What is Breast Augmentation?
There are several variations in breast enlargement, also known as breast augmentation, allowing a variety of alternatives to customize each procedure. There are several distinctively different breast implants currently available and two very different positions for implant placement.
The sculpting of the implant space is critical to shaping the breast. We do not perform the “belly button” approach because of a very high likelihood of irregular breast shape, or even deformity. Issues such as available recovery time, skin quality and desired shape will determine which type of breast augmentation is best for you. Our main objective is to create the most beautiful breast possible based on your unique starting anatomy.
Breast augmentation surgery involves the placement of the implant either under the pectoralis muscle or on top of it. There are many implants to choose from and each has its own advantages and disadvantages.
Who Is An Ideal Candidate For Breast Augmentation?
Several factors help determine the feasibility of breast augmentation for prospective patients. Generally, the best candidates are in good physical health and have had a normal mammogram. During our consultation, we discuss with each patient what they can and cannot expect from breast augmentation to help set realistic expectations.
How Is Breast Augmentation Performed?
Breast augmentation is performed as an outpatient procedure. Patients are given general anesthesia. The procedure involves making an incision to place implants. There are several possible locations for incisions. Location choice depends on the type of implant selected. Smaller implants may be inserted through a periareolar incision made just around the colored skin on the breast. The inframammary incision is quite common. This incision is made along the crease beneath each breast.
During breast augmentation surgery, tissue is raised to make a pocket. Implants may be placed just beneath the superficial tissue or in a pocket beneath the muscle. After closing the incisions, the surgical team applies a compression garment and the patient is moved to a monitored recovery area. The procedure takes 1 to 3 hours.
Different Breast Implant Options
The most common implant in use is a smooth surfaced round implant which most find to have a softer more natural feel and a lower tendency to show ripples through the skin in thin individuals.
Textured surface implants may slightly discourage capsular contracture (scar tissue firming up around the implant over time) but tend to be easier to feel and more likely to show surface ripples.
Anatomically contoured implants were designed in an attempt to create a more sloped or natural upper pole but most plastic surgeons do not believe they are very successful in this regard. They occasionally shift position and create unsatisfactory shapes.
We also use medium and high profile round implants in individuals with certain starting anatomy to get a fuller result when the breast is limited in it’s diameter. High profile implants may allow larger breast augmentations in a petite individual.
Silicone gel is increasingly popular and makes up 70% of my augmentation practice at this time. It is no longer limited by the FDA.
Saline vs. Silicone Gel Implants
Breast implants are generally categorized by their “fill.” Patients primary options to consider are saline and silicone. WIthin these categories are additional features that influence the outcome of surgery.
Saline Breast Implants
Saline breast implants contain a sterile salt-water fill. This type of implant is approved by the FDA for patients between age 18 and 22. In addition to being approved for younger patients, saline breast implants may be preferred by some for their safety. An implant leak results in a flattened breast. The body naturally absorbs the saline. Another benefit of saline implants is that they tend to provide optimal upper pole fullness. Because this type of implant is filled after it has been situated, the surgeon can adjust size according to need. This option may be good for women with unequal breast size.
Patients should be aware that saline breast implants typically do not feel as soft and natural as silicone implants. There is also a risk of rippling under the skin. While saline implants may initially offer more projection and upper pole fullness, their weight can cause the breasts to eventually become more bottom-heavy.
Silicone Breast Implants
Silicone breast implants are approved for patients over the age of 22. THey are pre-filled with a silicone material that feels soft to the touch. Silicone implants are round so, should they rotate, the shape of the breast should be unchanged. Breast shape is also unchanged if a leak were to occur. For this reason, it can be difficult to identify a leak or rupture. Women who receive silicone breast implants are advised to have regular MRI tests for this reason.
Highly Cohesive Silicone Gel Breast Implants
In recent years, manufacturers developed a highly cohesive gel material for breast implants. These are commonly referred to as “gummy bear” implants because they resemble the consistency of a gummy bear. Form-stable implants may be round or teardrop shaped. They are slightly thicker and firmer, so may not feel as natural as standard silicone breast implants. However, if the implant were to rupture, silicone remains intact.
