Breast Procedures

Breast Augmentation
          One of the most popular cosmetic operations in the western world is augmentation mammoplasty (breast enlargement) with breast implants. Throughout the world there is a growing demand for this operation, and it runs a close third to rhinoplasty (nose alteration surgery) following liposuction in frequency worldwide. It is also one of the most satisfying of all cosmetic operations in terms of patient happiness, ranking on a par with cosmetic surgery of the nose and liposuction to remove fat.
            Every woman wants to look as good as possible in clothing and every woman wants to have a well-proportioned, pleasing silhouette. Classic beauties of the world have had firm, lifted breasts with balance and symmetry to the waist and hips. There is no question that aesthetic surgery of the breasts can result in a more pleasing appearance and a rebirth of self-confidence.
            There is a new flair for life and deeper sense of pride in appearance for women who have grown up with small breasts and suddenly have a full figure. They feel more fulfilled and less cheated by nature’s meager endowment. It is no wonder that women who observe fashion models and movie stars with full breasts have a desire to be what the world considers more attractive. Part of life’s challenge is to feel a rich sense of acceptance. Breast augmentation surgery alone will not accomplish this, any more than a nose change or liposuction will, but it does contribute to the overall satisfaction of feeling more feminine and lovely, and that is why so many women seek the procedure in today’s world.
            Two groups of women generally seek breast augmentation. The first is made up of women in their late teens or early twenties who have never enjoyed a well-proportioned bosom. The second includes women from the late twenties, all the way to the sixties. They may have lost breast size and shape after childbearing and/or breast-feeding. Or they may be women who have come to terms with their dissatisfaction of so many years without full breasts. They can afford the surgery and want the results that this procedure can bring. Both groups of women desire a more pleasing shape that is usually associated with a more youthful body and a better appearance in all types of clothing.

What Breast Surgery Will Do
            Basically, breast implants will make small breasts larger and fuller. To help you understand what this will do for you, the surgeon must visually examine your breasts. At the time of examination, you will be asked what it is you wish to achieve in breast enlargement in terms of size and shape. Your surgeon may have some questions for you and point out what is possible and what is not. Torso size, fat distribution, amount and distribution of breast tissue all play a role in what will give you the best result. Listen carefully to what he/she tells you. Make mental and written notes of what is discussed, so that you can determine in your own mind the probable results of the surgery. The surgeon will discuss with you the pros and cons of where the incisions will be placed and what type of implant will be used. He may show you samples of implants. If he doesn’t, you may want to ask him to show you one. At the examination time the surgeon will undoubtedly explain the best approach with the least amount of scarring for you.

Patient Choice of Implant
            Allow your surgeon to indicate what he thinks is best for you. Occasionally, after surgery patients wish that they had selected a larger or smaller implant. There are some who insist on smaller implants and know just what they want and why. The jogger or athlete may want them smaller for sports reasons, yet would like to fill out an evening dress or swimsuit. The choice may be difficult, but there is choice involved.

           Surgeons recognize that a cosmetic surgery patient is the type of person who is not satisfied with their present appearance and wants a visible change. It is important neither to overdo nor to under improve the appearance. The desire to change the appearance is a strong drive. This is normal, healthy, and fortunately often attainable.
          The drawings depict the two methods of breast implants. One method is to place the implant behind the muscle and the other method is to place atop the muscle.

