Breast augmentation, also known as mammoplasty, is a surgical enhancement procedure to accentuate the size and shape of a woman's breasts. While breast augmentation will make the breasts larger, the surgery will not move the breasts closer together or lift sagging breasts.  Breast augmentation is a help to patients who desire a fuller profile, who have lost breast volume due to pregnancy or nursing, or who have undergone breast reconstruction and want to gain a more natural look again.

Reasons for Considering Breast Augmentation:

• Enhance body shape
• Increase breast volume after pregnancy and nursing
• Equalize a difference in breast size (cup size) to gain breast symmetry
• Reconstruct breasts following a mastectomy or injury

General Procedure

                   BBreast augmentation involves making a small incision to insert a breast implant into the breast area in order to enlarge the breast.  There are several possible locations for the small incision that will be used for inserting the breast implant.   Usually, a one-inch incision is made along the lower border of the areola.  Another technique, though less frequently used, involves making an incision in the armpit.  And sometimes an incision is made in the crease beneath the breast.  It is possible to use an incision in the belly button, but there are more concerns when this approach is used.  The best technique will be decided together between the patient and the surgeon during the consultation.

During surgery, the breast is raised to create an open pocket under the breast tissue or beneath the chest wall muscle.  Inserting an implant behind each breast can increase a woman's breast size by one or more bra cup sizes.  Implants typically contain a saline solution (similar to saltwater) although the implants can contain a silicone gel.  Several types, and a large number of sizes, are available.  In some circumstances, particularly those in which there is breast asymmetry (uneven breast size), an inflatable implant may be used to allow the surgeon to adjust the level of inflation to attain breast symmetry and balance.  Surgery typically lasts from 1 to 3 hours.  The surgery is performed under general anesthesia, administered by a board-certified anesthesiologist, at our fully accredited surgical center.

Recovery Process

Generally, post-operative instructions call for limited movement in order to speed up the healing process and recovery time.  Bandages are applied right after surgery to aid the healing process and to minimize movement of the breasts.  A specialized  bra will need to be worn for several weeks.   Pain associated with the surgery varies, depending on how much the muscle pocket needs to be stretched.   Potential problems can be minimized by carefully following the instructions given by the physician, and by calling the doctor if any questions arise.

More Details About Breast Implant Issues:

(The following informational article was published for other types of doctors)

All natural breasts are physiologic. The media can be indicted with excess portrayal of certain breast shapes and sizes, yet this is most likely done to increase viewership. Theories have stated that breasts are symbols of femininity or of secure nurturing. I believe that the mating ritual theory expounded by Desmond Morris (in Body Language) has validity. In any case, there are a number of reasons that this procedure is popular. Some reasons, such as to “make my husband (or boyfriend) happy”, are not valid. And, as with other cosmetic procedures, the decision to proceed should be based on complete and accurate information.

Regarding this procedure, I prefer to discuss the potentially negative issues first. The possibility that breast implants cause autoimmune disorders has been thoroughly investigated, and no relationship has been found. However, I think that the most significant problem with breast implants is “encapsulation”, also called ”capsular contracture”. The body’s normal reaction to the implant is to form a fibrous scar around it. This capsule of scar can become thick, and it can contract. When this happens, the space available to the implant shrinks, causing the capsule/implant to assume a spherical shape and feel harder. The degree of induration varies from the implant being very easy to palpate (but still fairly soft), to very firm. In some unusual cases this can cause aching, and in rare cases a bone-hard shell can form. It is thought that the most common cause of firm capsular contracture is irritation of the fibrous capsule by non-pathogenic bacteria. There are surgical techniques that seem to decrease the rate of early capsular contracture. Unfortunately, however, this problem often occurs even many years after surgery, and thus it is not necessarily related to surgical technique. It is thus fair to inform each patient that this firm spherical condition is likely to occur, at least eventually, in her case. Firm encapsulation can be treated by surgically removing and/or severing the encapsulating scar tissue.

