Breast Augmentation Dallas
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 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 several implants to choose from and each has its own advantages and disadvantages. 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 and is no longer limited by the FDA.
“As a Registered Nurse and seeing many of Dr. Stagnone’s patients through the years, I had no doubt what doctor I wanted to consult with for my Breast Implant surgery. That time came for me and knowing many of the health care professionals I’ve worked with over the years had placed their trust in him for their care or their loved ones care, made my decision as easy one.
Being on the patient side of things, gave me a different perspective and the entire experience was one I would recommend to anyone. I want to extend a big thank you to Dr. Stagnone & all his staff for their exceptional kindness and care. Never doubted you, only reinforced what I already knew to be true!”– Sincerely!!!
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 is one of the most popular 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.
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.
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 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 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 us usually more accurate and the additional layer of tissue covering the implants decreases the likelihood of seeing of 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 is 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.
Breast Implants – Saline vs. Silicone Gel
The FDA removed its restrictions on the use of silicone gel implants in November, 2006, opening the door to a wider range of choices for women seeking breast augmentation surgery. In my practice, over 60% of patients chose silicone gel in the first year after they were made available. As the safety of these implants has become more and more accepted, over 90% of my patients choose silicone gel today. There are potential benefits to each implant.
Saline implants are inserted empty and filled by the surgeon during the procedure. This allows a slightly smaller incision and somewhat greater accuracy in correcting asymmetry in breast size since the surgeon can choose to fill one more than the other. Saline implants are less expensive, too, approximately $900.00 per pair less than silicone gel filled implants. If a saline implant leaks, it deflates and that breast loses volume, creating a sense of urgency for surgical replacement. Some patients enjoy the peace of mind knowing that it contains only sterile salt water and is quickly absorbed by the body. Others are distressed that a leak in the implant creates a situation of necessity to have replacement surgery.
Saline implants feel stiffer in patients with very little breast tissue and the folds in the implant can more frequently be felt or seen, a condition called rippling. Also, saline implants look less natural in some patients, especially those with very small breasts before surgery. This is considered an advantage for patients who prefer a tighter, rounder, less “natural” augmentation. Although most of my patients request results that look natural and proportional, those who prefer a more spherical and visibly augmented look are often better served with saline implants. In my experience this is a more frequent request in younger patients, which is fortunate, since the FDA (without explanation) restricts silicone gel to individuals age 22 or older.
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). Many patients feel that gel filled implants result in a more natural shape since they settle and move more like breast tissue than saline implants. Gel implants do require a slightly larger incision since they are pre-filled. Routine mammograms are still necessary for breast cancer screening and in addition, when the FDA removed their restrictions on silicone gel breast implants, they suggested that women with these devices consider an MRI scan after 3 years and again every two years to evaluate the surface of the implant.
The importance of this in terms of patient health is debatable however, since the fourth generation silicone gel is so thick it would be unlikely for it to flow out of a small crack in the implant shell. Additionally, the MRI scan is not infallible, and there is the possibility of an inconclusive result and even the known risk of a false positive MRI scan which could create unnecessary confusion. It is my feeling that an MRI scan is warranted when there are unexpected or suspicious changes in the breast but that it is debatable as to the need for regular or frequent MRI scans as a method of surveillance. Additionally, as mentioned, current data show that there is no known illness or disease caused by silicone. Since it appears harmless, many physicians feel that it is of questionable value to obtain MRI scans in a problem free augmented breast. This may be a decision best left to a woman and her plastic surgeon, but the FDA’s position is to consider an MRI scan after 3 years, then every 2 years thereafter.
In summary, saline implants are less expensive, adjustable in volume, and provide good results in most women with a reasonable amount of breast tissue to minimize rippling. Silicone gel implants feel more natural and appear to decrease the risk of surface rippling and in many instances appear, feel, and move more like actual breast tissue. It is my feeling that silicone gel provides the most “real” or “natural” breast augmentation. Saline implants go flat when they leak and replacement may be psychologically urgent. Silicone gel may require an MRI scan to detect failure.
Each woman must weigh these pros and cons to determine the choice of implant which is right for her.
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: 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.
CAPSULAR CONTRACTURE: 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.
HEMATOMA: 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. Stagnone 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. Stagnone 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.
B. Hypersensitivity: 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.
SAGGING: 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 currently a fourth generation device which has been modified over the years to decrease the risk of failure or rupture. Fourth generation implants have thicker more resilient rubber surfaces. Also, the silicone gel on the inside is now thick 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. Given the fact that there is no medical consequence of such minute exposure to silicone gel, and the implant maintains its shape, it is difficult for me to strongly advise the need for frequent MRI studies to look at the surface of the implant. 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. Besides the evidence showing that silicone is harmless and already present in the body from other products, my biggest concern over this recommendation is that the MRI scan itself is not perfect. A certain percentage of MRI scans are “false positive”. What this means is that the MRI scan may be inconclusive or may suggest to the radiologist that there is a problem with the implant even though it is intact.
This is certainly problematic if the patient becomes concerned enough to want to have surgery for reassurance. If an operation is performed and the implant is normal there will be no warrantee coverage whatsoever. Thus the patient assumes the financial responsibility for exploratory surgery in the event that the MRI scan looks suspicious but the implant is not defective. It is my opinion that, particularly early on, if the breast is soft and ideal and unchanged in its shape, appearance and feel and has no symptoms of discomfort, it is very difficult for me to defend the choice of having costly MRI scans in such an asymptomatic breast. I personally have seen a patient who presented with MRI “confirmed” ruptures of both silicone gel implants and the operation revealed two absolutely normal and intact implants.
If I were advising my own family member I would advise her to only consider an MRI scan in the event that there was something abnormal with her breasts. If everything was perfectly normal, I still might consider a prophylactic or investigative MRI at nine and a half years or so, shortly before the 10 year warrantee expires. This is a choice for each individual to make and I certainly do not discourage patients from getting MRI scans as recommended by the FDA. I do however have concerns about the cost and the relatively low yield for the study, particularly since it has been shown that silicone does not cause any disease. 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.
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