          The common question regarding size of implants is what will look best for your body. Ask yourself what size you would like to be. Do you want to fill a "B," "C," or a "D" cup? In part, the answer to this question depends on how much breast tissue you already have. This may even be different for each breast. It is also not uncommon for a person to have different size breasts.
          Occasionally, a patient will choose implants that are too large for the body, or they may be so large that they over stretch the skin and may develop stretch marks that can be unattractive. This is why it is important to listen to the advice of your surgeon. Also, the smaller the implant, the less problem you may have with formation of capsule contractures. With smaller implants the feeling of firmness may be less noticeable. Also, the possibility of distortion is less with the same amount of capsule formation when the implants are smaller. There are very few older ladies who desire size D breasts. Having said this, a large number of studies have been done on satisfaction following breast augmentation surgery. Over 95% of women would repeat having their surgery done. The only thing that most would change is that the vast majority said that they would like to be larger.
On the other hand, you want the implant large enough to achieve full breasts. You will have a fuller look with larger implants and enhanced cleavage. Before and after pictures of previous patients can be helpful in selecting size of implants. Let the surgeon point out those patients’ photos that most closely fit your body type. Viewing the photos of those who have undergone the procedure allows you to see graphically what someone else has achieved by seeing the person before breast augmentation, and after.
           Be open with your surgeon. It is important that you communicate your desires, your concerns, as well as any fears you may have. Feel free to ask any questions you may have. Listen carefully to the answers. Be sure you understand and that the comments make sense to you. Some surgeons perform exactly the same operation on every patient. There are many variable between patients and your surgery should be tailored to you specifically, what your end goals are and what is best for you in terms of scarring and long-term sequelae. Your surgeon should be able to show you a repertoire of different approaches and results which were tailored to each patient. You should leave with all questions answered and a clear idea of what to expect. Remember though, breast augmentation and/or breast lift will provide improvement, they will not always yield perfection.
          In cases of unequal breast size, the surgeon can usually minimize this defect. Correction of asymmetry in volume, combined at times with a change in position of the inframammary fold (the underside of the breast on the smaller side) can give a pleasing balance to the breasts. The breasts will look more alike. Other asymmetries, such as inverted nipple, large areola, or ptosis (drooping or sagging) on one side require additional techniques for correction in addition to augmentation. A slight amount of droop can be corrected with just the augmentation and this is desirable due to the small incisions necessary for the procedure. Do not make the mistake of having too large an implant placed just to correct a significant droop, in this instance a breast lift procedure should be done at the same time as a more reasonable augmentation (this is called augmentation mastopexy).
          There are several implant manufacturers currently in the market. They offer the safest, most natural-appearing implants available. Implants are filled with a saline solution. In the history of breast-enhancement surgery, it was discovered as early as the 1960s that silicone liquid injections for breast augmentation led to unacceptable results fraught with complications. In 1963 the silicone-gel implant was developed. The bag consisted of a silicone membrane filled with gel that felt firm and had a teardrop shape.
          Today the technology of implants has improved. Saline-filled breast implants are presently available for initial breast augmentation. Improved and natural feeling silicone gel implants are available for reconstruction and repeat augmentation patients. Extensive research on silicone gel implants has found no harmful affects from their use. Newer implants are under development and there is a new gel silicone implant that does not flow when it is sectioned. These may provide the most natural feel yet provide patient peace of mind.
Sites of Incision
           As a rule, the surgeon selects the site of incision. There are at least three entry areas of the breast to insert the implant. The surgeon will discuss the site of implant entry and may even offer a choice, but it is best to follow the recommendation for best results. Most patients accept the surgeon’s evaluation as to the best incision site.
           For the patient with drooping breasts, in which the skin of the breast touches the skin of the chest wall when the patient is standing upright, the inframammary incision (under the breast) is performed by placing the incision slightly up on the breast, perhaps one-fourth to one-half inch above the inframammary fold. The incision will be almost completely hidden and may be the most preferred site of entry. This is an excellent incision site in non-Caucasian patients with dark skin and dark areolas who desire an incision on the breast and not under the arms.
           Ordinarily, the areola incision, made in the wrinkles of the brown skin of the areola, heals with the least amount of visible scarring, except in pendulous breasts. This is often the preferred incision site in those individuals with very light colored skin since the incision is almost imperceptible. This incision also allows full access to the breast tissue and can be used should re-operation be necessary.
           The areola approach is the only one of the three most-used incision sites that invades the breast tissue itself. The thousands of surgeries performed have demonstrated that there is almost no danger of breast nodules or cysts developing in the lower portion of the breast when this approach is used. Many patients who have had this approach have subsequently become pregnant and have breast fed their babies. This is true of all approaches. Breast self-examination and mammography can also be done without difficulty.
           The under arm incision is the only one of the three most common incisions which leaves no scar at all on the breast or chest. This is preferred if the patient is to be seen nude a great deal. The down side of this incision is that it is visible when the patient raises their arm or is in sleeveless dresses. There is also a problem in that if repeat surgery is necessary or if there is a problem with bleeding during the surgery, a second incision may be necessary. The use of an endoscope allows for full view of the breast pocket through this incision. It is still necessary to place a second incision for future surgeries should they become necessary.
            There are other lesser-used incisions such as that at the level of the belly button. This incision is almost imperceptible but it is far removed from the area of surgery and special instrumentation is needed. The breast pocket (the space where the implant is to be placed) cannot be made directly by this route and it is very difficult to make the breasts as even as by other methods of implant placement. This raises the risk of implant rupture or patient injury. Should re-operation be necessary, additional incisions are necessary. Many implant manufacturers do not cover the cost of implant replacement in the event of rupture if placed by this method. The incisions used in augmentation surgery with saline-filled implants is only about one inch to one and a half inches long, it stands to reason that this incision placed closer to the site of the procedure is the best for most patients.