Can you “tell” if a woman has breast implants by looking at her? Usually this cannot be discerned, unless she has capsular contracture. (So, since we often can see ladies who look like they have breast implants, encapsulation must not be rare.) To be fair, a few young women have firm breasts that look like implants when a push-up bra is used.

A small amount of blood normally collects around the implant after surgery. In some cases, this blood can come through the incision several days after the surgery; this can frighten the patient, but it is not harmful. In the very unusual case where bleeding is greater than desired, it can be necessary to return to surgery to stop bleeding or to remove excessive blood around the implant.

Sometimes a small amount of air is trapped around the implant. This will dissolve in a week or two, but in the meantime it results in a “sloshing” sound with sudden movements.

Infection can occur after any operation, but when a breast implant is present, pathogenic bacteria can become established on the implant, even many years after surgery. (Bacteria briefly appear in our blood after brushing teeth, for example.) Although serious infections of breast implants are rare, they do require that the implant be removed (and usually left out for a number of months).

Innervation of the nipple is primarily via the fourth lateral intercostal nerve, which traverses the breast. But this does vary somewhat between individuals, and surgery sometimes interferes with nipple sensation. Temporary, or minor, loss of sensation is fairly common, but it is uncommon (yet possible) for this to be significant and permanent.

Most mammographers know to use special techniques for patients with breast implants. However, even with these techniques, it is estimated that about 20% less breast tissue is imaged for patients who have breast implants. For this reason, a person with significant risk factors for breast cancer is usually discouraged from having breast implants. On the bright side, it has been very well documented that breast implants do not cause breast cancer.

Breast implants are not expected to last a lifetime. All breast implants available today are made of silicone. The highly polymerized outer shell of silicone can be filled with a less-polymerized silicone gel, or with normal saline (.9% sodium chloride). Gel-filled implants blend better with the natural breast texture; thus, they feel more natural. I do not personally prefer to use the gel-filled implants, since they seem to rupture earlier (80% in 10 years in some studies), and the gel causes an inflammatory giant cell reaction when loose in tissues. It should be noted that the gel from a ruptured gel implant would usually be retained within the fibrous capsule, and this is probably not harmful. Nonetheless, a ruptured gel implant is an indication for its removal. Moreover, the gel does not migrate to other areas of the body, although major trauma can (rarely) force the gel into adjacent areas, such as the axilla (which would be a problem). It is estimated that saline implants have a rupture rate of approximately 1% per year.

When a saline implant ruptures, the patient notices that her implant has deflated.

Saline implants come to the doctor filled with air. At surgery the air is evacuated, and saline is placed into the implant. Although the silicone outer shell of these implants is somewhat elastic, this outer shell is also rather thick (which decreases elasticity), so as to resist rupture. When an implant is filled with the proper amount of saline, it is slightly firmer than breast tissue, and thus the implant is palpable. Some wrinkles are present in the implant shell, and these are more palpable. Although there is a little leeway, if less than the proper amount of saline is placed in the implant, the implant will be softer, but it will have many prominent wrinkles. If a little too much saline is placed in the implant (in an attempt to remove nearly all wrinkles), the implant becomes undesirably firm. Because of these factors, it is not very realistic to adjust the size of an implant by placing more or less saline within it. (Interestingly, implants that are filled more tend to rupture less.) Fortunately, a large array of sizes is available. For a woman of average size, an implant of about 200 cc produces an enlargement of one bra cup size, and (depending on the manufacturer) implant sizes come in increments of 25 to 30cc.

Plastic surgeons want their patients to be satisfied in the short term, but also in the long term. The larger the implant is, the more it will sag with time, and the more the breast will take on the characteristics of a “water bag”. Because of this, there is a tendency for plastic surgeons to be a little conservative about size. Different implant companies make implants with slightly different implant diameters for the same volume. Nonetheless, an implant that is too small makes a narrow-looking nodule on the chest, and an implant that is too large will impinge on arm movement somewhat.

