Breast Enlargement | BREAST AUGMENTATION | Augmentation Mammoplasty

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BREAST AUGMENTATION

While breast augmentation will enlarge the breasts, it will not alter basic defects in breast shape or form. Major asymmetries may be improved, but will not be completely corrected. A slight difference in the size or shape of the two breasts is considered normal and should not be a cause for concern. If breast size or nipple position asymmetries are severe then additional procedures to further improve symmetry may be necessary. Long experience with this operation has demonstrated it to have highly satisfactory results for the majority of patients who are considered suitable candidates for the surgery.

The operation is carried out in our Cosmetic Surgical Center under general anesthesia on an outpatient basis. An implant (prosthesis) is placed through an incision, under the breast tissue or under the muscle. The incision can be made under the breast, around the nipple or in the armpit. It generally takes two to three hours to complete the entire procedure. A breast implant is composed of an outer shell filled with saline (salt water). The outer surface may be smooth or textured, and implants come in various shapes to meet the individual woman’s needs.

For most of our patients, getting back to work early is a priority. Thanks to an innovative post operative regimen designed by Dr. Thomas, return to work the very next day is possible now. A special set of exercises instituted on the first post operative day helps to reduce the discomfort and tight feeling after surgery. Fifth generation silicon gel implants are preferred for augmentation as the feel is closest to natural. US FDA has declared silicon gel implants as safe for breast augmentation.

The US FDA has approved both saline and silicon gel implants for breast augmentation. Studies have shown that implants do not increase the risk for breast diseases. Detection rate of breast cancer is unaffected if mammography and physical breast examination are combined.

Only a qualified cosmetic surgeon can determine whether breast enlargement is right for any one individual, but there are some groups for whom it is generally considered unadvisable and others for whom careful consideration is recommended, such as teenagers. Young women under the age of 18 are generally considered not to be good candidates for breast implants because the breasts continue to develop on into the early twenties. To find out if you are a candidate for breast augmentation, schedule a consultation with a Dr. Mohan Thomas.

As is the case in all surgery, there are certain risks that are inherent in this operation. Irregularity or thickening of scars can occur which might require revision. Rarely, hemorrhage may require removal of prosthesis to control the bleeding. Infection is probably the most serious risk of breast augmentation. If an infection occurs, antibiotics alone will rarely clear up the infection unless the implant is removed. It is necessary to leave the implant out for a period of about three months before it is safe to attempt replacement. The risk of infection is less than 0.5%. Infection is usually confined to the early post op period, however infection can show up much later, fortunately the prosthesis can usually be successfully replaced at a later time after the infection has completely resolved.

Another potentially serious complication is implant rejection. Silicone is the least reactive material used for implant construction. Most patients tolerate the material without difficulty. Nevertheless, a very small percentage will react to the material making successful augmentation an impossibility.

Sensory changes can occur resulting in numbness or discomfort, and while these symptoms are usually not long-standing or severe, they can be in some cases. Temporary sensory changes are common and usually last 2 to 6 months. No studies have indicated that implants interfere with nursing.

The natural tissue capsule that forms around the implant within the body can sometimes thicken or contract causing unnatural firmness or shape to the breast. This condition is called "capsular contracture". This is a very uncommon complication which can be reduced by exercises. If it occurs open or closed capsulotomy may be required.

Rippling, or surface irregularities over the implant that can be seen or felt, is a potential problem with any type of breast implant. The added risk of rippling is the trade-off for the increased safety of the saline filled device. Because of the potential problem, placement of the saline filled implant under the muscle may be indicated to help decrease the risk of rippling. This may be particularly true for patients who have very little mammary tissue.

In selecting the size of the implant, the general choice should be jointly made by the patient and the surgeon prior to surgery. While ultimately, the choice of size is made by the patient, she should recognize that there are advantages to a conservative selection. Capsular contracture and rippling are more common with larger implants. Postoperative numbness and long term sagging are also more common the large size selected. However, despite the increased problems with larger implants, it is rare that our patients complain of being too large following breast augmentation. In general, our patients say they are extremely pleased with their new size, with 3-5% saying they might have gone slightly bigger if they had to choose over again. The shape of your augmented breasts depends on the implant size and shape along with how your breast appear prior to surgery. The same size and shaped implant on one patient can look completely different on someone else. Therefore, one should avoid picking a size or shape solely on what ‘looks good’ on someone else.

