|Breast Augmentation Surgery: Overview
Breast implants are performed to enlarge small breasts, underdeveloped breasts, or breasts that have decreased in size after childbearing. Your doctor will help you determine the most effective surgical approach following a thorough examination of your breasts. They will discuss with you the various alternatives of anesthesia available for your case, they will describe the surgical procedure, what results as expected, and the possible risks and complications.
Screening for breast cancer using mammography and other tests such as ultrasound or MRI are required prior to surgery. Preoperative instructions include the discontinuation of certain drugs in order to decrease the possibilities of bleeding. Prophylactic antibiotics are routinely prescribed to prevent postoperative infection. Breast implant surgery does not generally interfere with the ability to breast feed.
Three general types of breast augmentation surgery are currently available: saline implants, silicone implants, or breast augmentation with fat injections (autologous fat transfer).
Breast augmentation with saline or silicone implants is performed through skin incisions placed either under the breast (inframammary), within the areola (transareolar or periareolar) or within the armpit (axillary). Saline breast implants may also be placed through an umbilical incision (transumbilical breast augmentation or TUBA). Endoscopic breast augmentation or endoscopy-assisted breast augmentation refers to techniques in which a surgical telescope is used to create the space for the implant. Transaxillary endoscopic breast augmentation is the most common type of endoscopy-assisted breast augmentation.
The space in which the breast implant is place is known as the surgical pocket. The implants may be placed in a surgical pocket either under the chest muscles (subpectoral or dual-plane) or over the chest muscles (subglandular). With the exception of transumbilical breast augmentation, a third surgical pocket is available over the chest muscles, but under the fascia which covers the muscles – the subfascial plane.
Both saline breast implants and silicone breast implants are available in two basic shapes: round and anatomic. Each shape is available in three different profiles or degrees of forward projection from the chest: low profile (moderate), medium profile (moderate plus), and high profile. The external surface of all breast implants is available in either smooth or textured varieties. Saline implants are designed to be inflated after they placed into the surgical pocket. Silicone implants come pre-filled and require larger skin incisions for insertion.
There is no single technique of breast augmentation which is best for all patients or for all surgeons. Each method of breast augmentation has advantages and disadvantages which must be considered. Excellent cosmetic results can be achieved with any technique when it is well performed in a properly selected patient with a properly fitted implant.
Breast augmentation using the patient’s own fat (autologous fat transfer or fat micrografting) is a procedure that involves removing fat from one or several areas of the body by liposuction and then injecting that fat into the breast tissue to achieve a cosmetic augmentation. Modest augmentations are possible with current fat grafting techniques. Be aware that unlike saline or silicone breast augmentation, some loss of the implanted volume is typical in the first three months after surgery. In order to compensate for this effect, many women are augmented to a larger initial volume. Another factor to consider is that the mammographic changes created by implanted fat may make the future interpretation of such studies difficult. For this reason, it is recommended that patients considering this type of breast augmentation receive proper mammographic screening prior to surgery and not have an elevated risk for breast cancer.
Breast Augmentation Surgery: Details
Site of Incision
The options for site of incision are underneath your breasts (inframammary), around the nipple (periareolar), in the armpit (transaxillary) or through the belly button (TUBA or trans-umbilical breast augmentation). All these approaches have advantages and disadvantages.
The incision around the nipple can lead to numbness, and can be quite visible because it is the focal point of the breast, it may also result in difficulties with breastfeeding.
The inframammary incision under the breast is placed within or near the crease beneath the breast, the scar is usually hidden under the breast. This incision can sometimes become lumpy and could become very visible.
When the incision is placed through the belly button (TUBA), the incision is hidden inside the belly button. The technique requires an experienced surgeon in order to avoid breast implant rupture during placement, undercorrection of certain breast asymmetries, incomplete control of shape, and bleeding. When properly performed, it is an excellent scarless alternative to the other type of incisions.
The transaxillary approach is extremely popular with many patients because the incisions can be made smaller and they are almost invisible (they are hidden in the skin crease in the top of the armpit.)
