Procedures

Procedures : Breast Augmentation

Patient Before and After Pictures – Please feel free to call our office at 214-823-1978 and speak with either Annette or Kurthene to have photographs e-mailed to you. We do not post these photographs on the internet because of widespread internet pornography, but welcome your call.

When should you consider Breast Augmentation and what can you expect?

It would seem intuitively obvious that the indications for breast augmentation would be anyone wanting to enhance the size of their breasts. Although that goes without saying, there are patients who are more ideal candidates than others. The ideal candidate would be a patient who desires breast enhancement but has enough breast tissue to adequately cover the implant. Typically the most ideal candidate would be a woman who has had an average B size cup who has had children and has now lost some of the volume and has mild droopiness to the breast in which she wants to be enhanced to her original shape or slightly above.

However, it still remains true that any patient wanting larger breasts is a candidate for breast augmentation. However, many women compare the results with friends and it can be very frustrating if the patient does not realize that the chest width, bone structure, and most importantly, the amount of breast tissue one starts with and the droopiness of the breasts one begins with determines the eventual outcome. There are certainly technical considerations that must be maintained, however, one must keep in mind that it is literally impossible for someone with a board-like chest with hardly any breast tissue whatsoever who wants to be enlarged to a full C to D breast not to see the implants. This certainly means that one could have the desired look in clothes; however, a general rule is that the larger the implant compared to the size of the breast one begins with, the more the breasts can be seen and the higher the complication rate. Having said this, many patients with very small breasts who want to be large are happy with the results although they must have a realistic expectation.

Technical Considerations: There is a point at which the breasts can be so droopy that they cannot achieve a satisfactory cosmetic appearance without tightening of the breast itself. This procedure is called an augmentation/mastopexy. Although there are rare exceptions to the rule, a good general outline is that if there is a greater than 9 cm distance from the nipple to the fold of the breast as measured along the inframammary fold then a mastopexy is needed. The exception is if the patient is willing to accept very large breasts. The best analogy given here is that if one starts with softball size breasts and expands to a basketball size breast during breast feeding, then typically the basketball size skin will not snap back to the softball size in most cases, especially with multiple children. Therefore, when one is augmented a basketball size implant will be required to fill a basketball size envelope. The only way to achieve the original softball size breast is to reduce the basketball size skin envelope to the softball size envelope. By reducing the skin envelope to the desired amount one can minimize droopiness and maximize breast contour.

Goals and Hazards:

My goal in breast augmentation is to achieve a natural appearing breast at the size that the patient desires. Sometimes this cannot be achieved if the patient desires too large an implant or if there are physical limitations on that particular patient as described above. However, within reason there are hazards to be avoided. Particularly one must avoid the breast riding too high and the breasts being spaced too far apart. Each person’s chest wall will dictate the degree to which that can occur. However, in general those are two major giveaways of an unnatural appearance and a sign that the patient does not have natural breasts, but rather breast implants.

What type of implants should I get?

Type of Implants:

I choose implants based on my goals for the patient to have the most natural appearing breasts. Both saline and silicone implants are options. I believe women are born with nipple and areolar complexes and a cone to the breast, and that this natural breast shape strictly needs to be augmented. There are physicians I respect that prefer anatomic or tear dropped implants. Although I respect them personally I disagree with this approach professionally, based strictly on the fact that these implants, in my opinion, have a tendency to ride too high despite their teardrop affect due to different thicknesses in the implant when placed underneath a tighter skin envelope. This can be overcome with more aggressive dissections; however, I do not like to destroy and over dissect the inframammary fold if at all possible since this natural fold will give the most natural appearing breast. Furthermore and more importantly, these implants are textured and I disagree with the use of any textured implant due to the fact that it is immobile. Once a textured implant is sticky and sticks to the tissue it does not move. Therefore, even if the breasts look perfect when upright, when the patient bends over or lies down they are immobile and look artificial in my opinion. Therefore, I choose a smooth, round implant which allows the implant to move to the side when one lies down and comes back to the midline as a natural breast would. I believe that this approach achieves most effectively a naturally appearing breast shape.

