Breast Augmentation Procedure
For breast augmentation using implants, Dr. Sweat will make an incision and lift the tissue to create a pocket for the implant. The pocket will either be made underneath the breast tissue or the pectoral (chest) muscle depending on your anatomy, the type of implant you desire and your occupation and fitness level. Considerations that will need to be addressed include the type of implant that is chosen, the location of the scar, and the position of the implant in relation to the breast tissue and chest muscle.
In the US, there are two basic types of implants in terms of the material with which the implant is filled. The implant can be filled with either saline (salt water) or silicone gel. The shell of the implant is made of a solid silicone in either instance, so ultimately every breast augmentation patient will be exposed to silicone in one form or another when implants are used. Implants come in varying shapes and sizes and can either have a smooth or textured shell. If the implant is anatomically shaped (teardrop) the texturing is required to prevent rotation and malposition of the implant. Texturing can also help to decrease the chance of capsular contracture (scar formation around the implant) if the implant is placed over the muscle rather than under. Placement of the implant beneath the muscle helps to decrease the risk of capsular contracture as does the use of a saline implant rather than gel. However, most people agree that the gel filling gives the implants a more natural feel. Texturing has more commonly been associated with a very rare type of cancer recently discovered to be associated with breast implants called Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).
In addition to anatomically shaped implants, round implants can have different profiles, or projections. The projection can vary from a low profile implant which is flatter but wider to an ultra high profile implant which is much taller with a narrow base. The anatomy of each individual patient coupled with the choice of size usually determines the profile of the implant rather than patient choice.
If the patient is undergoing a lift procedure (mastopexy) in addition to augmentation, the lift will determine the scar placement. Before the FDA approval and subsequent re-introduction of silicone gel implants to the general public in 2007, incisions around the nipple were very popular since the saline implants are not pre-filled and can be placed through very small incisions. Since the re-introduction of gel implants, the inframammary fold incision (placed in the fold under the breast) has surged in popularity and is thought to be associated with a lower incidence of capsular contracture. Incisions in the armpit have also decreased in popularity with gel implants and an incision in the belly button can only be done with saline-filled implants and should not be done since it voids the manufacturer’s warranty. Due to potential positional problems, Dr. Sweat recommends avoiding implant placement through a tummy tuck incision when performing a mommy makeover.
Breast implants are usually placed either over the pectoral muscle in a sub-mammary (under the breast) position or under the pectoral muscle in what is commonly referred to as a dual-plane approach since the pectoral muscle does not entirely cover the implant. In the lower outer part of the breast, the implant will be covered only by the skin and breast tissue and thus will be easiest to feel in that location. Total muscle coverage is possible but is rarely performed since it is more painful and unnecessary. Saline implants are placed under the muscle to help cover and camouflage the implant and avoid rippling of the implant which is occasionally visible in the upper part of the breast. Gel-filled implants are placed under the muscle to help decrease the risk of capsular contracture if a smooth surface implant is chosen and to help hold the implant in the proper position when the skin and soft tissue has been stretched by breastfeeding or weight loss.
The downsides of placing the implant under the muscle are weakening of the pectoral muscle, increased postoperative pain compared to a sub-mammary position, and animation deformity. Animation deformity refers to the abnormal shape of the breast tissue that occurs when the pectoral muscle is tightened, but resolves immediately upon relaxation of the muscle so that the implant falls back into normal position. Animation deformity and loss of pectoral strength can be important considerations in women who are very active physically for their jobs or past times.
The downsides of placing the implant over the muscle are less support for the implant, greater risk of implant visibility or palpability (being able to feel the implant), and increased risk of scar tissue forming around the implant, especially with smooth or gel-filled implants.
