Breast Augmentation
Procedure: Breast Augmentation
Surgery Length: 2 -3 hours depending on extent
Anesthesia: General
Where: Outpatient or overnight stay.
Recovery: Patients wear a support bra for 1 week after surgery. Temporary numbness, swelling or bruising, Discomfort with movement of chest muscles
Back to work: Back to work in 4-9 days; avoid strenuous activity for 3-4 weeks.
Full activities: After 4 weeks
Risks: Bleeding, scarring, infection, scar tissue resulting in capsule formation thus requiring re-augmentation, possible future Implant rupture requiring implant replacement and possible need for capsulectomy, possible future breast-feeding compromised
Augmentation of breasts is particularly done in those patients who have had breasts that have shrunk following pregnancy and particularly in those cases of extended nursing. Augmentation is also utilized in those cases of breasts that have been small in women all their lives or in cases of where one breast is inordinately smaller that the opposing breast.
Lack of breast development or losses of breast contour following weight loss or pregnancy are problems seen in many women. In some cases the breast shape can be restored by increasing the breast volume of the sagging breast with a breast implant. The patient who has no breast development will require simple augmentation with a saline or silicone implant.
The augmentation procedure can be performed from two commonly used incisions. One is around the nipple (periareolar) and the other is just above the crease underneath the breast (inframammary). These approaches are more advantageous than a rarely used incision coming from the axillary (armpit) area. Using the armpit incision, the approach is very blind and one cannot detect bleeding. The nipple incision affords the best scar. This incision is said to possibly injure the nerves of feeling, but in our experience that has not been the case. With any type of incision (periareolar, inframammary or axillary) there can be some damage to the nerves of sensation. However, this is usually temporary and very infrequently permanent. In cases of very small nippled patients we are forced to use the inframammary incision. The inframammary scar (under the crease of the breast) can show with the use of bathing suit tops. It can be covered by a breast, which tends to sag, but the inframammary scar can spread and even require revision (re-excision). The nipple incision can also spread and become thickened, but this is seldom seen as compared to the inframammary incisions. An Inframammary incision bear the weight of the implant and are more prone to coming apart (dehiscence) then is seen with the other incisions.
Augmentation of breast tissue can be done with a saline implant filled with saline (salt water) or an implant filled with silicone gel. Surgical implantation of the implant through either the nipple or inframammary incision can be performed in two ways. An implant can be placed submuscular (put underneath the muscle,), of the chest wall, i.e. (pectoralis major muscle), thereby protecting the implant with more skin and muscle tissue. In some instances this decreases the incidence of scar tissue around the implant as compared to placing the implant underneath the breast tissue (subglandular placement). Scar tissue forms around the implant as the body’s natural defense against foreign material. The more compact the scar tissue, the harder the feel to the implanted breast. However, there is some problem with placing the implants under the muscles in women who have drooping in their breast skin (ptosis). The implant tends to ride higher on the chest wall and the appearance is one of a slightly “snoopy nose” breast, i.e. the loose breast tissue hangs over the breast mound under the muscle. In addition, patients who have implants placed under the muscles may experience some discomfort with movement of the muscle tissue, especially during athletic activities.
Submuscular implants tend to ride outward as well as upward and may not lend to the midline cleavage that can be acquired with subglandular implant placement. As far as positioning the implant under the breast tissue (subglandular) there is found to be a higher chance of scar formation and subsequently a firmer breast. All implants, like any foreign body, predispose to secondary infection. For this reason, patients are prescribed antibiotics at the time of surgery or at the time of any other surgical procedure, which may occur subsequent to their augmentation. This even includes a dental cleaning when there can be more circulating bacteria which could embed in the breast’s foreign body implant and subsequently infect it.
The incidence of capsular or scar formation around these implants is 100%. Scar tissue forms around the implant as a means for the body to protect it from harm. The extent of scar formation is what determines how firm or hard the breasts are. Massaging the implants and moving the implants to maintain the breast pocket assures a soft implant. Some Patients have firmness to the extent that an open capsulotomy technique is required to restore their breast pockets. This entails repeating the augmentation mammoplasty procedure by cutting the scar tissue and returning the implants to their pockets. An open capsulotomy can be done for either a sub pectoral or submammary implant. That is, even when an implant is placed under the muscle, capsule formation can occur. Despite open capsulotomy techniques, some patients do go on to have continually hard breasts. In rare instances, patients falling into a category of 1% or less, require removal of the hardened implants. Saline implants tend to wrinkle or show curtaining of the implants. For this reason they are placed under the muscle to allow another layer to hide the wrinkling. They are also overfilled to allow less wrinkling of the implant, but this makes for a slightly firmer feel to the prosthesis. Deflation of these saline implants occurs at a rate of 0.3% or more per year. In these cases the implants must be replaced.