Dr. Walker insists on each of her patients having an unparalleled experience. Breast augmentation is a big decision. It is met with meaningful conversation regarding the desired outcome and how to achieve it.
Silicone gel breast implants have changed dramatically since their introduction in the 1960s. Silicone can be manipulated chemically to be a liquid or solid rubber or anything in between.
Earlier versions of the contained silicone gel were less formed and could flow out of a tiny crack in the implant. The earliest models could even “seep” through the intact rubber shell, a process called gel bleed.
The newer implants, which are a fourth generation device, have gel so thick that, like Jell-O, it maintains its shape for a prolonged period, even if cut in half. The silicone rubber shell is far more durable too, further decreasing the risk of leakage.
Current data show that over 94% of today’s gel implants are still intact at 10 years. Studies also show conclusively that silicone has no relationship to the development of any known disease or illness, one of the main factors leading to the FDA’s approval.
The advantages of silicone gel breast implants include a more tissue-like quality which feels more like breast tissue, and a lower risk of feeling the implant folds or seeing them through the skin (rippling).
Each woman must weigh these pros and cons to determine the choice of implant which is right for her.
“I got a breast augmentation & I’m absolutely in love with the results. If I could give this place 100 stars I would! Everyone here is so warm & welcoming! From the receptionists, to the assistants, to the injectable nurses & the lovely surgeon Mrs.Walker. They really are an amazing team. Nothing but positive things to say about my experience here! If you are looking to get any procedure done I would highly recommend coming here if you want the best of the BEST. I am so happy with my results! Thank you Plastic Surgery Center of Dallas!💜 "
The Plastic Surgery Center of Dallas has an extensive catalog of before and after photographs demonstrating the possibilities. We also perform different breast lifting procedures which can tighten the sagging breast, creating a youthful, more beautiful breast with or without implants.
Breast Augmentation – Myths and Truths
Breast augmentation is now the most common cosmetic surgery performed in the world! According to the American Society of Plastic Surgeons, approximately 300,000 of these are performed per year in the U.S. alone. It is estimated that nearly 3 million American women have breast implants.
Since the “implant crisis” of the early ’90s, studies have been completed which show that there is in fact no association between breast implants and autoimmune or other diseases. With this reassurance, the popularity of breast augmentation has been steadily increased in popularity.
Why Do Women Get Breast Implants?
Surprisingly, it is usually not to attract men or primarily for the appearance of the exposed breast. Most women want breast implants to create a better body proportion and look good in their outfits. A lot of my patients answer that question by saying they just want to look normal.
Relatively few outfits “off the rack” will properly fit a woman with very minimal breast tissue. An equal number want implants to restore the breast volume and shape they lost following pregnancy.
Interestingly, husbands and boyfriends sometimes put up resistance because they completely misunderstand and assume their mate wants to be more attractive to other men. For many women, this is not even an issue. As a rule, breast implants are chosen for proportional and relatively natural-looking in the vast majority of my patients.
Breast augmentation is one of the most popular breast surgeries in the U.S. for many reasons. Some women decide on breast surgery to create symmetry between the two breasts which frequently differ slightly. Most just want better body proportion. There is often a dramatic improvement in self image. The improvement in proportion often gives the illusion of a smaller waist.
Can a Woman Choose Any Size or Shape She Wants?
Every woman has her own unique starting point. Occasionally someone comes in with goals that simply are not possible with their tissues. I spend a lot of time with my patients teaching them about their own anatomy and their own range of possible results.
The compliance or (elasticity) or each woman’s skin and the size of her rib cage establish the limits in the size of implants she can accommodate. When you try to exceed those limits, the result is often a tight, unnaturally round breast, which I think is a poor trade-off for greater size. On the other hand, if the tissues are loose, deterioration in shape and sagging can occur with overly aggressive augmentation.