Approaches:

I utilize all three popular approaches to breast augmentation. Inframammary, periareolar (through the nipple/areolar complex), and endoscopic Transaxillary augmentation (This approach is from the armpit with the aid of an endoscope.) The inframammary approach is the most popular among my patients, as these patients typically want to minimize any scar or the small but slightly increased incidence of decreased sensation when going through the periareolar nipple complex. Some younger patients want to avoid scars altogether on the breast and opt for the armpit incision; however, they must understand that this incision is the only one that is not hidden under a bra or bikini. Therefore, at least in the first 6 months to a year this incision can be noticed as a red, immature scar. This scar usually heals exceptionally well and long term the goal is achieved of an almost imperceptible scar. The inframammary fold scar is approximately 1 to 1-1/3 inches long depending on the anatomy of the patient and is well hidden underneath the breast. In the upright position this scar is unnoticeable in almost every circumstance.

Choosing of Size:

There are many different approaches to the choosing of size. I prefer to determine the patient’s biases as the time of consultation by taking a detailed history and getting to know the patient personally. Photographs of models in swimsuits or bras are helpful to determine what the patient desires. Oftentimes the patient will quote cup sizes, but the pictures do not correlate. Therefore, pictures are encouraged. Also, the general lifestyle of the patient, their activity, their modesty or lack thereof, is helpful to take into account. When all things are considered detailed notes will be taken and placed in the patient’s chart as well as any photographs, and a thorough discussion will be carried out at the time of consultation. During the operation several times, and at the completion of the case in the operating room, the patient is set up to ensure a natural appearance of the breast and a shape and size consistent with the pre operative consultation.

What are the possible complications from this procedure?

Capsular contracture is the most significant complication of breast augmentation as it is the most common. It is a hardening of the breasts themselves; the implants do not harden. It is the scar tissue around the implants that squeezes the implants causing them to be hard. Once the scar tissue is removed, then the implants relax. It is much like a water balloon that is squeezed tight in your hands is firm, but if it placed on a table one can depress the water balloon very easily as it remains soft. Therefore, the theory of my operation is to maintain a pocket larger than the implant. (Please note: That is why the larger the implant with the less room for shifting results in a higher complication rate with regard to capsular contracture.) The capsular contracture rate is widely reported and varies from 10-30%, but suffice it to say that it is higher with silicone implants than with saline on average 5-7% higher. The responsibility I have is to make a pocket adequate and a larger size than the implant and the patient has the responsibility to move the implants in all 4 directions post operatively for several week and months on a regular basis to maintain the pocket. Once this is done then the results are genetically determined with regard to capsular contracture. There is a low-grade infection theory to capsular contracture, as well as a response to the silicone shell or filler; however, it is interesting to note that it is very common for capsular contracture to develop only in one breast. Therefore, we are still somewhat puzzled by the overall etiology. I can assure you that everything is done to maintain the capsular contracture rate, and the infection rate at the lowest possible state. The pocket is irrigated with antibiotic solutions. There is current evidence that antihistamines and anti-inflammatory given pre and post operatively for 6 months may limit the rate of capsular contracture, and although this has only been proven in laboratory animals, the low morbidity of taking a non-specific anti-inflammatory and antihistamine such as Claritin or Zyrtec justifies its use in our patients currently. We will always try to stay on the cutting edge of this technology and minimize complications as much as humanly possible.

Rate of Deflation:

The rates of deflation vary again, but are noted with saline implants. They usually occur with a fold or wrinkle in the implant underneath the breast and a slow, constant rubbing against the capsule that eventually causes a pinpoint leak of the saline. This is not dangerous as saline is simply expelled in the urine, but is noticeable as a deflated implant. One simply calls the office and an implant exchange is carried out within a few days. Women often refer to this as an implant rupture but usually a rupture does not occur due to trauma. Oftentimes trauma may simply push a pinpoint weakness in the implant to being leaking.

Skin sensation changes:

It is not uncommon for the skin to have decreased sensation, especially on the inner aspects of the breast, if one starts with lateral breasts and wants cleavage or breasts that are close together in the midline. When dissecting near the midline of the chest, nerves are divided in order to get the breasts to move to these positions. However, this does not translate into decreased nipple/areolar complex sensation. Every precaution is taken to avoid decreased sensation to the nipple/areolar complex and this loss of nipple/areolar sensation should be in the range of 1-2%. It is not uncommon for there to be temporary decreased or even increased sensation in the nipple/areolar complex (sensitive to the touch); however, any sensation at all will almost uniformly result in a return to normal sensation in the nipple/areolar complex. Please note, the incidence of nipple/areolar sensation loss is substantially increased for revisionary work since the nerve that supplies the nipple/areolar complex is bluntly pushed aside during the original breast augmentation surgery and is therefore lying on the capsule in the scar tissue around any breast augmentation. This has to be carefully dissected free and can be damaged on revisionary work.

