Breast Augmentation – Everything You Need To Know

Breast Augmentation – Everything You Need To Know

Breast Augmentation is one of the most common cosmetic procedures performed today in the world. Women choose to undergo the procedure for a variety of reasons including most obviously to increase size, to correct asymmetry, to replenish breast tissue which was lost following weight loss or pregnancy and in conjunction with a breast lift.

Most patients are aware that the first generation of silicone implants in the 1980s and early 1990s had problems. Dow Corning was sued countless times for claims by women that they were harmed by breast implants. Dow later filed bankruptcy and silicone implants were taken off the market by the FDA. Saline implants, which are made out of silicone on the outside and sterile salt water (saline) in the inside, later were the only option for women desiring breast augmentation. In 2000 the FDA started a prospective study for the next generation of silicone gel breast implants and the study was supposed to be a 10-year investigation.

The new implants were far different than the older implants which frequently ruptured and were filled with liquid silicone.  The new implants in the study were “cohesive gel” filled, aka “gummy bear,” and they had a much stronger, rupture reducing outer capsule.  The study only included candidates who had previously had silicone implants, had multiple, documented problems with saline implants, were to undergo a simultaneous breast lift or were to undergo breast reconstruction following the treatment of breast cancer.  Drs. Carlotti were both physicians who participated in the study with their patients until 2007 when the FDA stopped the study.  Overwhelming data gathered by the FDA demonstrated that the new generation of silicone gel breast implants was not linked with greater incidence to typical forms of breast cancer or auto-immune diseases as was previously asserted against the first generation.  Rupture rates were also far lower as well. 

Today, 83% of patients nationally chose silicone gel breast implants over saline implants.  Although slightly less expensive, saline implants for all intent and purposes are “water balloons.”  As such they do not feel as natural as do gel implants as the viscosity of gel implants much more closely mimics that of breast tissue.  Additionally, saline implant manufacturers will advise patients that they will start to lose volume and deflate between 7-10 years necessitating replacement.  Although no implant, whether a cheek, chin, hip or breast implant can be ever considered to be “permanent” there is no standard to guide a woman when or even if she will ever need to replace gel implants at any given interval.  This means in most instances unless the woman is having a problem, the reasoning for replacement might be to increase/decrease the size, to assist in a breast lift or because otherwise, the woman’s body changes around the implant requiring a change over time.

A common question is whether or not to place the implant above or below the chest (pectoralis) muscle.  In circumstances when the patient has highly developed chest musculature such as a professional female bodybuilder or if the patient has tuberous breasts which is a congenital abnormality of the breasts and underlying muscle, we will, in fact, place the implants above the muscle on certain occasions.  In general, however, it is best to place the implants below the muscle because (1) the muscle helps support the weight and position of the implant (2) the more tissue between the skin and the implant the more natural it looks and feels and most importantly (3) it is far easier for Breast Radiologists to examine the breast tissue in imaging studies when the implant is separated from the breast tissue by the layer of muscle.  Long-term, implants placed below the muscle tend to stay up in position better.

Incision placement can vary. For saline implants, it is best to place them through a small incision in the armpit (axilla).  For gel implants the crease beneath the breast (inframammary crease) is ideal.  We typically do not use nipple incisions (periareolar) incisions for breast augmentation as these scars will typically widen, become dark (hyperpigmentation) or light (hypopigmentation), or worse the nipple can lose sensation more readily.  Some surgeons use the belly button (TUBA or trans-umbilical breast augmentation) for the placement of saline implants, however, we have found this technique unnecessary and a bit gimmicky.  It also more unpredictable to obtain a true total submuscular implant placement with this technique.

Choosing implant size to meet the patient’s goal is an art form. Truly, breast augmentation is a procedure where your breasts are simply made bigger.  If one nipple is slightly lower than the other, this will be the same after the procedure.  We can improve breast asymmetry of size by placing balancing sized implants, but will never make them symmetrically perfect.  There is no “B cup” implant or a “C cup” implant, etc.  The height of the patient, the width of their chest wall, the starting volume of breast tissue and ultimately the desired size and shape they wish to be after surgery all dictate the size of the implant placed.  Deliberate, effective communication with the patient at length prior to surgery is how we consistently achieve the result they desire by together choosing the correct sized implant before surgery.  We do not decide for the patient and we certainly do not change our minds in the Operating Room without the patient’s consent!

The actual breast augmentation surgery is quite simple surgically.  On average, actual surgery time for us is less than 20-25 minutes with total time in the Operating Room for about an hour.  The most common complaint of patients following the procedure is tightness in the chest due to the expansion of the muscle and placement of the implant.  This usually significantly subsides in 24 hours, is well controlled with prescribed pain medications and is 95% improved in 4 days.  Most patients will go back to work, with minimal lifting, in about a week.  Final results as the muscle, then the breast tissue and finally the skin finally stretch to accommodate the new implant takes about 3 months.  We advise patients to wait to buy that expensive bikini or bra until the breasts have considerably settled and softened giving the final result.

We tell every patient the same thing:  breast augmentation is the “happiest operation we do.”  Most women after surgery say that they wish they had done it sooner as it gives them more confidence in and out of clothing.  With a male and female perspective, the advantage of having two experienced surgeons, two sets of hands and two sets of critical eyes, the patient truly benefits in our practice.

-Dr. Albert Carlotti D.D.S, M.D

Fellow of the American Academy of Cosmetic Surgery 

Posted in: Breast Augmentation

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