The APSI Guide to Breast Augmentation Surgery

For more than a decade, breast augmentation surgery has been one of the most popular (if not the most popular) cosmetic surgery performed at Austin Plastic Surgery Institute.  Over this same time period, we have seen immense controversy and scrutiny aimed at breast augmentation.  There seems to be a lot of good information out there about the surgery and a lot of misinformation.

Without exception, the consultation experience surrounding a request for breast augmentation should be thorough and educational.  It is an important decision for the patient and we should arm our patients with the best guide possible to make this decision a good and happy one.  

If you are considering breast augmentation surgery, please spend a little time and read this article (average reading time: 15 minutes).  We feel that it is well worth your effort.

Here at APSI, we do not believe in disingenuous marketing hype.  Our board certified plastic surgeons believe in performing effective surgery for the patient with immaculate attention to the technical aspects of surgery followed by excellence in patient care.  

Candidates for Augmentation Surgery

Women who seek out breast augmentation surgery are often wishing to replace volume that has been lost due to pregnancy, weight loss, or aging.  Some are trying to improve upon asymmetric breasts where the breasts can be different in size and shape.  Some are simply trying to enhance the way they fill out clothing and get that ‘I like the way my breasts look in a bra’ appearance.

Whatever your reason, do not feel judged.  All women are on their own path to a healthy body image and breast augmentation can serve a purpose.  

Ultimately, women who are candidates should be healthy enough for a 1 hour procedure done under general anesthesia.  They should not be pregnant or breast feeding.  If they are 40 years old or older (or younger with a significant family history), they should have a recent, normal mammogram.  They should have reasonable expectations of their body.  They should have flexibility enough to take a week (or more) off of work.  They should only move forward with the surgery for themselves.   

Some Basic Truths to Address Common Questions

Implants and augmentation patients have been well followed and studied.  Implants do not cause or increase the risk of cancers or autoimmune disease such as lupus.

Mammograms remain very effective in cancer screening despite augmentation.  The best position for the implant is behind the muscle in order to obscure mammogram images the least.  Mammogram centers are well versed in the need to take additional images to push the implant out of the way during a screen.  Research continues about the role an augmentation plays in effective mammograms.

There is no maintenance schedule for replacement of implants.  They are not treated as you would an air filter in a car with a suggested time to exchange them.  There is very little risk that a saline or silicone implant will rupture (or break) within the first ten years.  And, all surgeons have removed implants for a variety of reasons that may have been 25 years old that were found to be intact.  The rate of rupture does increase with age.  Saline implants rupture more frequently and are very obvious since the saline is absorbed and the breast appears deflated.  The silicone used today is cohesive (sticks to itself) and does not behave like a liquid.  This makes detection of a rupture more difficult, but an undetected rupture is not found to be harmful.

There are several different brands/profiles/shapes/surfaces associated with silicone implants.  Different surgeons have different biases.  And, most experienced plastic surgeons have very good results with their given biases.  There is no one-implant-fits-all.  You have to feel confident in the size and implant type selected for your needs.

Breast augmentation can be done conservatively and appear and feel very natural.  

Sensation to the breast and nipple as well as the ability to breastfeed is frequently preserved.

A very large implant does not typically create a true and lasting ‘lift’ for someone with a true excess of skin and a low nipple position.  For an excellent result, a lift along with an augmentation is needed.

Fat grafting has increasingly been offered as a substitute for traditional breast augmentation.  Fat grafting techniques are still being improved.  When plastic surgeons are honest about the most likely outcome from fat grafting (transferring fat via liposuction from one part of the body to the breast), they have to admit unpredictability in the volume of fat that can survive.  The fat grafting procedure typically costs more due to time spent and can require repeating 6 months later and still not achieve the predictable volume of an implant.  Studies are still ongoing about long term effectiveness, risk of distorting mammograms, and cancer risks.  So far, it is most frequently used to improve the appearance of breast reconstruction cases following mastectomy.

 

Types of Implants

There are three companies producing implants currently FDA approved (Mentor, Sientra, and Allergan).  All companies appear to be producing good quality implants.  Surgeons may prefer one company over another due to familiarity or other bias. 

Saline vs Silicone 

90% or more of the implants currently used in cosmetic breast augmentation at APSI are silicone filled.  Saline filled implants are disliked by many women and especially those with thinner tissue due to a more enhanced palpability (the implant shell is easier to feel) and more potential for visible wrinkling.  