Infection:

Infection is uncommon with breast augmentation, but is extremely problematic and inconvenient if it does occur. The problem exists in that if breast infection occurs the implant must be removed and left out for approximately 6 months until the breast softens and then the implant can be replaced. The incidence of infection is approximately 1% or less in our practice. For more information on the incidence of complications you can CLICK HERE to see an article written about 3000 cases in our center. To find out more about the facility we use for our procedures please CLICK HERE for a link to the Dallas Day Surgery Center. A special bra can be fitted if only one implant is infected which can be utilized for the time period until the implant has to be replaced. If you have one infection it does not mean that you are at higher increase with the next augmentation. Having said this, it is extremely rare in my practice, and I have only had 2 infections in 13 years, one of which was a more complicated breast augmentation involving a breast lift aug/pexy in a 50+ year old cardiac patient, and the second was a rare infection 7 years after the augmentation in which the patient contracted tuberculosis.

Bleeding:

Bleeding can occur, albeit rarely, after breast augmentation. If it does occur it is usually accompanied by painful swollen breasts within the first 2-3 days, and usually the first 24 hours post operatively. This requires a return to the operating room, evacuation of the blood, thorough inspection of the dissected pocket, and replacement of the implant. This does not require removal of the implant permanently but just requires evacuation of the blood and correction of the bleeding vessel. This could occur due to increased blood pressure post operatively in the recovery room as these coagulated vessels can begin to bleed post operatively and randomly.

Cancer:

There is no increased risk of cancer with breast augmentation. There is some evidence that would even suspect that there is a decreased risk with breast augmentation, although this is not clearly understood. Although the risk is not increased, every woman with breast augmentation still runs the same risk of 1:9, 1:10 of developing breast cancer in their lifetime. It is also well known that a small percentage of the breast is not seen on routine mammography; therefore, one extra view is required (three views as compared to the normal 2 views). However, it is imperative to perform monthly self-examinations. It has been proven that monthly self-examinations and the extra view allow patients to pick up any breast cancer at a similar stage for women that do not have breast implants. Therefore, this responsibility must be taken seriously by every woman considering breast augmentation.

Autoimmune Disease:

Autoimmune disease was highly touted as possibly being caused by breast augmentation with silicone implants in the late 80′s to early 90′s. Although many lawsuits arose from these accusations, it has now been proven that there is no correlation between silicone breast implants and autoimmune disease. In 1987 the American Academy of Rheumatology concluded that they could find no cause and effect between breast augmentation and rheumatologic disorders. This should allay one’s fears even more when knowing that the unwarranted concerns were dealing with silicone implants. Today saline implants are used for primary augmentations in the United States today.

Fold flaws, Wrinkles, Irregularities, and Asymmetries:

These can occur in any breast augmentation. There can be subtle shifts. There can be irregularities, and it will be pointed out at the time of consultation any irregularities or asymmetries in the patient’s breasts pre operatively. It is the rare patient who has perfectly symmetrical breasts. 99% of women have some asymmetries in their breasts, and when breasts are augmented these asymmetries may be more noticeable. There are certain things that can be done to minimize these asymmetries, but natural appearing breasts have some minor asymmetries. However, fold flaws and wrinkles can be noted and they are more common with textured implants and implants that are not slightly over inflated. These are also more common for patients with larger implants and smaller breast pre operatively, as stated above. Once again, the smaller the breast tissue coverage the more likely it is for the implant to be seen, which makes intuitive sense. These cannot be totally avoided in certain patients, but can be minimized greatly by surgical technique of placing the implants under the muscle or over the muscle and by slightly over inflating the implants to avoid fold flaws and wrinkles. We place the majority of patients of primary breast augmentations underneath the muscle. This provides more tissue between the external environment and the implant; thereby maximizing contour and a natural appearance. There will also be slightly less implant masking breast tissue on mammography if placed under the muscle; however, this is a minor consideration. The exception to this rule is that it is occasionally beneficial to place the implant above the muscle in patients who have mild droopiness of their breasts and at least a B breast or greater, i.e., enough breast tissue to cover the implant adequately. If enough breast tissue is present but is droopy, a more direct lift on the breast can be done above the muscle and may save the patient a more extensive lifting procedure (mastopexy).

