Cosmetic Surgery: Promises and Pitfalls™

Our Approach in Dallas to Breast Augmentation Surgery

  The Breast Augmentation Procedure

• Anesthesia
  • General anesthesia: unconscious anesthesia
    • Commonly used for breast augmentation
  • Local with intravenous sedation: twilight sleep
     
• Surgical Procedure
  The concept of the procedure is simple -- placing an implant in a pocket or space behind the breast tissue to increase the breast volume. Surgical techniques differ, depending on the surgeon, incision, implant position, etc. There are two major differences in goals of the procedure. Their differences are rarely discussed with the patient:
  • Large pocket: Creating a large pocket (bigger than the implant) requires more extensive surgical dissection, but has a softer feeling breast in the early post-operative period. Many surgeons attempt to maintain the large space and, hence, soft breasts, by having the patient manipulate or massage the implants post-operatively.
  • Small pocket: Creating a pocket that just accommodates the implant. This is technically easier and quicker to do, but, in our opinion, the resultant breast is firmer than with a larger space. This is used for shaped and textured implants.

Back to Topic List
 

Potential Risks

Bleeding -- Bleeding is not life threatening bleeding but rather an excessive collection of blood in the pocket surrounding the implant. This can cause excessive pain and swelling, usually just on one side. Treatment often requires a return to the operating room to remove the accumulated blood and generous washing of the pocket. Care is taken to identify any ongoing bleeding and stop it, though ongoing bleeding is uncommon. Failure to remove the blood can lead to pain in the short-term and capsular contracture in the long-term.

Infection -- Infection is a very rare complication but if it occurs can make the patient very sick and lead to implant exposure if not dealt with urgently. Infection presents as a painful, swollen, red breast. Acute or early infection almost always requires the implant to be removed and not replaced until the infection has cleared and inflammation has subsided, usually at least 3 months. Late infections are uncommon and are usually associated with infections or bacterial exposures elsewhere in the body. Often these infections can be treated with antibiotics alone.

Wrinkling -- Wrinkling are visible creases of the implant that are apparent on the breast skin. This is usually seen in the cleavage area when bending forward. It is seen when patients have thin tissues, implants place on top of the muscle, textured implants, under-filled implants or oversized implants.

Deflation -- Though your implants should last a good long time, it is likely that someday you will experience a deflation. If you have saline implants, the shell tears and the saline is absorbed presenting as an obvious decrease in size. No special tests or x-rays are needed to make a diagnosis, it is that obvious in most cases. If an implant deflates, surgery is required to replace the implant. The manufacturer of the implant offers warranties for implant replacement and, depending on time, may cover a portion of the surgical fees. For more warranty information, please see the Mentor Website. How often do they rupture? This varies from one person to another but a recent study shows a 3.7% deflation rate in 7 years with a smooth, round implant. A common myth is that implants should be replaced every 10 years. This is not true and implants only need replacement if there is a deflation or other problem.

Silicone implants are different. There is usually no clinical signs of rupture and they do require radiographic evaluation to diagnosis rupture.

Capsular Contracture -- When a foreign device like a breast implant is place in the body, scar forms around it. Obviously, we would like that scar to be as thin and soft as is possible and this is the usual case. However, in a small number of patients, this scar capsule gets thick and firm making the breast firm and may even move the implant and misshape the breast. The cause or causes of this are unknown for certain, but are most likely related to a bacterium that doesn't cause an infection but only an inflammatory process. Prevention is through the use of antibiotics, larger pockets and post-operative massage. If a significant capsular contracture occurs, surgery may be required.

Secondary Surgery -- Although breast augmentation is widely performed and produces very satisfactory results, this surgery may require an additional procedure. In fact, of all the cosmetic procedures, breast augmentation has the highest rate of secondary surgery reported in some places as high as 20%. However, true complications are rare and the usual indication for re-operation is aesthetic (appearance) considerations such as changing size.

Re-operation rates are often touted as an indication of the quality of a given surgeon. However, in cosmetic surgery re-operation rates are effected by other factors such as the surgeons agreeing to re-operate and the patients willingness to pay additional money to make a change. Low rates of re-operation do not necessarily reflect the quality of the surgery or patient satisfaction. Preoperatively, patients should understand the possibility of secondary surgery and know her financial policy with respect to complications and re-operation. Further, she should be provided with a copy of the manufacturer's warranty. In other words, the patient should be aware of her financial responsibility if a second surgery becomes necessary to correct a problem, to treat a complication or to improve the initial result.

Back to Topic List
 

Incision Choices

• Inframammary -- incision under the breast
  • The easiest approach from the surgeon's standpoint, though many surgeons believe this approach limits the exposure to some areas.
  • Major disadvantage: resultant scar is in a visible location, which is permanent, but may fade with time.
• Periareolar -- incision around the lower border of the areola (pigmented part of the breast)
  • Technically, it is somewhat more difficult, but provides excellent access to the surgical space for implant placement (the pocket).
  • If the incision is carefully placed, the scar is invisible. Abnormal scars are extremely rare in this area.
  • In our experience, there is no greater incidence of nipple numbness with this approach.
• Transaxillary -- armpit incision
  • Technically, it is much more involved, as it usually requires a general anesthetic and the use of specialized equipment to adequately visualize and incise the muscle in the lower part of the breast.
  • Though scar usually does well, it is located in an area that is visible in many clothes, so if the scarring is abnormal, it can be obvious.
• Transumbilical -- umbilical or belly button incision
  • An incision placed away from the breast has marketing appeal, but is of questionable advantage over the other incisions.
  • Also, as in the armpit approach, specialized equipment is required.
  • This approach has not had wide acceptance by plastic surgeons.

Back to Topic List
 

Above or Below the Muscle?

• In women with little breast tissue, as is the case for most candidates for augmentation, the pectoralis major muscle is used to hide the implant.
  • On Top of Muscle (subglandular)
    • This was used extensively with the silicone gel implants, but used more selectively with saline implant due to higher risk of palpability and wrinkling.
    • Used only in those patients with adequate breast tissue to hide the implant.
    • Often produces a more rounded breast shape.
    • Major advantage from the patient's perspective is less postoperative pain than under the muscle.
    • Some surgeons believe this gives added lift in patients with sagging. This is highly disputable and can be problematic when used in this situation.
    • A disadvantage: there is more potential wrinkling and palpability of the implant.
  • Under the Muscle (submuscular or subpectoral)
    • This is the most common location for the saline implants.
    • Advantages: implant hides it better, there is a more natural slope of the upper breast and there is usually no perceptible difference in muscle function.
    • Disadvantage: postoperative discomfort may be greater. This can be controlled to some degree with muscle relaxers. 

 
Back to top

Our Dallas Plastic Surgeons' Bios  +  About Us  +  Cosmetic Surgery Procedures
Promises & Pitfalls  +  Am I A Candidate?  +  Before & After Photos  +  Skin Care
Patient Forms  +  Contact Us  +  Office Locations  +  What's New  +  Home  +  Sitemap

© Copyright 1999-2009 North Dallas Plastic Surgery. All rights reserved.