Procedures

Breast Augmentation

Mammary hypoplasia or small breasts refers to an anatomical state in which the breast size is not in harmony with the rest of the body. Small breasts may be: congenitally inherited, a result from loss of breast tissue secondary to child bearing and breast feeding, a factor of aging (mammary atrophy), or a result from significant weight loss. Occasionally, injury of the breast in childhood may result in lack of breast development. It is also not uncommon to have one breast larger than the other.

There is no ideal age for breast augmentation. The procedure is frequently done on women from their late teens to seventy plus years of age. Motivations, health, and breast anatomy contribute to whether a person is an ideal candidate.

As a rule, breast augmentation will not interfere with normal sensation and breast function. Most of our patients have had no difficulties with breast feeding. Pregnancy and/or breast feeding will usually produce some contour changes in both the augmented and non-augmented breast. Some may prefer to wait until their family is complete and then correct the post nursing breast shape. It is not wrong to have an augmentation prior to pregnancy, but just be advised that the shape will change after nursing.

The optional incision sites for breast enhancement can be; at the base of the areola (nipple), under the breast, in the armpit or in the umbilicus (belly button). I would like to describe and give the pros and cons of each:

Periareolar - This is the most popular choice. The incision is made around the base of the areola border (the dark area around the nipple and breast skin). When healed, it virtually defies detection. Healing is quite nice since the nipple skin does not develop hypertrophic scarring. (Hypertrophic scarring is evidenced by a thick red raised scar that the patient's body produces. It is not typical scarring.) There may be a temporary loss of sensation in the incision line, but nipple sensation is very rarely affected. The incision is positioned to miss as much breast tissue as possible. Periareolar incisions have been very popular with saline distensible implants. The surgeon can still use this periareolar approach with large saline implants. However, silicone gel implants in larger sizes can be a challenge. Of course, this also depends on the size of the areola.

Inframammary - This incision is made just above the fold under the breast (inframammary crease) and varies from 1 ½ inches to 2 ½ inches long. Larger silicone implants are often best placed via this incision. With normal healing, it also defies detection. However, the concern about this incision is that it can form a noticeable scar if the patient has a predisposition to hypertrophic (thick) scarring. Unfortunately, this potential for bad scarring cannot be pre-determined, unless the patient has had previous indications of bad scarring on the torso.

Axillary - Better known as the armpit incision. This incision is usually well hidden, but it can show a visible scar in some people when the arms are raised. Like the periareolar incision, it is more difficult for larger silicone gel implants, but it works for saline distensible implants. The axillary approach at times is followed by lateral implant drift (implant moves back toward the side). I feel it is a less efficient way to assure maximal cleavage because of the lateral drift. Another problem is that the axillary incision is a difficult route for solving complications. This may automatically require a second incision to resolve a problem. Over the years, this incision has had varying popularity.

Umbilical - This belly button incision is mentioned only to be soundly and totally condemned. Only flimsy shell-distensible saline implants are possible, never silicone gel implants. It is largely a blind procedure in which the implant shell is placed under the breast tissue (not under the muscle) and distended to essentially rip the breast from its attachments. The weak shell implant frequently breaks. Replacement often requires implementing one of the other incision methods. Many liability companies that cover plastic surgery and hospitals will not insure for this umbilical approach, because there have been deaths from under the rib misplacement and lung puncture. I will not perform the umbilical technique. The umbilical incision is not done at Stanford University Hospital or at UCSF Medical Center for good reasons! I feel this route is dangerous, produces poor results, will not accommodate silicone gel implants and should be relegated to historical interest only.

The next point of interest is implant placement. Implants can be placed above or below the pectoralis (chest) muscle. Although going above the muscle is easier for the surgeon and less painful for the patient, there are many other reasons why beneath the muscle is the most common placement. Mammography and cancer detection is easier with the implant placed under the muscle. Other advantages to going under the muscle include: an extra layer of protection, a more natural appearance and fewer incidences of capsule contracture (firmness). Capsule contracture is a condition where the patient's body reacts to the implant by building scar tissue around it. It is similar to how the body would react to a sliver under the skin. This scar tissue can make the breast firm and asymmetrical. It can happen in one or both breasts at any time. Attempts have been made to reduce the possibility of capsule contracture, but none have proven completely successful. I believe that capsule contracture potential can be reduced by placing the implant under the pectoral muscle, rather than just underneath the breast tissue. Every surgeon who has performed breast augmentations has had patients who have experienced capsule contractures. Some will return to surgery to release the scar tissue and replace the implants, and others might choose to just remove the implants. The degree of firmness can vary from acceptably mild to being painful and unnatural. There is no way of pre-determining who will form a capsule contracture. Saggy breasts or breasts with stretch marks tend to have higher incidents of capsule contracture.

Let's discuss implants. All breast implants contain silicone. The main two types available are silicone shell with saline fill or silicone shell with silicone gel fill. Over the years, the companies producing breast implants have produced many types of implants with various fills. They have differed in size, shapes, textures and profiles. Many arguments and controversies have ensued. The greatest and most recent controversy regarded is the safety of the silicone gel filled implant. Silicone implants have now been approved for safety. The silicone gel implant is better, more natural in appearance and feel, has better longevity and is overall my number one choice. Natural round, smooth gel implants "teardrop" when standing up and will act like normal breast tissue in a reclined position. The saline implants are also fine, but can produce a ruffled unnatural feel and appearance in some patients. Saline implants have less capsule contracture potential, but they can break or leak. When they do, they will need replacement. At the time of this writing (2007), the two main manufacturers today, Allergan (formerly known as Inamed/ McGhan) and Mentor, offer lifetime warranties that will replace the deflated implant free of charge. If deflation occurs within the first 10 years, the manufacturers' will contribute $1200.00 to $2400.00 toward the cost of the operating room and surgeon's fee. Silicone gel implants rarely break and your body provides its own secure capsule around the implant.

There are smooth and textured implants. I prefer the smooth, because I feel the rough surface of a textured implant may act like sandpaper in the body of some patients. The most common implant shape in augmentation is the mid profile. Candidacy for low, mid or high profile is discussed and determined during the consultation. The "teardrop" shaped implants can be problematic and very few patients are candidates for this shape.

Choosing the right size implant is a major point of discussion and interest. The right size is based on the patient's desire and the limitations of her anatomy (amount of existing breast tissue and body frame). I feel for every patient, there are multiple "correct sizes". It is a plastic surgeon's job to listen very carefully, then examine, assess and then offer ranges in sizing. It is interesting to know that probably 95% of breast augmentation patients wish that they had gone larger one year post operatively. On the other hand, if a surgeon implants a size too large for her frame and tissue to comfortably accommodate it, this can increase the chance of creating a capsule contracture complication. In addition, if excessively large implants are used, there is a greater tendency for the implants to bottom out. This means that the lower pole of the breast expands and the implant drops. Gravity is often not our friend. I have a formula for my patients that helps them determine which size they prefer within the range I've given them. This gives them the opportunity to determine or confirm the size they think is correct. This works out fine 99% of the time.

Breast augmentation is an "out patient" procedure that is performed best with the patient asleep. It takes 1 ½ - 2 hrs. The patient may go home with a responsible adult that will remain with them the first 24 hours. Recovery takes about 10 days. Most patients return to work after two weeks with minimal discomfort.