Breast Implants
           Government regulators control implant manufacturers today. It is their job to offer the safest implant. It is very difficult to make a completely safe implant that looks natural. The saline-filled implants are not optimal aesthetically but are safe in the event of rupture. Many strides have been made in the past few years in this area. The manufacturers know that what the patient wants is the best possible appearance with the least amount of problems. Some implants are filled with a saline solution that, if they should leak (rare), will not cause infection or other medical problems. Others are filled with a silicone gel. There is also a combination saline and gel implant that is used. Gel filled implants and combinations are less used today because of increased government regulations.
           In the 1970s, saline-filled implants came on the scene. The problem with these early saline implants was the leakage and deflation rate, which had crept up to nearly 25 percent of those receiving the implants. Saline implants used today rarely leak, due to improved technology. Both saline and silicone gel implants come in a smooth surface or in a textured surface. Capsular contracture (a tightening around the implant causing it to feel abnormally firm) is thought to be less frequent with the textured surface implants. There are two possible locations for implants in the breast: beneath the pectoral muscles or between the muscle and the breast tissue. Let the surgeon decide which is best. You can ask why one or the other, but at this level of understanding about the procedure, where the implant is placed is the surgeon’s preference in each individual case. It is a technical matter that the surgeon must decide. Basically, the placement of the implant beneath the muscle is not physiological. The breasts will be further apart and will not appear as natural. The problem is that with the currently available saline-filled implant, the outline of the implant can be very visible if not placed under sufficient tissue. If a more natural looking implant was available filled with a more viscous filler, all implants would likely be placed on top of the muscle.

Risks
           Infection is always a risk with any surgery. Breast surgery is no different. Should infection develop, the surgeon has a host of acceptable methods to deal with it. The fact that there is a foreign body in place increases the risk of infection when compared to surgery where only the patient’s tissues remain. In the extremely rare cases where the breast patient develops an infection, it is usually best to remove the implant and leave it out until all infection is gone. When the tissues are soft and pliable again (a minimum of three months in most cases), then the implants can be replaced in the breast.
           Bleeding is another factor to guard against and breast hematomas are a not too infrequent complication of the surgery. In severe cases this may require return to the operating room for removal of the blood clot. Drains may be used when necessary to help prevent this complication but careful surgery by a highly trained plastic surgeon is the best way to reduce the risk of this complication.
           Scarring occurs due to the nature of placing an implant under the surface of the skin, where an opening has to be made. Most incisions are made in an area where they are hidden from view. Many things can be done to make scars look better should that be necessary. These range from the use of silicone gel or sheeting on the scar surface to injection of the scar with steroids to excision of the scar and changing its direction with plastic surgical techniques. These procedures are rarely necessary.

Asymmetry
            As with scars, all breasts are different to some extent. It can be mentioned that nature made no two snowflakes, grains of sand, or anything else a human can see, exactly alike. Whether or not there is significant asymmetry is a matter of opinion. The patient is the best judge of this and it is important for you to tell the doctor of any perceived uneven features of your breasts prior to the surgery. These can often be addressed by the surgery and largely corrected.
          Many asymmetries exist before surgery. The surgeon will try to correct what is visible and make the two breasts as symmetrical as possible during surgery. The surgeon may also be able to improve abnormal shaping of the chest with implants.
          With time, in the event of a capsule forming around the implant and contracture of the scar tissue occurring, the breasts can become asymmetrical. This often needs to be corrected with a repeat surgery.