Implant Specific Considerations
Rupture: Implants are not meant to last a lifetime. On average, implants are thought to last 10-15 years before the shell of the implant will break, though this can happen at any time after placement, even within the first few months. While the implants do not “explode” or break after a certain period of time like a ticking time bomb, they are also not designed to be lifetime devices. As such, any woman considering breast augmentation should take into consideration that this may not be the last operation she ever has on her breasts. While saline implants leak salt water which is reabsorbed by the body and will give an indication of rupture by the decreased size of the implant (and breast), gel-filled implants are designed so that the gel continues to be cohesive after rupture. As such, a gel-filled implant could break and never give an indication that this has happened (this is called a “silent” rupture). When the FDA reintroduced the implants to the market in late 2007, they recommended that women have an MRI to screen for rupture (breakage of the shell) at 3 years after placement and every 2 years thereafter. Many women and plastic surgeons do not follow this recommendation and the implants are guaranteed for a lifetime (if they ever break during the lifetime of the patient, the manufacturer will replace the devices for free). However, if they rupture within the first 10 years after placement, the manufacturer will replace the device at no cost and provide financial assistance for implant exchange. For this reason, many women mistakenly think that implants need to be replaced every 10 years, but instead, Dr. Sweat recommends checking the implants for rupture before the 10-year mark. With gel-filled implants a breakage may not show external signs and women may never even know that the implant is broken. During your consultation, Dr. Sweat will discuss with you the concerns associated with having a broken gel implant.
Capsular Contracture: When scar tissue forms around the surface of the implant, this is referred to as a capsule, and every implant develops a capsule around it. When it is thin and soft, the scar tissue is virtually unrecognizable. However, the scar tissue can become very thick and contract against the surface of the implant, which can then cause the implant to seem very hard and unnatural. Plastic surgeons have not yet come to fully understand the causes of this. It could happen at any time after surgery. Luckily, the risk of developing a capsule that is very hard or even painful is less than 10% but when it happens to this extent, unfortunately, surgical intervention becomes necessary. The most common theory about why this happens is because of contamination on the surface of the implant and thus replacing the old implant with a new one in addition to completely removing the scar tissue is usually recommended. However, even if a new implant is used, there can be upwards of a 50% chance of the scar tissue returning after the second operation. Dr. Sweat can discuss with you various treatment options for scar tissue that returns repeatedly.
Infection: Because the implant is a foreign body, if it becomes contaminated with bacteria at any point, the body cannot fight the infection through traditional means. While every effort is made to avoid any source of contamination, unfortunately, implants do on rare occasions become infected. Treatment for this usually involves removing the implant and leaving it out until the infection has completely resolved and then replacing the implant. Each of these steps means additional surgery as well as potential costs. The risk of infection is very low, but it does occasionally happen. As with any surgery, there are no guarantees against the associated risks.
Malposition: Even though the placement of the implants is very precise during the surgical procedure, every person’s tissue will heal differently. Sometimes, especially when large implants are placed, the tissue does not properly support the implants and various issues may result. This can include implants that fall too far to the side when the patient lies flat, double bubble deformity in which the implant falls below the fold under the breast, or when the implants stay too high and the breast tissue falls over the implant. Further surgery may be necessary if implant malposition occurs.
Breast Augmentation Results
At first, you will experience swelling in your breasts. As the swelling goes away, you will begin to see the final results of your surgery. Don’t expect this right away because it can take several weeks for the actual size and shape to be obtained. Once the recovery process is complete, you will notice a different size and shape of your breasts. Please remember that your breasts may change after your surgery based on weight fluctuations, pregnancy, or aging. Choosing a plastic surgeon that is right for you is also important to the results of a breast augmentation surgery!
Dr. Sweat advises patients considering breast surgery in Sacramento that gone are the days of overly large and fake looking breasts. In past years, people found this to be very attractive and aesthetically pleasing. However, with the change in times, the public has had a shift in attitude about what they feel defines the perfect breast shape. With breast surgery, there is a definite swing on the pendulum toward an “authentic” and “normal” look and shape to a woman’s breasts. The decision to find the authentic and perfect look, feel, and size is something only you can decide with Dr. Sweat during your consultation and pre-operative appointment.