Endoscopic Transaxillary Breast Augmentation
The standard placement of breast implants, regardless of the incision site, is essentially a blind operation that makes intraoperative visualization of the surgical area difficult for purposes of dissection of tissue planes, for the accurate division of muscle fibers, and the control of bleeding. The use of illuminated surgical retractors has offered only a partial visualization solution.
The introduction of the endoscope has substantially improved the accuracy and predictability of breast enlargement with breast implant surgery. The addition of the endoscope has been is a major breakthrough in the area of cosmetic surgery including breast augmentation.
The ideal incision site to perform endoscopic breast augmentation is the axilla (armpit). The endoscopic transaxillary augmentation allows the cosmetic surgeon to create crease symmetry, muscle division, implant positioning and bleeding control under total endoscopic visualization with great control and ease.
The safe and effective performance of endoscopic transaxillary breast augmentation procedures requires expertise with the use of the endoscope. Surgeons with endoscopic or laparscopic expertise usually deliver excellent results with this method. Surgeons with lesser endoscopic experience complain that the technique yields suboptimal results. In truth, any technique yields suboptimal results in inexperienced hands.
Implant position (Above or Below the Muscle)
Above the Muscle (Subglandular Implant)
The breast implant is placed over the pectoralis muscle and below the breast tissue.
- Less postoperative discomfort and swelling
- Lower chance that the breast will appear to move when the patient exercises the upper body
- Greater risk of visible rippling appearance of the breast
- Worst cosmetic results are seen in women with small breasts
Beneath the Muscle (Subpectoral Implant)
The breast implant is placed under the pectoralis muscle.
- Less interference with a mammogram
- Less rippling appearance in the upper half of the breasts
- More cushion between the implant and the skin
- Ideal for thin and small-breasted women
- Not well suitable for large breasted women
- Worse cosmetic result are seen in athletic women
Implant Shape: Round or Teardrop
Round implants are shaped like jelly donuts. They are not affected by rotation and cost less than teardrop implants. There are no disadvantages to round implants. It is favored by most cosmetic breast surgeons. Teardrop implants are shaped more like the breast. The teardrop implant may rotate, creating a distorted breast shape. It also requires a textured surface to prevent rotation.
Implant Surface: Smooth or Textured
Textured implants are rough, similar to sandpaper. They were developed to decrease the risk of capsular contracture. However, studies have not shown a consistent advantage over smooth implants regarding capsular contracture. They have an increased risk of rippling, have a higher deflation rate and are firmer than smooth implants. They are also more expensive. Most breast cosmetic surgeons favor smooth implants.
Implant size and volume
Breast implants are available in various sizes ranging from 200 - 800 ml. The range 300 - 450 ml is the most common. Choosing your desired size can be a difficult decision - it is highly personal.
You can determine the size you want by placing breast implant sizers in your bra and then putting on a sweater, blouse or a t-shirt. You’ll want to decide your cup size and that will determine how large your implant will be. A 400 ml implant placed in a woman with an A cup will produce a C cup. The same implant placed in a woman with a B cup will produce a D cup. Bring the pictures of your desired size (take a look at a lingerie catalog or swimsuit pictures) to your consultation. Take the time to decide what you will be happy with so you don’t feel the need to undergo a second surgery.
Each saline implant must be overfilled by an additional 25-30 ml. This technique decreases the risk of deflation, rippling, and sloshing. There are no disadvantages to overfilling. Implants are meant to be overfilled, and the implant manufacturers recommend surgeons to overfill them.
Saline vs. Silicone Gel Implant
The FDA has recently approved silicone gel breast implants for use in primary breast augmentation for any woman over the age of 22. The main disadvantages include a possible higher rate of capsular contracture, the incision to place the implant is larger than the one needed for placement of a saline implant, and the cost is substantially higher then saline breast implants. On the other hand, they provide the most natural look and feel ideally suited for women with a modest amount of breast volume.
Breast implant projection (Standard vs High Profile)
With a high profile implant, the liquid volume is the same as a standard implant but its diameter (footprint) is narrower and the projection (the amount it protrudes out and away from your body) is greater.