Breast Volume
         The size of the breast can be controlled. The doctor can use implants of different volume to help correct asymmetries in size and shape. There is a wide range of implant sizes and shapes to fit the needs of individual patients, and an experienced surgeon knows which size to place in which breast.

Firmness
           Firmness occurs due to capsular contracture. There is a tightening of tissue around the implant, causing it to feel abnormally firm. Often it will not affect overall appearance. Be assured that this is not a medical problem in the usual sense. It is a matter of softness versus firmness. There are exercises that your doctor may show you if you need them that help to soften the breasts following implant surgery. At times additional surgery is needed to correct the firmness.

Breast Lift (Mastoplexy)
          This procedure raises and reshapes sagging breasts. It is called a mastopexy. The surgeon removes excessive skin and repositions the remaining breast tissue and nipple. Their will be swelling and bruising along with discomfort, even numbness, but the results are most often rewarding. Some scarring is to be expected, but in most patients it is quite acceptable. The scar varies with the amount of droop that was present and the amount of skin that needs to be removed. In order to give a natural appearing breast, an incision in the shape of an anchor is necessary, i.e. there is a scar around the areola, down the meridian of the breast and then along the inframammary fold for a variable length. The procedure and scar length can be abbreviated for smaller lifts to the point that a small lift can be done with only an incision around the areola. To try to perform a major lift through just this incision is a terrible procedure in my opinion with very widespread scarring and flap breast shape as a result. The lifting procedure can be combined with breast augmentation (augmentation mastopexy) in those individuals who desire to be larger and have a large amount of droop.
          Recovery takes one to two weeks depending upon the degree of lift performed. The results last many years.

Breast Reduction
         Large, sagging breasts can cause back pain, pain of the shoulders from bra straps almost embedded within the skin, infection and sweating constantly under the breasts and a host of other discomforts. There are also psychological and practical problems when a woman has large breasts. The breast reduction removes excess breast fat, glandular tissue, and skin. Also as in mastopexy, there is repositioning of the nipples and areola and remaining tissue. In very large reductions, it may be necessary to detach the nipple and areolas and place them as free grafts on the new breast mound. This obviously completely denervates the nipple and severs all of the glands so that erogenous sensation and breast-feeding are not possible. This is only done in a very small number of cases and may be discussed fully with you by your surgeon prior to it being contemplated. Drains are often necessary for a few days. This is occasionally a medical problem that is covered by medical insurance. Surgery can take up to four hours and is done under a general anesthetic. At times it can be performed in the surgeon’s surgicenter, or otherwise, hospital surgery is required.
       This is a complex surgical procedure with very real risks of bleeding and infection. Yet, it should only be performed by a highly trained plastic surgeon that routinely performs many such procedures. When so done, the procedure is one of the most rewarding for both patient and physician. The patients tend to be even more appreciative than those following augmentation procedures.
         Following surgery there will be bruising, some numbness, and swelling. Also, scarring remains. There is usually some shift in the size of breast after a few years, but not a great deal unless there is excessive weight gain. There is no long-term hardening of the breasts since only your own tissue is present. The initial recovery time is usually one to two weeks. A lesser procedure that removes the fat of the breast, decreasing the size, can be done with almost no scarring.
          Surgery for breast reduction is performed by removing a section of the breast above and to the sides of the large breast. At times the surgeon may replace the nipple to achieve a more lifted look to the breast.

Breast Reconstruction
           The absence of the breast following mastectomy for breast cancer can be emotionally devastating and an awkward adjustment in appearance. Fortunately, there are several surgical techniques that can restore the shape and contour of the removed breast.
           These techniques include simply placing an implant under the chest muscle, tissue expansion, followed by placement of a permanent implant, and flaps. Flaps involve taking tissue from another part of the body to use in building a new breast. The latissimus flap uses tissue from the back, while the TRAM flap uses tissue from the abdomen. Very pleasing results can often be achieved with these techniques, allowing a more complete self-image. The final result can be made complete with making of a nipple and tattooing of the areola.
          As was stated in the beginning, breast surgery is the most satisfying of all cosmetic surgery procedures.

          Classic full breasts that so many women wish to have as a pleasingly, shapely body.

Before                          After

Before                           After

Before                                After