We have a really effective system of sizing, in which I precisely measure each patient’s ideal breast diameter and match it up what a range of appropriate implants using reference charts.
The most commonly used implant comes in 16 sizes. Usually, two or three different sizes are available to most women to offer a range of possibilities that will look right on their body.
We then help our patients try on each of her choices with pre-filled sizing implants in an unpadded bra and she can choose the size she likes best. This step is done by one of four members of my staff, and all of them have breast augmentations which I have performed.
This step is usually a lot of fun for the patient. She can try the sizers with different outfits. Patients often bring their husband or boyfriend for their “vote!” Once the size is selected, we try to show results that are realistic for that individual using hundreds of “before and after” pictures of my patients.
Why Are There So Many Different Breast Implants?
In an attempt to create the ideal breast, a number of different implants have been developed. Anatomically shaped, or “teardrop,” implants were devised to try to create a more naturally shaped breast, but many plastic surgeons don’t consider this successful.
Anatomically shaped implants have a rough-textured surface, which keeps them from shifting position by adhering to the adjacent tissues, but the texturizing process requires a thicker implant, which can feel stiffer and move less naturally.
Many plastic surgeons have abandoned anatomically shaped implants completely. I have found that a naturally shaped and softer feeling breast can usually be created using smooth-surfaced implants which are thinner and more pliable.
Smooth implants are round in shape, but different breast contours can be created by adjusting the fill volume of saline implants or choosing from 3 different “profiles” using silicone gel. Each individual has their own starting shape, which defines and limits their choice.
We will spend time during your consultation listening to your hopes, but before you leave, we will work to be sure your expectations are realistic in term of what is possible with your starting anatomy.
Silicone gel implants are generally softer and more natural feeling that saline implants. This is especially important in women with minimal breast tissue. Round silicone implants appear to shift in shape more like real breast tissue too.
In my practice, over 90 percent of our patients choose silicone gel implants over saline. Sometimes, women with saline implants will have subtle rippling, which can be felt through the skin and occasionally is even visible. Silicone gel implants will often prevent or minimize this rippling.
Do You Use The Same Method Of Breast Augmentation On All Of Your Patients?
Absolutely not. There are number of choices, and it is very important to consider each individual’s unique starting anatomy, their specific goals, and their history.
Implants can be placed below or on top of the pectoral muscle. Every patient has her choice. Occasionally, better shape can be obtained with implants placed on top of the muscle.
Most patients select placement under the muscle, however, because the mammogram is usually more accurate and the additional layer of tissue covering the implants decreases the likelihood of seeing or feeling implant ripples.
I also believe that with submuscular implants, the upper pole contour is better, especially in thin women with very little breast tissue.
I still use some anatomically shaped implants for certain breast shapes but more commonly prefer low, medium or high profile round implants to offer a wider variety of options.
High profile implants may be a good choice for someone with a narrow chest who wants larger breasts. I also still use surface textured implants occasionally if I’m performing corrective surgery for capsular contracture, which is unnatural hardening of a previously augmented breast by the patient’s own excessive formation of scar tissue.
It’s important to be able to vary your technique and to have a good understanding of each of the available implants, especially when performing corrective surgery.
Do You See Many Patients For Secondary Or Corrective Breast Augmentations?
Yes I do, and it has become an area of special interest to me. We have so few laws regulating our specialty that any physician can legally perform these procedures with no formal training in plastic surgery. Gynecologists are now doing them in the Dallas area. Insufficient training can result in a lot of avoidable problems.
One way to be more confident about your choice is to confirm that your doctor is a plastic surgeon who is certified by the American Board of Plastic Surgery.
Nonetheless, even with proper training, if a breast augmentation is rushed or performed without meticulous attention to detail, there are many potential problems with final shape or symmetry.
Many of the corrective surgeries I have performed appear to be very dramatic, but technically, only involve refining or finishing up underdone operations and placing correctly sized implants.
