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Breast Augmentation or Enlargement

Breast augmentation refers to the enlargement of the female breast utilizing either silicone or saline breast implants.  It is one of the most commonly performed cosmetic surgical procedures and is done to improve the patient’s body proportions, as well as, her self-image.

Though generally a very safe procedure with a high level of patient satisfaction, a woman considering breast augmentation should carefully consider the various options and potential risks of the procedure that may have lifelong implications.

Though the concept of placement of an implant to enlarge the breast may seem simple, there are many differences in opinion as to which of the following variables will produce the best result. (most attractive, least potential for complication, etc.).

• Incision location
• Implant type (saline vs. silicone)
• Size selection
• Location and size of surgical pocket (space) created
• Post-operative care/ activity, drains, compression etc.

One should understand that there is no standard breast augmentation operation. Each surgeon has their own opinions and methods. One should select the surgeon they trust and feel most comfortable. Based on professional judgment and experience, the surgeon will explain the procedure, options and make a recommendation based on evaluation of the patient’s examination, discussion and goals.

INCISION LOCATION
There are three standard breast augmentation incisions; peri-areolar, inframammary and trans-axillary. Selection of an incision site is based on which incision is most hidden and patient preferences. The peri-areolar incision is located at the transition between the pigmented areolar skin and the breast skin. It takes advantage of the color transition to hide the scar. This area scars very well and is often difficult to see once the scar has matured. Though often a concern to patients, there is no greater post-operative pain with this incision nor is there a greater risk of loss of nipple sensation. The inframammary incision is probably the most common incision and is located in the fold under the breast. It is a well hidden incision in patients with a little droop to their breasts and goes through a minimum amount of breast tissue. Trans-axillary incisions are placed under the arm and are touted for not requiring any incisions on the breast. However, they have many limitations in what can be done through these incisions, difficult placement of silicone implants and placement of an incision in a place that is commonly exposed, and not suitable in the unlikely need for a secondary procedure. Therefore, we rarely use this incision in our practice.  

IMPLANT TYPE (SALINE vs. SILICONE)
Silicone implants were taken off of the market in 1991 because they were suspected of causing an auto-immune disorder. This has been disproven and these implants have been returned to the market. Both saline and silicone implants are safe and can produce an excellent result. However, each implant type has advantages and disadvantages that must be considered by the patient. The primary advantage of silicone is that it feels most similar to breast tissue. It also is lighter and has less effect on the breast that has poor support and is usually a better choice for use with a breast lift. The biggest disadvantage is that implant failure is typically only detectable by MRI. The FDA recommends routine MRI follow-up for patients with silicone breast implants. Saline breast implants are best in patients that have denser and greater soft tissue coverage to hide the implant. Saline implants are less expensive and there is rarely any doubt when one fails. Saline implants are more palpable (easier to feel) and have a higher risk of visible wrinkling. 

SELECTING AN IMPLANT SIZE
This is one of the most difficult challenges of this operation. Every surgeon has their methods. The bottom line is that we want to achieve your size goals but help you to avoid potential complications and problems related to going too big. These problems include stretching of the lower portion of the breast, higher risk of palpability, visible wrinkles and an unnatural appearance. We typically address size in two ways, an objective and a subjective manner. Objectively, measurements of key dimensions of the breast can give us a range of implants that will fit your breast. Subjectively, you can help us understand your goals by bringing in pictures that demonstrate your goals. Other means of sizing are trying on implants but this is often unrealistic. One key to success is spending as much time as is needed at a pre-operative visit and on the day of surgery to understand your goals. 

BREAST ENLARGEMENT WITH FAT TRANSFER
This is a new concept in breast enlargement that most Board Certified Plastic Surgeons, are awaiting better long term data before injecting autologous (from the patient) fat into the breasts. The major concern is long term effects of fat injections into the human breast, both in terms of potential tumor formation and interference with imaging studies and physical exams. While there is no proof that these concerns are justified, guessing wrong could prove harmful. A recent American Society of Plastic Surgery task force opened the door for consideration of this procedure, but advised caution and deliberation when considering this procedure In order for this treatment to be effective, good quality fat is required. The Body Jet has been used extensively in Germany to harvest fat for transfer to women’s breasts. German MRI studies have verified a 70% take of fat transfer to breasts. Multiple procedures are usually required to obtain a significant increase in breast size. Cost can exceed that of an augmentation with implants.

OUR APPROACH

Remains conservative (safe) but we are hoping this treatment is shown to be safe and effective.

BREAST LIFT (MASTOPEXY)
A breast lift, or mastopexy, is a surgical procedure that lifts and reshapes the breasts. It can also reduce the size of the areola (the dark skin surrounding the nipple). Many women seek mastopexy following weight loss, pregnancy or menopause. There is a common misunderstanding that a sagging breast can be lifted by using a large implant. Simply adding a large implant to a sagging breast will result in a larger sagging breast, so this should be avoided. Breast lift is a very satisfactory procedure.

There are a number of possible surgical techniques based on the amount of sag, the areola size, nipple position, breast volume, and the amount of excess skin. Specific procedures are discussed during the consultation. The procedure may be performed under either intravenous sedation or general anesthesia. The operation takes about three hours as an outpatient.