Implants may be round or teardrop-shaped (anatomical). The choice depends on the look you want to achieve. While teardrop (anatomical implants) may seem like a good idea they have some drawbacks. Teardrop implants widths are different than their length and any rotation may produce an unwanted asymmetry. Round implants are the same diameter all around but not ball shaped. They come in a variety of widths and varying amounts of projection that helps fit the ideal implant for ones goals and anatomy. One such factor to consider prior to surgery is breast width, which along with nipple position and implant size determines the amount of “cleavage” between your breasts. The outer curves of your breast are also determined by all the above and should fit your upper torso but also balanced with you hips.

We recommend that our patients purchase a soft non-padded bra in the approximate cup size that they believe they would like to achieve. Padding the bra by using baggies filled with cloth to estimate the approximate additional volume they desire can help estimate the size implant that would be required to achieve their desired result. The final decision, of course, will be made during the time of surgery, based upon the patient's desires, as well as which implant seems to look and fit best. In some cases, this could result in the breast being augmented slightly more or less than the patient had anticipated.

The breast normally covers a muscle on the chest wall called the pectoralis muscle. Breast implants can be placed above or below this muscle. When implants are placed below the muscle, it is called a submuscular placement or a subpectoral placement. When the implant is placed above the muscle, it is called a subglandular or submammary placement, meaning that it's below the mammary gland.

A possible advantage of submuscular placement is that it may allow better mammography. It is generally felt that there is less chance of missing a lesion on mammography when the implant is below the muscle. The pectoralis muscle tends to hold the implant against the chest wall during mammography. Another advantage of submuscular placement is that the implant is entirely beneath the breast tissue, decreasing the possibility of interference with breast function.

It is also felt that submuscular implants are less likely to develop firmness (capsular contracture). This may be the result of pressure or internal massage of the muscle around the implant and its associated scar tissue (capsule). While this has not been definitively proven, it is our feeling that patients have less capsular contracture when implants are placed in the submuscular position.

Disadvantages of submuscular implant placement include a more painful recovery than the subglandular approach and longer healing times. Although soreness is typically somewhat more that for submammary implants, the increase in discomfort is not long term and most patients feel back to near normal in 2 weeks. The most severe pain last for one week on average. We tell our patients to avoid lifting anything over 5 pounds the first week and 10 pounds the second week. Patients should also avoid raising their elbows above shoulder level the first 10 days. Over use of the arms and pectoralis muscles can cause the submuscular implant to ‘ride up’ initially. And, submuscular implant position does require more time to settle than submammary implants. Slight flattening beneath the breast should be expected initially. This requires one to two months on average for the breast tissue to stretch and soften in order for the breast to ‘round out’ in the lower half.

There are several ways in which the breast implant can be inserted. An incision can be made under the breast (inframammary), in the armpit (transaxillary), or around the bottom of the areola (periareolar). We offer all of the three incision choices, but prefer the inframammary incision in most cases. The incision under the breast (inframammary) is the most common, and is a favorite due to a number of reasons. First, it is the area that is hidden in a crease and hemostasis is easy. Finally, inframammary scars usually heal well and the incision has been used for decades and remains a viable option that usually has no major problems.

The periareolar incision is made in a semicircular fashion around the lower half of the areola approximately 4-5 centimeters in length. When placing implants above the muscle, we often make the incision around the areola. Although this technique is somewhat more difficult, it offers the major advantage of a smaller and much less noticeable scar. It also offers additional advantages of keeping the incision far away from the implant and allowing good surgical exposure of the entire pocket. The incision may have a slightly higher risk of more sensory compromise to the nipple/areolas complex compared the transaxillary incision, but remains an excellent incision option. If a simultaneous breast lift is required this incision is often used since there will likely be nearby incisions that are already going around the areola.

Since blood around the implant can organize and eventually lead to thickened scar tissue, it is important to perform the surgery in as bloodless a field as possible. The use of endoscopic surgery has allowed us to carry out breast augmentation with more precision and less bleeding. Special instruments designed for this purpose allow us to work through very small incisions, monitoring the operation on a video screen. The dissection is performed under close observation using an endoscopic telescope with a built in video camera to project the inside of the pocket on a large operating room screen. The pocket is then tailored under direct vision rather than the traditional blind dissection. The improvement is obvious since it is always better to see clearly what one is cutting. This is Dr. Thomas's area of expertise due to his mastery of Endoscopic Surgery - first in India!

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