Today we’re going to talk about breast augmentation. When we think of breast augmentation, I think the first thing we have to consider is that the implant may not last a lifetime.
You got to remember the implant is a machine and like any machine, it has a life span. The two major companies, implant companies, warranty their implants for 10 years. So they’re convinced an implant won’t break, leak and tear in 10 years.
An implant may last 15 years. It may last 25 years but it’s likely not to last a lifetime. So if you’re thinking about breast augmentation, I think this is the first thing you have to consider, that at some point during your life, you may have to have another surgery because of this implant.
So once you make that decision and decide that the breast augmentation is for you, the next big consideration is what type of implant do you want. There are two types of implants available in the United States now- the saline-filled implant and the silicone-gel-filled implant.
Both the implants have the same shell which is a solid silicone rubber. There has never been any concern or any evidence that the silicone, the solid silicone rubber shell has caused any problems at all.
In the 1990’s, the silicone gel implant was taken off the market. It was taken off the market because there were some findings of silicone fibers leaking through the shell of the implant being found in the lymph nodes and because the lymph system has to do with the immune system, there was concern that the silicone gel may have an effect on the immune system.
The implants were never FDA-tested when they first came out in the 70’s, because in the 70s, the FDA did not test devices. The FDA demanded that the implants be tested.
So from the 90s to the 2000s, to the middle of the 2000s, the implants were being tested. They were tested during breast reconstruction. The implants were available for breast reconstruction during that time.
What was found with the study was that there was no relationship between the silicone fibers and autoimmune disease. The silicone fibers did leak through the shell but there was no sign and no evidence they caused any problems at all.
So that’s why the implants were released for use after that. Now the changes that were made to the silicone gel, the silicone gel used in the earlier implants was more like oil. If you cut that implant, the oil would run on the table just like a thick oil.
The silicone gel that’s available now is more like the gummy bear. They’re solid. If you cut it, it doesn’t move. It stays there. So the thinking was that if this is more cohesive, the chance of these fibers getting out into the lymph nodes is much less. So that was the idea behind that.
In the United States now, the majority of the implants that are sold are silicone gel for the implants. Probably some place between 65 and 70 percent of the implants sold are silicone-gel-filled implants.
The advantage of silicone gel for the implants is that they’re smoother and they’re softer. The look between a saline implant and a silicone gel implant is probably not different. I can’t tell if I just see someone whether or not it’s a saline implant or a silicone gel for the implant. The difference is in how they feel. With the saline implant, you’re more likely to be able to feel the edge of the implant and tell where the implant starts and stops. With the silicone gel, it’s more difficult to tell where the implant starts and stops.
The other thing is that the silicone gel implant is smoother. So feeling the implant wrinkle is much less likely with the silicone gel.
The complication of feeling the implant wrinkle is called rippling and that again is more common in the saline implant and it’s more common in the lower outer quadrant of the breast because the tissue is thinner in that area and the implant is closer to the skin.
So that is the main advantage of the silicone gel implant over the saline implant is that it’s smoother and softer, a little bit more natural-feeling. The look between the two is probably the same.
Now when we do an augmentation, most of the time, we’re going to put the implant under the muscle and it’s called submuscular augmentation.
Now the reasons why is that when you put the implant under the muscle, you have more of your own tissue on top. So it makes it more natural. Another reason is that there are some studies that show that when the implant is under the muscles, scar tissue formation around the implant is less likely to happen. If scar tissue happens, it’s called a capsular contracture.
But those are the two main reasons why putting the implant under the muscle is more common.
There are different incisions you can use to put the implant in. The two most common incisions are an inframammary incision, which is under the fold of the breast and the periareolar incision which is on the lower portion of the areola.
There are also incisions in the axilla which is less common but also done and then the umbilical incision. Not as common anymore because the silicone gel has taken over and the saline implant could be put in through the umbilicus but not so much the silicone gel. So that’s not as common as it was before the silicone gel was released back onto the market.
The incision that I use to put in the majority of time is a periareolar incision. The reason why I do this is because that area heals better than the chest wall especially on anyone that has pigment. The chest wall incisions tend to darken anyone with a darker skin tone.
Now, the thing that I do when I make the incision through the areola is I did not cut through the breast tissue directly down to the chest wall. I will make the incision through the skin and then make a tunnel underneath the skin above the breast tissue and go down to the inframammary fold and then go underneath the breast tissue to reach the muscle, separate the muscle and put the implant in under the muscle.