Most women are better candidates for standard implants. If the diameter of the implant size (standard implant) you selected is about the same as, or smaller than, your measured breast diameter, then a standard implant is your best choice. If the diameter of the desired breast implant size is larger than your breast diameter, then a high profile breast implant is best.
Frequently Asked Questions
View Breast Augmentation Surgery Photos
Q. What are the limitations of breast enlargement with implants?
A. Breast augmentation with implants will not improve nipple asymmetry, move your breasts closer together, lift droopy breasts, or remove stretch marks. Also, breast implants are not completely free of problems. [Return to Top]
Q. What are the possible risks and complications of breast enlargement with implants?
A. Anesthesia reaction, asymmetry, bleeding, breast droop, capsular contracture (hardening of scar tissue around implant), deflation (approximately 7%), displacement, hematoma (pooling of clotted blood, risk is 3-4%), implant leak, infection (risk is less then 1% and always involves removal of the implant), interference with mammography, keloid (heavy scar), nerve damage, nipple numbness, pain, permanent numbness (risk is 15%), reactions to medications, rippling, rupture of the implant (often due to injury), seroma (pooling of watery blood), skin irregularities, sloshing, slow healing, swelling, symmastia (breasts merge into one mass), and visible scars. [Return to Top]
Q. What are the patient instructions after breast implant surgery?
||Above the muscle
||Below the Muscle
|Mild to moderate discomfort;
1-2 weeks of pain medication
|Moderate discomfort; 1-2 weeks of pain medication
||4 days to 2 weeks
||2 to 12 weeks
||Up to 2 weeks
||Up to 2 weeks
||1 to 2 weeks
||Up to 2 weeks
|Return to work in 1 week
|Return to work in 1 to 2 weeks. If job is strenuous or requires lifting, wait 1 month
||Wait 2 to 4 weeks
||Wait 2 to 4 weeks
On the day of surgery you will feel sleepy and may feel pain or be nauseated. Your chest may feel tight and uncomfortable. Your arms and back may also be sore. Pain medication will be prescribed to minimize your discomfort.
After surgery your breasts will be very firm, high, and swollen. After about a month, the swelling will be gone and they will be lower, smaller, and softer. It may take several months for the implants to settle into a permanent position.
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Q. What kind of anesthesia is used by for breast augmentation?
A. General anesthesia, intravenous conscious sedation and local anesthesia are used for breast augmentation. The choice is usually determined by the surgeon and takes into account the degree discomfort anticipated during surgery. A very safe and popular method is intravenous conscious sedation in conjunction with local anesthesia. [Return to Top]
Q. Explain breast augmentation with fat injections (microfat grafting).
A. Patients who desire breast augmentation but are wary of implants are candidates for breast enlargement using their own fat utilizing the microfat grafting technique.
Fat is removed from selected areas of the body by liposuction, purified,, then re-injected into the breasts. The process of fat injection involves scores or hundreds of injections with very tiny syringes into the breasts.
The procedure is designed to fill the breasts so that they appear lifted and perky. The fat is injected into different areas of the breast and at various depths so that the patient will get the highest permanent absorption rate. Surgeon experience with the technique is important to achieve a uniform, smooth, normal appearance on the breasts. [Return to Top]
Q. What are the advantages of breast augmentation by fat transfer versus breast implants?
- Less expensive
- Minimally invasive with less trauma to the breast
- No visible scars
- Can be done as an office procedure totally under local anesthesia
- Avoids tissue or foreign material (implants) rejection because the fat is an autologous graft
- Fewer postoperative complications
- Touch up procedures are easily performed
- Fat transfer does not make the performance on a future breast implant placement more difficult
In the past breast augmentation using fat injections was frowned upon by breast surgeons because of the pressure of fat necrosis (a frequent benign breast tissue change resulting from the fat transfer) would interfere with breast cancer detection. But MRI technology changed that because the MRI can determine the difference between fat necrosis and cancerous tissue. [Return to Top]