Learn About the Various Breast Procedures in Chicago.
Patients interested in breast enhancement are frequently confused about the choices and options available to them regarding the type and size of implant, location of implant placement ( under or over the muscle) and the type of incision. There are many reasons for the confusion, one of which is because questions cannot be answered independently of one another and therefore various decisions need to be made simultaneously. The other reason for confusion is that much information is biased and opinionated and does not allow for a rational decision.
I am going to start with the most difficult issues regarding the type of implant to use, saline versus silicone and its placement, above or below the muscle.
Let’s provide some factual information:
1. Saline implants require a smaller incision.
2. Saline implants provide flexibility in scar location.
3. For a given final volume, the envelope in a saline implant is smaller than that of a silicone implant resulting in a firmer implant as it lies outside the body.
4. Saline implants placed under the muscle tend to feel softer than above the muscle.
5. The firmness of the breasts is directly related to the scar tissue formed around the implant, inversely proportionate to the amount of breast and muscle tissue in front of the implant and the inherent firmness of the implant.
6. When an implant is placed underneath the muscle only the upper inner part of the implant is covered with muscle. The outer and lower part of the implant is covered by whatever breast tissue, fat, or skin is available.
7. Silicone implants are much more amenable to placement above the muscle.
8. Silicone implants are more expensive than saline implants.
9. Silicone implants are felt to be longer lasting than saline implants, but the present type of implants have been on the market only since 2006 and have been implanted in trial since 1992.
10. Implants placed subpectorally have three drawbacks:
a. They are more painful in the immediate postoperative period.
b. They can occasionally result in distortion of the breasts with muscle contracture.
c. If the patient has some breast tissue and the breasts themselves are soft or become softer over time, the breast will tend to drop down while the implant stays in its initial higher position under the muscle. However, an implant placed underneath the breast tissue will tend to migrate down with the breast tissue, maintaining the aesthetic result longer.
11. Cleavage issues: the implant must be centered underneath the nipple; therefore, the cleavage is directly related to the distance between the sternum in the midline and the nipple itself, and the size of the implant to be placed in that space. As the implant gets larger its radius becomes larger and if the center of the circle is at the nipple, then the larger radius will allow for more fullness medially and, therefore, more cleavage.
12. In order to have a satisfactory result with implant placement above the muscle, 2 cm of breast tissue in the upper pole are needed. With silicone implants, we are not as strictly restricted as with saline implant by this law.
13. Mammography: The sensitivity of a mammography decreases with any type of implant in any position. Generally, radiologists prefer implants placed subpectorally.
MRIs are very valuable if implants are present and are required for patients who have silicone implants.
14. Incision site: there are four types of incisions available.
The inframammary incision is the most common incision and is felt to be the safest. The next common incision is a periareolar incision. The way I perform the enhancement, is by making the incision in the lower part of the areola elevating the skin off the lower part of the breast and then going down underneath the breasts with a similar dissection as an inframammary incision. The axillary incision is performed less commonly. Its drawback is the inability to always properly dissect the lateral pocket to provide a natural result. If bleeding were to occur, it will occur farthest away from the entry site and may require a separate inframammary incision for control. Sometimes curvature of the chest prevents the surgeon from visualizing well the medial and inferior aspects of the pocket. Therefore, I personally reserve it to a situation where small implants are going to be placed. The last incision is from the umbilicus. This does not allow for silicone implant placement and voids the warranty that the manufacturer provides. I do not offer it to my patients.
Implant size: the way we manage size is a combination of the patient’s desires, the result of sizers tried in the office at least two times and the measurements we obtained during the examination. All that combined with my surgical experience dating back to 1987 is used to help the patient chose an implant they are happy with.