The reason why I do this is because ducts, because of the ducts of the breast have bacteria in them. I don’t want to expose the implant to ducts. When you cut through ducts or when you cut through the breast tissue, you cut through ducts and you may cut through nerves. So there’s more of a chance of causing problems with decreased nipple sensation.
The ducts have bacteria. So we cut through ducts, you can expose the implant to bacteria. If you expose the implant to bacteria, there’s a chance for infection. The other thing is that, that exposing the implant to bacteria can also cause the scar tissue formation. Anything that causes inflammation can cause the capsular contracture which is the scar tissue formation.
The two main things we know that cause this are one, bleeding and the second is infection. So trying to decrease infection, trying to decrease bleeding, helps prevent this capsular contracture or scar tissue formation. So that is how I access the inframammary pocket to place the implant.
Now the considerations. When we think about the implant size or implant shape, we have to kind of decide on what we’re trying to do, what look we’re trying to get.
Now, in general, if you choose an implant that is the same diameter or slightly less of a diameter than the patient’s chest wall, you get a more natural-appearing implant where the chest wall controls the implant.
If you choose an implant that’s a wider diameter than the chest wall, you get a more augmented-appearing augmentation, meaning that the implant starts to control the chest wall instead of the chest wall controlling the implant.
So depending on what look you’re trying to get, those are the things you might think about to try to get the look that you’re interested in.
Now, the other thing we have to consider is the skin. The two things that – there are really two things that make a perfect augmentation. One, it’s choosing the appropriate size of implant for the patient and two, it’s making the pocket in the correct location, centering the pocket behind the nipple.
The nipple must be the center of the pocket. If the nipple is not the center of the pocket, you create problems. Now, in general, if you make a pocket higher than the nipple, the nipple will point down. If you make a pocket lower than the nipple, the nipple will point up.
If you make a pocket to the right of the nipple, the nipple will point to the left and if you make a pocket to the left of the implant, the nipple will point to the right. So centering the implant behind the nipple is a key to a good augmentation.
The other thing we have to consider is the size of the implant and when we consider the size of the implant, we’re considering the skin envelope. If we put an implant that is too heavy or too big for the skin that’s available on the chest wall, we’re going to damage the skin. We’re going to get more ptosis, maybe stretch marks in the skin.
So we have to consider what the skin envelope is. When you get an implant that matches our – fits the skin envelope and when you place the implant in the proper location behind the nipples, centered behind the nipple, you have a very nice, natural-appearing augmentation. The other thing we have to think about the implant is weight. The larger the implant, the heavier the implant is. The heavier the implant is, the more strain on the neck and back.
So you can cause more strain and pressure on the back with a larger implant. The other thing is again we come down to the skin. When you put a larger, heavier implant in, it stretches the skin. So a lighter implant at 10 years would probably look better and more natural than a heavy implant at 10 years because the breast will be low and stretched and have more ptosis with the heavier implant. So those are all things you have to consider when you think about the breast augmentation.
Now, the recovery. Breast augmentation tends not to be terribly painful. More of a throbbing, achy, bruisy kind of pain. Most of the pain that’s present is the pain of the muscle being stretched by the implant. When you put the implant under the muscle, it’s a tighter space and the implant must stretch the muscle and make the appropriate space.
So that’s where most of the tenderness and pain and things come with the augmentation. But in most people, it’s not terribly painful. It’s more of a throbbing, achy, swelly kind of feeling than a knife pain, than a sharp pain.
Initially, the implant is going to be high. The implant will be high because most of the surgery that you’re doing is on the bottom half of the chest wall and the breast. So since you do more surgery on the bottom of the breast, you have more swelling on the bottom of the breast.
The swelling will push the implant up. So shortly after surgery, second day after surgery, the implant is slightly high because the swelling is pushing the implant up. As the swelling goes down, the implant will fall back into the normal space. So it’s very common for the implant to be high initially after surgery. In fact it’s almost expected.
The other thing that we have to think about so far is the size of the implant. When you try the implants on in the bra and try to get the size of the implant, it always will look bigger when you try them inside the bra than it will be in the body.
So generally, if you decide I like a 350 cc implant, when you try it on the bra, you might want to think about using a 375 cc implant or even a 400 cc implant to get the look of the 350 cc implant once the swelling has gone down and once the implant has fallen back down to its normal location.