Others are more technically challenging and involve reshaping the breast tissues using a variety of breast lift procedures in addition to corrective augmentation. I especially love these challenges, because they are artistically interesting and no two are the same.
What Is The Mommy Makeover And How Does It Complement Breast Augmentation?
It’s pretty common to see patients with multiple areas they’d like improved. A lot of the breast changes we see following pregnancy are accompanied by unwanted changes in the abdomen, hips, and thighs.
It’s very common in my practice to perform abdominoplasty (or tummy tuck) at the same time as breast enhancement. Even before pregnancy, fat accumulation in those same areas can often be improved by sculpting away the bulges with liposuction.
Total body contouring or “Mommy Makeover” are terms we use to describe the process of analyzing the relationship between different areas and developing a plan to improve overall proportion which enhances the entire body.
Interestingly, I even combine breast surgery with facial cosmetic surgery, especially enhancement of the nose, eye and lips. After 12 years in practice, one of the things that keeps it fun and challenging is this variety. Every individual is different and requires a unique approach. That’s the art of plastic surgery.
Can A Breast Lift Be Combined With Breast Augmentation?
Breast augmentation can be combined with a breast lift. Together, the two procedures can improve fullness, shape, and projection. A breast lift can help correct sagging and deflation and restore optimal symmetry.
What Results Should I Expect After Breast Augmentation?
Breast augmentation surgery is one of the leading plastic surgery procedures in the United States. It has a strong history of success, seen through consistent results in adult women of all ages. Patients can expect to look and feel fuller and shapelier after their implants have settled in the breast pocket.
The results of breast augmentation can be long-lasting, but certain factors can influence them. For example, healing is hindered by smoking too soon after surgery. This habit also ages the skin more quickly. Breast sag may also occur due to unprotected sun exposure. One sunburn may have little effect on the breasts, but regular tanning can affect not only the firmness of the skin but also breast augmentation scars. Finally, the results of this procedure may be prolonged with habits that maintain a stable weight.
Will I Have Any Scarring After Breast Augmentation?
Incisions cause scarring. There is no way to avoid this. What we do is try to control the visibility of surgical scarring. Dr. Walker does this by making incisions in the most discreet area possible. Patients can promote optimal incision recovery by following their post-op instructions. It is critical to avoid smoking after surgery. Patients must wear their compression garment as directed and should keep their incisions clean while the skin is healing.
How Much Time Will I Need To Recover After Breast Augmentation?
It may be beneficial to schedule as much as two weeks off for breast augmentation recovery. Several factors determine how soon a patient can return to work and other activities. Generally, patients should avoid lifting for two weeks. The breasts may be tight and swollen for the first several days after surgery, as well, so care must be taken to avoid activities in which the breasts may get bumped. Medication may also impair activity for a few days. Patients should reserve at least a few days to discern how their medication affects them before they venture out. Patients cannot drive until they are no longer taking narcotic pain medication.
Scheduling two weeks off work does not mean every patient needs that much time. Some patients can return to their normal activities within a few days, after their first post-op visit.
Breast Implants – Risks and Choices
Breast augmentation, like all other forms of surgery, is a real operation with real potential risks. The following is a summary of the most common complications that we feel every patient should acknowledge and understand prior to surgery. All of these do happen occasionally and are a function of the operation itself and how the human body reacts to this operation.
Rippling describes visible ripples in the breast following breast augmentation. This is far more common with saline filled implants and relatively uncommon with silicone gel implants.
The reason for rippling is that all implants are compressible, not rigid spheres and because of this they all have folds on the surface of the implant.
With saline implants, since they contain just salt water inside, the implant folds are much sharper. They are easier to feel and see through the skin in patients with small breasts, very thin skin or in those who choose larger implants, exerting more pressure on the overlying skin.
Silicone gel is much thicker and, while there are folds in a silicone gel implant, they are much more gradual and therefore rippling is less common. Rippling is a function of the amount of tissue you have to cover or hide the implant, not any kind of defect in the implant.
