of bleeding and accurate pocket creation.

Skin and Nipple Sensation after Breast Augmentation 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 14 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 and every effort is made to reduce risk wherever possible.  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.

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 reconstructive surgery may be necessary if you continue even minimal tobacco or nicotine use or exposure. E-cigarettes that provide nicotine are not allowed.

On the day of your breast enlargement 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 non-smoking driver as you should not drive a car for the first two days after anesthesia 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 since 1991.  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.  Every patient has sequential compression stockings to “pump” the lower extremity blood during surgery, reducing the risk of blood clots. 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 light general anesthetic so they are completely unaware of any discomfort during surgery.  Anesthesia choices range from local anesthesia with sedation to general anesthesia; your surgeon and anesthesia provider will determine your exact anesthesia after discussion with you. Surgeons who offer only local anesthesia plus oral or intravenous sedation may not have the full capability and accreditation to offer complete anesthesia services as MPS does. In some of these cases, “twilight anesthesia” is often touted as “safer” and less invasive than “general” anesthesia. Again, this may be “code” for non-ABPS-certified “cosmetic” surgeons operating in a non-accredited facility with limited anesthesia capabilities. Beware!

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 2.5 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. We take great pride in helping make breast implant surgery as comfortable and beneficial as possible for our patients, who come not only from Minneapolis and St. Paul, but from throughout Minnesota and the entire country. We have the capability to use “twilight anesthesia” as well, but these patients may experience pain, awareness, and more PONV than our completely-comfortable (asleep) TIVA patients undergoing the same procedure!

The Operation

I see each of my patients prior to surgery for preoperative measurements and markings.  I review your goals, sizing, and answer any final questions. Your preoperative photographs should have been taken during your consultation, or when you arrive for surgery, but before marking. You will meet with your CRNA anesthesia provider, and an intravenous (IV) line will be started.  Oral muscle relaxants and anti-inflammatory medications are given to you in the pre-op area so your tissues will have adequate levels of these medications prior to surgery. A family member may be with you until you are taken into the operating room.   Breast augmentation surgery takes about an hour; recovery room adds another hour or so.  A breast lift involves more incisions and surgical closure, and will require correspondingly longer operating time and cost.

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 340cc, 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 around 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 intraoperative 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 "Baywatch coconut" look).  Capsular contracture around an implant can also cause creases or folds 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 exercises (“massage”) are recommended to keep your implant pocket open and larger than the implant itself, which can aid in reducing the visibility of mild 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! Prior to your breast enlargement surgery, our staff will help you understand all the steps that will be taken after your procedure.

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 and submuscular placement in the first place.

In addition to the oral anti-inflammatory and muscle relaxants received prior to surgery and continued post-operatively, we use intravenous steroid (to help reduce swelling and stabilize cell membranes after surgery, as well as long-acting local anesthetic (Marcaine with epinephrine) in each breast pocket to numb nerve endings for hours after surgery, as well as Exparel (3-day extended-release local anesthetic Bupivacaine) to reduce post-op discomfort levels. We have found that pre- and post-op use of oral anti-inflammatory Celebrex and intra-operative use of Exparel has reduced our patients’ narcotic needs by about half, with a concomitant reduction in post-operative nausea or vomiting. Though some surgeons recommend ibuprofen (Advil) for surgical patients, I do not. Antiplatelet activity that Advil or Aleve have can cause a higher risk of bleeding. Tylenol or your prescribed narcotic do not have these concerns.

Prescriptions will be e-scribed 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. Your pain medication prescription cannot be e-scribed or called-in via phone due to new restrictions on narcotics. Your care-giver will be given a hand-signed prescription in the pre-op area so this can be filled prior to your pick-up from the recovery room. Written instructions and information about your medications will be reviewed with your family member or care-giver 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 me, our staff, or the plastic surgeon 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 hypertrophic or keloid scar. This genetic tendency 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 or armpit sweat glands, as well as postoperative bleeding or bruising, can cause an increase in implant biofilm and 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.

Several years ago, I 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, use of the Keller funnel, and control of all bleeding points is preferable to a drain, tight surgical bra, or elastic bandage after surgery! Intravenous antibiotics are used prior to surgery, and oral antibiotics are continued for several days postoperatively. Antibiotics cannot “sterilize” a contaminated implant, treat an established capsular contracture, and do not prevent all infections.

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 early or mild 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 a family member or responsible adult who needs to stay with you for the evening (not just “drop you off”). 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 dancing 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 resuture 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 to 6 weeks, depending on intensity.

 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 of patients who go out to dinner the night after surgery.

We also employ all of these “special” techniques, and in fact 97-98 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-three 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), not to mention the costs of re-operation.

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, pain medication, and anti-inflammatory before you leave our Clinic (these are now e-prescribed—except for the narcotic pain medication—and should be picked up prior to surgery so you don’t have to stop on the way home after surgery!) 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. 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 first three 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 (more than one) patient bleed 27 days after surgery; please realize that these patients thought they were 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! (And those “quick-recovery” “brand-name” operations don’t have any magical stop-bleeding tricks either—in fact, implying activity is OK or encouraged only increases these doctors’ re-operation rates for evacuation of hematomas.) Ask who pays for that?  Or, if taken to the hospital for re-operation, you can wait for the bill. There is a minimum charge of $1000 for re-operation in our facility in the event that one of our patients develops post-operative bleeding.

Following these recommendations will make the likelihood of a successful outcome as high as possible, and the risk of complications low. After your breast enlargement surgery, your final appearance will take some time to be achieved. During this time 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, as well as an antibiotic ointment barrier for bacteria on your nipples, covered with a Band-Aid. The Band-Aids are left in place for a week, but the Velcro bandeau will be worn only at night. 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 (weeks to months). Wearing the bandeau longer or tighter will NOT speed the time of implant dropping into position, but may increase the risk of capsular contracture. The amount of time necessary for final dropping, softening, and settling of implant position 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 weeks’ 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 will 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, with superior anesthesia, careful surgery, meticulous technique, precise hemostasis, attention to medications, not resuming strenuous activity prematurely, and equally attentive patient compliance, breast enlargement is a safe, 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.

Rev. 02-2017  copyright: Richard H. Tholen, MD, FACS

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Minneapolis Plastic Surgeon