Now, after the augmentation, you cannot do heavy lifting for two to three weeks and this is because of the chest wall muscle. The muscle is weakened from placing the implant under the muscle and you don’t want to injure the muscle. So you’re waiting for that to heal.
If you are doing too much activity or too much exercise too soon, you usually feel tenderness inside of the chest, on the inside of the chest and that’s really from the pectoralis major muscle.
So if you’re feeling that, you’re doing a little bit too early. So give yourself at least three weeks to kind of heal a little bit before you go doing a lot of lifting with the arms, weight lifting or a lot of exercise.
It’s OK at two weeks to exercise the legs because you’re not going to hurt the implant, but you must wait 4 weeks before heavy lifting. You need to give that chest wall muscle a little bit of time to heal and things like that.
Now the recovery, the implant will swollen. When the swelling goes down and the size of the implant will go down for probably maybe even the first three weeks or first four weeks. So additionally, it’s going to be swollen and larger and then as the swelling goes down and the healing and the implant go down to it’s normal position, it will get smaller for probably the first three to four weeks after surgery.
Then in that second month, the shape will settle. So probably at the end of the second month, you have a better shape and a more natural shape that you can do at the end of the first month.
So that is essentially what to expect with the recovery. Most people will take five to seven days off after the breast augmentation before they return to work. Now the next thing we have to think about is the complications of breast augmentation.
The most common complication is that scar tissue. This is what’s called a capsular contracture. Whenever you put silicone in the body whether it’s a finger joint, a silicone implant in the nose, silicone hip joint or the breast augmentation, the body will react to silicone and make a scar envelope.
Usually the scar envelope is thin and soft and that’s normal and it doesn’t cause any problems. If the scar becomes thick and hard, it’s called a capsular contracture. Now if this starts, the first thing you’re going to notice is that the breast will feel firmer.
If it continues to get worse, the shape of the breast will change. If it continues to get worse, you may even have pain. If this happens, it may come down to going back to surgery, taking out the scar tissue, exchanging the implant.
There are some medications that kind of stop the scar tissue if it starts or sometimes ultrasound therapy and massage can kind of stop the scar tissue if it’s starting in the early phase. But if it becomes severe and painful, it usually comes to surgery in order to solve that problem.
Now, like I said, inflammation is what causes the problems with the scar tissue formation. So trying to decrease inflammation after surgery decreases the chance of the capsular contracture.
During surgery, you try to get the smallest amount of bleeding that you can get because blood is an inflammatory substance. The other thing is infection. We don’t want infection. Any bacteria present will make the capsular contracture more likely.
So before I touch the implant I will exchange my gloves. So I will only use new gloves to touch the implant while I’m placing them in. We will clean the chest wall with antiseptic. We will irrigate the pocket with antiseptic. We use antibiotics into the pocket, around the implant in order to try to decrease any chance that there are bacteria present.
All these things do help and decrease the chance of capsular contracture. The chance of capsular contracture in studies varies tremendously. It could be from 3 percent at a time to even up to 11 percent at a time that you have this problem happen.
Now the other thing is infection. If we get an infection around an implant, the first thing that you want to do is use antibiotics but the implant is a foreign body. So if the antibiotics cannot kill that infection, sometimes the infection holds onto the implant and the only choice is to take the implant out, treat with antibiotics, get rid of the infection and come back in a month or two months later and put the implant back in.
Now decreased nipple sensation can be a complication of breast augmentation but again it is very rare, but that’s a possibility. The other things we have to think about is rippling. Rippling again is feeling the wrinkles in the implant through the chest wall and again this is more common in the lower outer quadrant of the breast because that area is thinner.
If that is a problem with the saline implants, sometimes you can exchange it for a silicone gel implant and try to get a smoother implant and try to decrease or eliminate the problem. Now so far as breast cancer, mammograms can still be done with implants in place. There are so many people that have implants. Every one doing mammograms knows how to do a displacement technique pushing the implant down and shooting the mammogram above the implant so that implants do not prevent mammograms and things from being done and do not hie breast cancer.
The other complications are wound healing complications. A wound breaks down and the wound opens, drainage or infection around the implant. So these are the things or these are the complications I think you have to consider when you think of breast augmentation. So that’s pretty much the conclusion to this discussion on breast augmentation.