Breast Augmentation Revision

The first reported breast augmentation was performed by Czerny in 1895 using the patient’s own fat. He actually used fat that he had removed from a fatty tumor called a lipoma. In the early part of the century synthetic injections were attempted by Gersuny in 1899 (paraffin) and by Pangman in 1951 (synthetic polyvinyl alcohol and formaldehyde polymer). In 1963, two United States physicians named Cronin and Gerow introduced the popular silicone implants that are used today.

In 1991, a moratorium was placed by the F.D.A. for the use of silicone implants. This decision was based on a concern from numerous women across the country who felt that their implants were responsible for development of immune disorders and breast cancers. Although the move to halt all silicone implants was controversial, the physicians agreed that further testing should be performed to determine the safety of silicone implants. Over a decade of studies has shown that, in fact, silicone implants have no relation to development of immune disorders and that women who have silicone implants are less likely to develop breast cancer. In March of 2007, the F.D.A. re-approved the use of silicone implants in all women aged 22 years and older.

Prior to March 2007, silicone implants could only be placed in women who needed replacement of their implants (saline or silicone), in women who had sagging of the breast requiring a breast lift, in women who had chest wall deformities, in women who had breast asymmetry, and in women who needed breast reconstruction for breast cancer. For all other patients considering breast augmentation for the first time, only saline implants are allowed. As of March 2007, the F.D.A. has approved the use of silicone implants in all women aged 22 years and older.

Most women who desire enlargement of their breasts are good candidates for breast augmentation surgery. In general, it is safer to place implants in patients who have not previously had breast symptoms such as: breast tenderness, breast lumps, nipple areola discharge, and breast infection. In addition, if the patient has had a family history of breast cancer, this can be concerning because it may increase the likelihood of breast cancer in the patient. If you have experienced any of the above concerns, a mammogram is recommended so that any breast abnormality can be detected prior to breast augmentation surgery.

Indications for having breast augmentation include inadequate breast volume and developmental delays in breast growth. Additionally, breast augmentation has proven to benefit psychological conditions such as: low self esteem, lack of self-confidence, or sexual inhibition. Finally, small degrees of breast droop (up to 2 cm) can be corrected with a breast implant placement.

The surgery involves placement of accurate preoperative markings including: the midline of the chest, the incision line (determined by the approach used), the inframammary crease (fold under the breast), as well as the pocket that is going to be dissected to fit the implant. The pocket size is determined by the implant size selected.

Following placement of the implants, the patient is sat upright so that breast symmetry can be confirmed. If there are asymmetries, the patient is placed back down and either pocket dissection or implant volumes are adjusted until symmetry is achieved.

Finally, the incision is closed in multiple layers and using plastic surgery closure techniques to ensure protection of the implant and an aesthetically pleasing incision line.

The various approaches to breast augmentation include:

• inframammary crease(in the breast fold): this approach provides the surgeon the best visualization of the breast pocket that he/she is dissecting thus ensuring breast symmetry following breast augmentation surgery. The most important advantage of this approach is that it provides the most direct access to the surgical pocket in the event that revision surgery is required.
• periareolar (around the areola): when this incision heals well, can be very well camouflaged. However, this incision is associated with several disadvantages including: surgical trauma to the breast glands, increased potential for nipple numbness, and poor scarring in the event revision surgery is required. Since the incision is circular, if opened a second time, it tends to contract into a straight line when healed thus distorting the areola.
• transaxillary (in the armpit): This incision tends to hide well as long as you don’t have to raise your arms as part of your occupation. However, it has several disadvantages including: more difficult dissection resulting in more difficulty obtaining symmetrical pockets, potential for arm numbness, potential for damaging large veins to the arm which if damaged could result in prolonged arm swelling, and a necessity to convert to another incision if a revision is necessary (revisions may include correcting asymmetry or to remove a thickened capsule scar). Breast implants using the armpit technique are usually placed under the pectoralis muscle.

On your initial visit, your surgeon will evaluate your health status by obtaining blood work. If you are 40 years or older or if you have had a history of breast symptoms (tenderness, lumps, nipple discharge) you will have to obtain a mammogram. If you are a smoker, you should quit for 1 month prior to your breast augmentation surgery to minimize the risks of implant infection. In addition, it is prudent to quit smoking for 6 weeks following surgery to ensure a well-healed surgical incision line. Finally, you will need to arrange for a friend or a spouse to care for any small children who may need to be lifted since you will be sore for the first couple days following surgery.