Since minimal breast tissue is removed in a mastopexy, the breast will remain the same size. If patient would like to be larger, implants can be placed during this procedure, The value of a personal consultation with a surgeon certified by the American Board of Plastic surgery cannot be over emphasized. Mastopexy with breast augmentation is one of the most challenging cosmetic operations.

BREAST REDUCTION
Breast reduction is an elective procedure for decreasing the size and correcting the sag of oversized breasts. This condition can have psychological implications for a young woman, but can be the source of physical symptoms in women of any age, including shoulder, neck, breast and back pain, shoulder grooving from bra straps and often headaches.

The surgery is usually done under general anesthesia, but can be done with just local and sedation. The procedure is designed to remove excess breast fat, glandular tissue and skin to achieve a breast size in proportion with your body and to alleviate the discomfort associated with overly large breasts. Nipple/ areolar complex is elevated to the appropriate level.

This procedure may or may not be covered by insurance. A consultation is necessary to address the insurance issue, as well as, to determine the appropriate procedure.

REDUCTION OF THE MALE BREAST
Gynecomastia, enlargement of the male breast, is a relatively common occurrence during puberty, as well as, later in life. Although cancer can occur in the male breast, symmetrical, soft enlargement of the male breast is a benign and self-limited process. Most adolescent breast enlargement dissipates spontaneously. Only occasionally is surgical treatment required. Middle aged men can develop breast enlargement, which if of significant size and psychological concern, can be reduced surgically. Various methods including liposuction and surgical excision are used depending of the specific situation.

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Breast Augmentation

OUR APPROACH
Our goal is cosmetically pleasing, long-term results -- a soft, natural appearance with an appropriate size for the individual patient.

• Anesthesia for breast augmentation: the type of anesthesia for this surgery is a decision made by the surgeon and patient and is based on several factors including patient's general health and preference. Local anesthesia only for breast augmentation has been suggested, but in our experience it is a bad idea since this approach can be uncomfortable. However, our preference of anesthesia for breast augmentation is twilight sleep which provides safe, effective anesthesia and shorter recovery with less postoperative nausea and vomiting. General anesthesia is used when appropriate or when it is the patient's preference. (See Promises and Pitfalls: Anesthesia ».)
• Location of surgery is also a choice of the patient. We provide surgical care in a variety of facilities including major hospitals, outpatient surgery centers and in our office-operating suite. Our office surgical suite is accredited by the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF). (See Promises and Pitfalls: Office Surgery ».)
• Specific surgical technique varies with individual patient, and is determined and explained at the initial consultation. Consultation is with the surgeon who spends adequate time with the patient to explain specifics of physical findings, recommendations and surgical plan.
• Implants used depends on the particular needs and request of the individual patient. Saline filled implants can be put in though a small incision, which is a factor when the peri-areolar incision is used. These are very safe and effective implants and are an option for patients to consider. In January 2007, silicone implants were released for general use and provide another choice for patients to consider. These implants are safe and effective and result in a softer feeling breast. A slightly larger incision is required (usually under the breast) and these implants are slightly more expensive than the saline implants. Both saline and silicone implants usually result in very satisfactory results.
• Suction drains are sometimes used.  When determined appropriate small drains are used to minimize fluid accumulation thereby preventing swelling and pain in the early postoperative period. These drains effectively minimize early distortion of the appearance of the breasts are-- the immediate appearance of the breasts are similar to the long-term appearance.

WHERE ARE THE BEFORE AND AFTER PICTURES?

Breast Augmentation

PROMISES

Breast augmentation accomplishes an enlargement and enhancement of the female breasts to improve body proportions and a patient's self-image

PITFALLS

• Selecting a Surgeon: Because any physician can represent himself/herself as a plastic or cosmetic surgeon and can do this procedure in an office facility, a patient should always check the surgeon's credentials. (See Promises and Pitfalls: Credentials ».)
• Variation in Techniques and Results: Though simple in concept, there are many specifics in technique that vary from surgeon to surgeon. A patient should approach the decision about this surgery in a cautious and thoughtful manner.
• Goals: A patient should have a clear concept of exactly what she would like to accomplish with surgery, and be able to express these goals to the surgeon. She should spend time with the surgeon, understanding his/her technique, goals and opinions. It is important that the surgeon determine whether the patient's goals are realistic. This discussion should be the responsibility of the surgeon, not an assistant.
• Breast Sagging: Breast implants alone cannot be expected to correct significant breast sagging. It is a mistake to place large implants to fill a sagging breast. This can cause unnatural and aesthetically displeasing appearances that can be difficult to repair.
• Risks: Although serious complications are rare, this is a real surgical procedure with all the potential risk of any surgery. Secondary procedures may be indicated in approximately 5-20% of patients undergoing breast augmentation. In order to be able to anticipate future expenses, the patient should be advised of her financial responsibility for any secondary surgery required.
• The Consultation: It is important to approach a consultation with an open mind. The research a potential patient does is helpful. Although there is a lot of information available in books, on the Internet, and in the media, it can be very difficult for the average individual to separate marketing hype and opinions from fact. The only way to find out specific information is in a personal consultation.
• Surgical Judgment: The responsibility of the surgeon goes way beyond the role of a surgical technician. The surgeon is expected to exercise judgment in recommending, planning and carrying out a surgical procedure. This judgment is the result of training and experience, and is the reason for choosing a surgeon certified by the American Board of Plastic Surgery. (See Promises and Pitfalls: Credentials ».)

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