The 5th generation silicone available now is very cohesive (meaning that it sticks together well like jello and is not a runny liquid).  So, when a small hole exists in the wall of a new silicone implant, the silicone is likely to stay within the shell and is relatively ‘form-stable’.  

There are the ‘gummy bear’ shaped implants that are more firm in nature.  These implants can be more costly and require a larger incision (2.5 inches vs 1.5 inches) to place them.  Shaped implants may never feel as soft as the round cohesive gel counterparts and must be placed within a carefully created pocket so as not to rotate and cause a strange appearance.  The use of ‘gummy bear’ implants is typically reserved for special circumstances.  

All implants regardless of the filler material have been found to be safe and are not correlated with the cause of disease or cancer.

Shaped vs round, textured vs smooth

There are many options in implants which can add to the confusion on the topic.  Surgeons frequently have a bias from the days of their training or due to their familiarity with products they have been using for years.  There is also debate about what constitutes an ideal breast form and how deflated breasts are best filled.

We find that many women are best served with round implants.  When women desire a return to the original form of their breasts (after aging, pregnancy, or weight loss), they want to replace the breast tissue that at one time radially encircled their areola and nipple and gave them a pleasant round quality, filled out their skin envelope, and offered some projection.  This loss can reasonably be replaced with a round implant.  The choice of size of the implant (in cc’s or grams) depends on the width of the breast, skin pliability, and the ultimate size desire of the patient.  A round implant typically gives the patient gains in upper pole fullness, but unless the implant size is excessive, the upper breast will not have unnatural cleavage unless a push up bra or other device better exposes that aspect of the chest.  

Shaped implants can offer more of a teardrop shape to the breast.  They have a textured surface so that movement of the implant is limited.  If the implants rotate, then the shape can become unusual in appearance and require revision of the implant pocket.  Also, these shaped, textured implants are never as soft feeling as the round, smooth implants can be.  They can also give an elongated appearance to a shorter breast.  For many surgeons, these implants create a more complex operation with the potential for malrotation with added cost.  Plus, when patients are standing, a round implant conforms with gravity and the shape of the breast to become somewhat anatomic.  So, even very experienced plastic surgeons can sometimes not tell the difference between the two after surgery.  The debate then becomes: are they worth the higher cost and loss of predictability?

Textured implants were developed to trick the scar capsule (a patient’s body always produces a scar capsule around an implant) into forming a bit differently to lessen the rate of capsular contracture.  Capsular contracture is a complication of breast augmentation surgery that can cause the scar capsule to change the appearance and firmness of a breast.  This sometimes triggers a revision surgery.  This was much more common when implants were placed under the breast tissue but above the muscle.  Now that most breast augmentation is done beneath the muscle, capsular contracture is much lessened and the need for textured implants remains unclear.  Textured implants always feel slightly more firm than the smooth counterparts and can cause a traction on the skin/scar capsule that can create visible ridges or rippling.  They also seem to rupture at slightly higher rates.  But, in the case of shaped implants, the risk of a rotation problem can be minimized by the textured surface.  And, if the surgeon needs more control over the implant pocket, then a textured implant can be appealing.  

What about size and profile?

We frequently talk about size in reference to bra cup sizes.  However, the fashion industry is not even standardized there.  So, there is no perfect recipe in cc’s or grams for a cup size.  Plus, depending on the size of the existing breast and chest width, a given implant can look vastly different.  For instance, in a very small, narrow breast 200cc could be a cup size enhancement.  On a broad, large breast, that 200cc implant may barely reach visible register.

We still talk in bra cup sizes because it helps us understand better how the patient views her own breasts and it puts a type of measure on the desired outcome.  But, the patient has to understand that she will always fit into a range of sizes depending on where she bra shops….perhaps a 36C at one place and a 34D at another.

When seen at a proper consultation, the patient and surgeon will discuss the patient’s goals.  Then, the surgeon will perform measurements of the current breast and will be able to provide the patient with his or her determination for the type of implant and size range best suited for the patient’s body and goals.  The breast width alone is an important determiner.  The nipple position, skin elasticity, and the patient’s current breast volume all become part of the calculation.  Placing an implant into a bra can be somewhat helpful but may offer a slightly false view of the ultimate projection of the breast.  

In general, an average sized, normal weight individual with modest breasts will see a ‘cup sized’ enhancement in the neighborhood of 250-300cc.  So, if they were shopping in the arena of a B cup previously, they will now generally find themselves in a C.  But, if they wanted to be a full C and occasionally finding D cups that work, then they may have to select a 350-400cc implant to get themselves there.  Some patients will work themselves into a frenzy over picking between a 325cc implant versus a 350cc size.  To be reassuring, implants come frequently in 25-30cc increments to adjust for small asymmetries between breasts.  Most people cannot tell a visible difference in implant size until they adjust by at least 50cc.  