Once the implant is placed inside the body the healing process results in a thin layer of scar tissue surrounding the implant much like a cocoon forming around a caterpillar. This layer of scar tissue is called a capsule, and in some individuals, the healing process is more aggressive than others.
If an individual’s scar capsule begins to tighten around the implant, it can make the implant feel firmer, appear more round in shape and even begin to cause the implant to rise upwards as the implant is shifted in position within its normal pocket. The capsule of scar tissue can also thicken over time, which makes the capsular contracture even more uncomfortable and visible.
There are many precautions with breast augmentation, which can minimize the risk of capsular contracture and we use all of these, including specific cleansing of the patient’s skin and the surgeon’s gloves prior to handling of the implant and the use of a triple antibiotic irrigation within the pocket. Using all of the current techniques to minimize this risk, it can be decreased to about 2% overall.
Roughly half of the individuals who develop some capsular contracture will respond to an oral medication, which is intended for asthma. As a side effect, this medication seems to modify the cells which create scar tissue, causing the scar capsule to begin to soften.
About half of the patients with early capsular contracture will achieve resolution with this medication. This leaves a small number of individuals who have enough unfavorable scar formation that they may benefit from surgery.
There is no warrantee for capsular contracture, since the implant company is very clear that it is the individual’s tissue response, not the implant becoming firm. When the implant is removed, it can be seen to be perfectly normal.
It is the scar tissue inside caused by the individual’s “overly aggressive” healing which results in capsular contracture. This is a risk that cannot be blamed on the surgeon or the implant manufacturer and one that every individual who wishes to undergo breast augmentation must accept.
Postoperative bleeding is a risk with nearly all surgeries. When the pocket for the implant is surgically created it is sculpted using a cautery. The cautery is a device that delivers an energy charge, which splits through tissues and seals them off, including muscle fibers, nerve fibers and blood vessels, as the implant pocket is formed.
Any bleeding is visualized clearly using a brilliantly lighted fiberoptic retractor, allowing the cautery to be used accurately to stop all active bleeding. The pocket is flushed out with an irrigation solution and suctioned so that any bleeding can be visualized and stopped before the implant is placed.
Nonetheless, after the surgery, if the tissues are traumatized in any way from over activity or if the blood pressure rises from emotions, pain or even just bad luck, bleeding can begin. Blood can collect around the implant causing the breast to enlarge and become somewhat sore and perhaps appear bruised; however, because it is a closed space, the bleeding typically stops and is not an emergency situation.
If you present to the clinic with an enlarged, tender, slightly bruised breast and we make the diagnosis of hematoma, it is best that you have surgery to remove the clot of blood around the implant or you will likely develop a deformity.
Dr. Walker never charges any surgeon’s fee for the operation to treat a hematoma and performs this surgery at no charge. The anesthesiologist however, will charge you to go back under anesthesia for the surgery and you will be responsible for that fee as well as the operating room fee, covering all of the equipment, supplies and staff necessary to perform this operation.
Dr. Walker feels very strongly that a surgeon should never charge or profit from surgery such as this but that the patient should also assume responsibility for their own activity after surgery.
Most hematomas, when discussed truthfully, follow some type of “event” by the patient. The overall risk is very low and in our practice is approximately one-half of one percent.
Loss of sensation or numbness
When the space or “pocket” is created for the breast implant, tissues which are adherent or stuck together are split apart in order to create that space. Among the tissues which will be split free are some nerve fibers.
It is common to have numbness or decreased sensation around the incision and sometimes in other areas on the breast. Occasionally, the nipple itself may lose sensation. This is more common when the patient chooses very large breast implants since more tissues must be split apart to create the necessarily larger “pocket.”
Also, the larger implant may exert more pressure on the adjacent nerves which causes the numbness in some cases. Many cases of numbness resolve spontaneously, since the nerve fibers are stretched or cauterized but not irreversibly injured.