Following the complete removal of implants, there can be some distortion of the breast tissue secondary to the underlying scar tissue.
The incision around the nipple is one that is preferred by many patients, as it heals quite well. As mentioned, these scars are more amenable to patients who wear bathing suit tops that may ride up and reveal the other incision underneath the breast crease or fold. The advantage of the periareolar incision is that it usually heals well and is hardly noticeable after several weeks or months. Although in very rare instances, no matter where the incision is placed, thickening of the scar is noted and cortisone injections or revisions of the scars may be necessary postoperatively.
In the case of scar tissue around the implant, some uncomfortable sensations have been observed from capsule formation probably owing to the scar tissue strangulating the sensory nerves. Again, this is an extremely rare event but has been observed.
Other than scarring, the major side effects of this surgery are obvious. Any operation can become infected. With such a problem in augmentation, the implant will have to be removed, the wound irrigated, the infection cleared and the patient treated with antibiotic therapy. After a period of three to six months, when the infection has totally cleared, the patient is re-augmented.
Likewise, with any operative procedure, bleeding can occur. This is, again, exceedingly rare, but when it occurs, the implant will have to be removed, the blood evacuated and the bleeding site coagulated. The implant is then returned to the pocket.
There is no increased or decreased incidence in cancer of the breast in those patients who have been augmented with any type of implant or in any position. However, once the patient has been implanted, she is a life long patient to a plastic surgeon. She must be examined at least once a year in order to rule out that the palpable lumps or bumps underneath the breasts are true cysts or tumors versus the implant or the surrounding scar tissue from that implant.
Pregnancy following any type of breast surgery can cause problems. There is the stretching of the skin as well as a darkening of your incisions. It is best for an augmented patient not to nurse after delivery to allow the breast size to reform to its pre-partum shape and contour and to avoid permanent stretching of the skin. Ideally, breast augmentation should be delayed until after your last child. In most cases where patients wear a good supporting bra, breast changes in pregnancy minimally affect the operative results.
The operative procedure itself is done as outpatient surgery at the hospital under general anesthesia. Patients are constantly monitored and usually have no difficulty with the procedure, which lasts approximately 2 to 3 hours. Patients are asked to have nothing to eat or drink after midnight before surgery. The day before surgery patients are placed on oral prophylactic antibiotics. They are to shower and shampoo well the morning of surgery. They are also asked to refrain from Vitamin E, anti-inflammatory products i.e., Motrin, Ibuprofen and aspirin for at least two weeks prior to surgery as these medications can thin the blood and increase their chances of bleeding. As nicotine compromises blood supply to the skin, patients are requested not to smoke or chew Nicoret gum for two weeks prior to and one week after surgery.
The usual down time from the operation is essentially 24 hours before you can really be up and around. Patients recover initially in the recovery area and then are driven home by a loved one to stay overnight. Dressings are changed the day following surgery and the patient is allowed to shower and to wear a support bra day and night for approximately one week. After that, a bra need not be worn at night and will probably not be required even during the course of the day at intermittent times. The down time from heavy lifting or performing elaborate household chores would be approximately one week from the time of surgery. We generally use the index of pain to govern what activities the patient can or cannot perform. If it hurts, don’t do it. There is usually a three to four week period following surgery before the last discomfort has disappeared. The submuscular augmentation is more extensive and therefore creates greater postoperative discomfort. Likewise, the recuperative period is somewhat longer for a submuscular augmentation. It is best that the patient allow for at least an extra week following the submuscular surgical procedure to recuperate and feel capable of returning to the working situation.
It is also best that the patient peruse this letter in terms of the side effects of this operation and to gain a better grasp of the procedure, and to discuss it with a neutral third party. Having someone with an objective mind, but with your interest at heart, you can better discuss the points in this letter and objectively approach a decision regarding surgery. You are encouraged to return with that person for your next meeting in my office so as to further discuss the points that have been raised.
Please feel free to ask Dr. Kennedy or any member of his staff questions on any of these points raised.