What procedures do you use and how do I choose the size I want?

Approaches:

I utilize all three popular approaches to breast augmentation. Inframammary, periareolar (through the nipple/areolar complex), and endoscopic Transaxillary augmentation (This approach is from the armpit with the aid of an endoscope.) The inframammary approach is the most popular among my patients, as these patients typically want to minimize any scar or the small but slightly increased incidence of decreased sensation when going through the periareolar nipple complex. Some younger patients want to avoid scars altogether on the breast and opt for the armpit incision; however, they must understand that this incision is the only one that is not hidden under a bra or bikini. Therefore, at least in the first 6 months to a year this incision can be noticed as a red, immature scar. This scar usually heals exceptionally well and long term the goal is achieved of an almost imperceptible scar. The inframammary fold scar is approximately 1 to 1-1/3 inches long depending on the anatomy of the patient and is well hidden underneath the breast. In the upright position this scar is unnoticeable in almost every circumstance.

Choosing of Size:

There are many different approaches to the choosing of size. I prefer to determine the patient’s biases as the time of consultation by taking a detailed history and getting to know the patient personally. Photographs of models in swimsuits or bras are helpful to determine what the patient desires. Oftentimes the patient will quote cup sizes, but the pictures do not correlate. Therefore, pictures are encouraged. Also, the general lifestyle of the patient, their activity, their modesty or lack thereof, is helpful to take into account. When all things are considered detailed notes will be taken and placed in the patient’s chart as well as any photographs, and a thorough discussion will be carried out at the time of consultation. During the operation several times, and at the completion of the case in the operating room, the patient is set up to ensure a natural appearance of the breast and a shape and size consistent with the pre operative consultation.

Post Operative Course

There is probably not another plastic surgery procedure in which women compare notes more than breast augmentation. I do not have one way of treating my patients. As you can see from the details above, implants may be placed above the muscle, below the muscle, different sizes, lifts, shapes, etc. I individualize the postoperative treatment care of my patients. If they have droopier breasts, I may place them in a bra post operatively. If they have smaller breasts and larger breast implants, I may want these implants to settle and drop and therefore will not place them in a bra post operatively. If during the operation the patient has been on aspirin or bleeds for whatever the reason, then drainage of any bloody fluid is mandatory to decrease their risk of capsular contracture. Although inconvenient, it is better in the long term, and I do not hesitate to place drains if necessary. However, it is much more convenient not to have drains, and if the condition warrants, the procedure goes well, and the pocket remains dry throughout the case, then drains will not be used. Again, individualization of each specific patient in her operative plan and postoperative care will be carried out. The post operative pain will be handled by oral pain medications and usually the first three days are the most intense, but tolerable with oral pain medications. An overnight stay at Dallas Day Surgery Center is recommended where one can sleep comfortably overnight and then be taken home the following day. After three days the intensity of the procedure diminishes greatly, as does the swelling, and the patient gradually improves so that a return to work at 7-10 days can be accomplished in most patients. Certainly some discomfort with jogging and running and sudden movements can occur for several weeks, but each week it improves to the point where there is a full recovery, usually be 4-6 weeks. Again, the post operative care is individualized, and if the patient is doing extremely well with minimal bruising and no discomfort, a return to light activity at 2-3 weeks is certainly indicated. Three to four weeks is more normal for exercise to begin. Certainly light work with weights on the legs can be carried out earlier than that on the arms, and no bend pressing or use of the pectoralis major for sub-muscular implantations can be carried out for 6 weeks. Aerobic exercise can begin as early as 2-3 weeks in some patients, but again 3-4 weeks is the norm.

What are the costs?

We do not feel that it would be appropriate or ethical to post prices for procedures on the internet. We do, however, understand that cost is a factor you must consider. We would be happy to speak with you about this so that you may determine whether the procedure you are considering falls within your budget. Our pricing structure is based on the time, complexity, and surgical costs involved. Please feel free to call our office at 214-823-1978 and speak with either Kurthene or Annette for more details.