Nonetheless, some cases of sensory loss are permanent. This is a non-negotiable risk of breast augmentation and must be accepted to be a candidate for this operation.
In some cases sensation is elevated and the breast becomes hypersensitive. Even the pressure and temperature of showering can be uncomfortable and this too is an inherent risk which cannot be eliminated.
This generally passes with time as the swelling and healing processes evolve. Although uncommon, there are reported cases of permanent hypersensitivity.
There is no technology to secure the breast implant internally to a rigid structure such as a rib. The pocket which is created for breast implants typically follows the shape of the normal breast fold and is designed to mimic the shape of the breast once the implant is placed inside.
The implant, however, is not “wired down” or fixed to anything internally. It simply sits inside that pocket similar to putting your cell phone in your shirt pocket. The breast implant sits on the breast fold, which acts as the shelf supporting the implant.
If your tissues are lax and loose, the implant may stretch your tissues and settle lower. It is important to understand this and to accept that you cannot always select any type of breast you wish with augmentation and why augmented breasts must be supported just like real breasts.
When you lie on your back, the implants can move to the side under the force of gravity almost like a ball on a hill. Thus over time, the space between the breasts can widen as sagging occurs in that direction. There is no way for the doctor to prevent this, so we emphasize that support is typically necessary with breast implants just as it is with natural breasts.
This is most important in patients with very loose, lax tissues or those who select very large implants, which exert more weight or pressure on your skin. Implants over 350-400cc are considered to be in that category by many plastic surgeons.
Deflation or Rupture
Saline implants can develop cracks in the surface over time or failure of the valve used to fill them with saline. Even the tiniest pinhole in a saline implant will result in leakage causing the implant to go flat. This creates, in some sense, a social emergency due to the sudden mismatch of an augmented breast on one side and a flat breast on the other.
The material which leaks out is just salt water and therefore there are no issues or concerns regarding safety. However, the potential to deflate or go flat suddenly is certainly a disadvantage of saline-filled implants.
Silicone gel implants are now a fifth-generation device which has been modified over the years to decrease the risk of failure or rupture. Fifth-generation implants have thicker more resilient rubber surfaces. Also, the silicone gel on the inside is now cohesive enough that if the implant is sliced in two, it maintains its form and cannot “flow away.”
Thus, if there is a tiny crack in a current silicone gel implant, it will not go flat. It will typically maintain its shape and size and will often be undetectable. There is no pain or deformity or disease from exposure to silicone.
In fact, silicone is already present in the body in concentrations much higher than the concentrations caused by an implant. Many products such as lipstick, underarm deodorant, hair spray, Mylanta, etc. contain silicone and it is a substance which exists in everyone’s body in a measurable amount.
Numerous scientific studies relating to silicone gel have confirmed that it does not cause any type of disease. Interestingly, if a puncture is made in a breast implant even with something substantial, and the implant is compressed, the gel will bulge out, but when it is released the gel is drawn back into the implant, behaving more like Jell-O than any type of liquid.
When the FDA removed their restrictions on silicone gel implants in 2006, one of its recommendations was that women consider monitoring the implant with MRI scans to look at the implant through the body at intervals of every two years. As of 2020, the FDA updated its recommendations to include ultrasound as an adequate screening modality.
Current data show that in ten years, the failure rate following primary breast augmentation for these implants is less than 6%. Routine mammography is still necessary to screen for breast cancer.
The above information summarizes what we consider to be the most commonly encountered risks of breast augmentation surgery. It is not an exhaustive list of all of the risks of this procedure.
Although most of these are either minor or relatively infrequent, they do occur from time to time and everyone must accept these risks and give their informed consent in order to proceed with surgery.
Breast Augmentation Cost
The process of determining breast augmentation cost involves taking a number of factors into account. The breast implant cost, anesthesia type, length of the surgery, and incision location all have bearing on the final cost.
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Articles written by Dr. Stagnone on Breast Augmentation and Enlargement Surgery. MORE RESOURCES
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