And what about different types of implants? There is no perfect implant for everybody. All have pros and cons, and none are distinctly bad. This will be a very brief overview of my opinions. A “textured” (slightly roughened) surface was introduced some years ago, and it seems to delay the capsular contracture process. But the capsule is more likely to adhere to the implant, causing wrinkles in the implant to show on the skin. This also prevents the implant from shifting within its pocket (a little less natural). The lack of shifting of the implant means that repeated wrinkling of the implant occurs in the same place with movement of the patient. It is felt that this is the reason that more of the textured implants rupture at five to ten years postsurgically. Paradoxically, “Anatomic”, or teardrop shaped implants do not necessarily produce a more natural appearance, and they seem to be firmer. These implants also can sometimes rotate, which can look quite unnatural. Thus, my preference is for smooth surfaced saline filled implants.

There are also choices as to the placement of the incision. The incision can be in the axilla, on the border of the areola, beneath the breast, or in the umbilicus. My usual preference is for a one-inch incision along the inferior border of the areola. The resultant scar is often hard to find after healing. A few individuals form widened highly visible scars, and this may not be amenable to improvement, no matter where the scar is placed.

The location of the pocket for implant placement can be either under the pectoralis major muscle or on top of this muscle. Since the breast ducts contain a bacterial flora that could contribute to encapsulation, and since the muscle provides a thicker cover over the upper implant edge, I nearly always place the implant under the pectoralis muscle. This gives better breast shape. But there are some disadvantages to submuscular implant placement as well. If the patient has a rather wide sternum, it may not be possible to create an “ideal” cleavage with this technique, even with detachment of some of the more lateral pectoralis origin. If, in an attempt to improve cleavage, the pectoralis muscle becomes detached from the sternum, a deformity results. Also, when the implant is under the pectoralis muscle, the muscle can cause the implant to move when the muscle is flexed. Patients who exercise the pectoral muscles heavily and repeatedly (with weights, for example) can “squeeze” the implant out of its submuscular pocket, displacing it infero-laterally; such patients may be an indication for implant placement on top of the muscle.

Unless a pre-existing asymmetry is severe, it cannot be improved very much by placement of breast implants alone. Breast implants do not alter the length of skin between clavicles and nipples or between the midline and the nipples. Asymmetry can even sometimes be worse after surgery. At surgery, the implants are placed higher than their ideal location, as they will “settle in” over the first few months.

Pregnancy after breast augmentation causes the skin to stretch more, and the breasts may then droop to some degree. (This is called ptosis.) Removal of implants, or replacement with smaller implants, also results in excess skin, which results in some ptosis. A breast lift procedure can be performed simultaneously with implant placement, and this is based on the length of skin between the clavicles and the nipples.

When a woman understands the above issues, she is nearly always very happy with the results of breast augmentation. Many of the above complications mentioned above can be treated or improved. (The costs of this are not covered by insurance, and the surgeon generally does charge for his time, the use of an operating room, and anesthesiologist’s fees.) Major breast implant manufacturers will partially reimburse patients for reoperation within five years of surgery, but only if the implant ruptures. Many patients with encapsulation or similar problems do not desire another operation. Yet reoperation rates after breast augmentation averages approximately 4% per year.

Discomfort during recovery is quite variable, and largely dependant upon the amount of stretching of the tissues (size of implant). The patient should be prepared for the first night to be quite painful, despite narcotic pain medications. Naturally, there are limitations on activity during healing, but many patients can perform activities that do not require reaching or lifting within a few days. Heavy lifting should be delayed at least a month, and use of the pectoralis muscles will cause some pain for the first month. A few patients have sharp, painful muscle spasms for a few weeks.

It is clear that the benefits of larger and better-shaped breasts must be weighed with all of the above issues. In view of this it is almost surprising that the satisfaction rate with this operation is so high. It is also clear that we should not adversely judge women who have chosen to undergo this popular procedure, as we cannot weigh all of the issues in their lives.