Profile of the implant (typically described as low, moderate, moderate-plus, and high) describes how the size in cc’s of an implant is distributed based on how wide the implant is.  These options allow a surgeon to pick the volume that best suits the patient’s body and desires in a base dimension that best meets the needs of the anatomy.  The profiles used with the most frequency follow the averages (moderate and moderate-plus) but high profile implants may be needed to achieve a certain volume with a narrow chest width.  

There is concern amongst surgeons that larger implants not appropriate for a given patient’s anatomy will lead to breast tissue and skin thinning and, as a result, more need for future revision surgery and compromised longevity of the result.  Please listen to your surgeon if they are refusing to implant a certain volume.  Even fairly conservative implants still add mass.  For example, a saline filled set of 350cc implants weighs about 1.5 lbs (about ¾ a lb each).  The silicone version of 350cc implants weighs about 1.7 lbs.  Patients tolerate this type of weight very well.  But, one can imagine why 700 or 800cc implants may feel differently.  

Postoperative breast shape

Patients should always keep in mind that what their current breast tissue and skin looks like has much to do with the final outcome.  Implants add volume and projection and certainly help fill out the skin that is there.  But, without any other modifying surgery (such as a breast lift), the postoperative breast looks like the preoperative breast.  

So, if you have widely spaced nipples, they will continue to look that way and may even be slightly exaggerated.  If one nipple is slightly lower than the other, that will still be the case.  

The implant should be centered under the nipple.  There should not be effort directed to surgically create breasts that now sit closer to one another.  The implant pockets could dive into each other creating a difficult to fix problem called symmastia.  In most patients, there is no cleavage without a good bra to achieve it.  The breasts sit somewhat apart from one another.  That is only natural.   

 

To Lift or Not to Lift

During the course of your consultation and examination your surgeon will evaluate your skin and nipple position.  

Some women’s nipples are at or above the level of their inframammary crease (the natural fold or crease under your breast).  In most situations, these women will only need a breast augmentation with a single short incision used.

Some women are certainly more borderline and may get some differing answers if they see more than one plastic surgeon in consult.  The current nipple position may lie somewhere in the neighborhood of less than 1 inch below the ideal.  In considering the quality of skin and volume desired, the surgeon may feel that the result will be acceptable without a lift.  The breast may have a more mature appearance but the nipple will remain at a cosmetically tolerable level.  However, these women should be counseled that their breasts may continue to age and droop and that a lift at some point may need to be performed for a good outcome.

There are other women that will have a universally poor outcome without a lift.  The nipple position may be several centimeters lower than the ideal and the skin takes on a stretched and overdraped appearance on the breasts.  An implant will never replace a lift.  The lift serves to put the nipple back into position and smooth the skin.  Without the lift, the nipple may point downward or the breast tissue and nipple may even appear to cascade off of the implant (the dreaded snoopy deformity).  The implant may be correctly located but the breasts sags off the base of it.  

Patients often fight the idea of a lift as they are trying to avoid unnecessary scars.  The vast majority of patients are happy about the tradeoff.  Scars can be quite good although still visible but the change in appearance is vastly improved with the contour of the breast restored.

How the surgery is done

The vast majority of primary augmentations that do not require a lift can be done in under an hour.  Patients frequently opt to have general anesthesia which allows for complete unawareness and pain control in addition to aiding the surgeon by virtue of some muscle relaxation.  From there, great attention to sterile technique is paid to limit any risk of infection.

 

Incisions

There are various incisions described for breast augmentation.  If you are having a lift performed, then the implant pocket will be accessed via the lift incisions.

The most commonly used incisions are the periareolar (following the line of the areola from the 3 o’clock to 9 o’clock position) and the inframammary (at or just above the fold underlying the breast).  These incisions offer the most direct approach to the breast and may limit the risk of malposition seen when surgeons access the breast under the arm or from the belly button.  Bleeding can be easily controlled and the pocket is created under direct visualization.  Some surgeons have a slight preference for the fold since the areolar incision may create a slightly increased for postoperative nipple numbness or contamination due to dissection through more breast tissue than what you would encounter through the base of the breast.  Either incision can heal very nicely with reasonable, short scars that are easily hidden.

The incision under the arm can create a scar visible to strangers depending on clothing choices and it is a more remote site potentially increasing risks for malposition (although only slight).  This site may also limit choice and size of implants since squeezing a larger silicone implant through that site may be impossible while keeping the incision short.

The belly button incision is also a remote site that can add time to the procedure since dissections is done via a scope and controlling the implant pocket and bleeding can be more challenging.  Also, only saline implants can be placed via this route.  Although challenging and limited in application, this can be done successfully but seems to be losing popularity with the resurgence of silicone implants.

Pocket (Where the implant sits)  

The large bulk of breast augmentation is currently being done in a sub muscular pocket with the implant placed beneath the pectoralis muscles of the chest.  This adds another layer of potentially camouflaging tissue over the implant and reduces the incidence of capsular contracture (a firm and distorting nature of the scar capsule).  Originally, breast implants were placed over the muscle and just beneath the breast tissue, but this subglandular position has lost a bit of favor due to higher risks of implant palpability, visible wrinkling, and capsular contracture.

Some patients will keep their subglandular position of their implant if they are having an implant exchange or lift some years later if they enjoy the look of their breasts and are having no problems with contracture.  Other women may be picking that position to avoid any animation of the implants that can happen a bit when they are placed under the muscle.  Other women are having their implants placed in that position to avoid a breast lift if they have adequate breast tissue coverage as the implant has the potential to more directly fill out the skin envelope in that plane (although it still cannot replace the lift achieved with a lift).

The vast majority are placed beneath the muscle although may not be truly submuscular (meaning every bit of implant is covered by some aspect of muscle).  The majority conform better to descriptions of partially submuscular or dual-plane.  This means that the pectoralis muscle overhangs the superior and most central aspects of the implant but that the base and most side (lateral) aspects are covered by breast tissue, fat, and skin.  The dual-plane position allows the implant to have protection and camouflage offered by the muscle but releases the lowest bits of the muscle to allow for more natural draping of the muscle and tissue over the implant.  This also probably limits the animation issue seen with some submuscular pockets.

What to expect after surgery

Patients go home after this outpatient surgery and need a trusted friend or family member to drive them and stay with them overnight.  Alternative options for this include some trusted nursing care to fill this role.

Patients have varied pain thresholds, but most patients require some occasional narcotic pain medication for a few days after surgery.  For this reason and ongoing discomfort, they are not safe to drive initially but can be quite functional at home preparing meals for themselves and walking and showering unassisted.

All patients describe soreness, throbbing, and tightness after surgery.  This always improves gradually.  Some patients note some occasional tingles or shooting pains and those also tend to disappear as the swelling subsides.  The lower aspect of your breast and/or nipple may feel relatively numb at first.  All patients have an adjustment period.  The implants may initially feel and appear too tight or high and may require a few weeks for settling.  During that time, your surgeon will keep you in soft, supportive bras that do not push your breasts up.  There will be activity and weight lifting restrictions initially that are communicated to you via your surgeon or staff.  These restrictions are important as they promote healing and reduce the risk of complications such as fluid collections or bleeding.  We want all patients up and walking to avoid the risk of DVT or blood clots.  

Patients will be back to showering quickly and most everyday types of activities within 48 hours.  There is very little aftercare involved with the incision and any suggested scar treatment will be discussed with you.  Patients will get instructions to begin massage of the implant to limit the risk of capsular contracture in the days-weeks following the procedure.  Most people (depending on work related activities such as weight lifting) are back to work at one week plus or minus a few days.

Your surgeon will see you back to assess your healing, breast softness, scars, and shape.  Photos are a necessary way to track your result.  

Risks

Risks will be reviewed with your surgeon but include infection, prolonged pain, poor scars, prolonged numbness, asymmetry, hematoma-bleeding, fluid collection, poor healing, implant failure, capsular contracture, unsatisfied cosmetic expectations, and need for further procedures or revision.  

Reasons for re-operation include infection, fluid collection, capsulectomy to remove a firm scar capsule, breast lift, implant exchange for failure or size change, scar revision, revision of the breast implant pocket.  

And, What About Cost?

Our surgeons understand the importance in being cost competitive here in Austin.  In general, a 1 hour silicone breast augmentation surgery which includes surgeon fee, cost of silicone implants, anesthesia, and facility fee is about $5,000 total.  There are always some costs that we cannot control that may change this pricing very slightly.

Thank you for reading our article.  We want the very best for our patients including thorough education.  We hope this helps!

 

 

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