Since your surgery will require general anesthesia and/or intravenous sedation, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated into your lungs during induction of anesthesia. Since, you will have anesthetic medications administered throughout the case, you will remain groggy for several hours and will require a ride to and from the surgery center. You should choose a caretaker who is conscientious and who can spend the first night with you.

Patients who undergo breast augmentation surgery are extremely satisfied with their surgery and will notice immediate improvement in their breast to body silhouette. A thorough preoperative assessment, safe intraoperative course, and close monitoring with frequent postoperative visits ensures that patients experience a speedy recovery and a return to a more productive and rewarding life. Patients are extremely pleased with breast augmentation surgery and radiate increased physical and mental confidence.

Since breast augmentation surgery will require general anesthesia, it must be performed in an operating room that is part of a hospital institution or outpatient surgery center. Less frequently, patients may be operated on in an in-house office based operating room, but it is of utmost importance for patients to make sure that the office facility is accredited by a surgical accreditation body such as AAAASF.

For the routine breast augmentation, the implants are placed in a submuscular plane which will require general anesthesia. For certain individuals, a subglandular (over the muscle) plane is recommended for which conscious sedation (sedation through intravenous medications only) will suffice.

Patients will awaken from general anesthesia to find their breasts wrapped with Ace Wraps as well as a breast band. The Ace wraps are to support the implants in their newly created pocket. The breast band is to prevent the implants moving up on the chest wall. Although this is not intuitive, for the first three weeks following surgery, breast implants tend to want to move up on the chest wall against gravity. The band counters this movement and ensures that the breast implant stay in the desired position. Patients will feel sore throughout the first 2 to 3 postoperative days. By placing long lasting local anesthetic solution in the breast pockets prior to closing the incisions, this soreness is minimized . Patients are asked to avoid lifting of weights greater than 15 pounds for the first two weeks. Incision lines will be sealed with special tape (steri-strips) for the first 36 hours so showering is delayed until the 2nd day following surgery. Finally, exercise should be limited for the first 4 weeks until the incisions and the breast pocket have completely healed.

Patients can expect to return to work at the earliest at 4 to 5 days following surgery if they have a sitting job. In general, patients are recommended to take 1 week off if their work permits. Weight restrictions are set at 15 pounds for the first two weeks to guide patients who may have more physical jobs.

There are several side effects that have been associated with breast augmentation surgery and these include:

1. High riding implants: Patient’s frequently notice high riding implants in the early postoperative period. The implants will drop into their desired, aesthetically pleasing position within 2 to 4 weeks. The tendency for the implants to sit high is countered by wearing of a breast band which will be provided by your plastic surgeon. The breast band will be worn for approximately 2 to 4 weeks until the implants fall into their desired space.
2. Numbness: Numbness can occur when sensory nerves are inadvertently traumatized during the surgery which requires creating a pocket for the implant to sit in. Since these nerves are extremely small, they are not apparent to the naked eye and so unavoidable. Clinically, the periareolar incision has been associated with increased incidence of numbness since the dissection is closer to the nerves. Fortunately, numbness is an infrequent event and when present resolves itself over 2 to 3 months.
3. Capsule formation: Capsule formation refers to the phenomenon of the body forming a scar around the implant. This is a natural event that occurs as the body tries to wall itself from a foreign body; this occurs when you get a splinter the body forms a scar around it that eventually helps the body spit it out. Usually, the capsule around the implant is thin and soft, and does not cause any problems. However, if the capsule does thicken it can lead to breast distortion and is referred to as capsular contracture. Capsular contracture is an infrequent event that occurs most commonly with silicone implants. The good news is that capsular contracture is rarely observed with saline implants and to be limited with the new generation silicone implants. Since capsular contracture tends to occur years after implant placement, time will tell if the new generation silicone implants prevent the development of capsular contracture.
4. Hypertrophic scar: Hypertrophic scar refers to the development of a thick scar in the skin. Since, most plastic surgeons use a similar technique for closure of their skin incisions, whether or not you are at risk for this depends on the healing capacity of your body. Contrary to common knowledge, the better healer you are
5. Mild asymmetry of breast size: Asymmetry of the breasts is considered a side effect only for the mere fact that most women have some degree of asymmetry. The surgeon must do his/her best to improve on any asymmetry by utilizing different sized implants. Thus, any preoperative asymmetry should be improved upon; as a rule of thumb, the surgeon should be able to get the breasts to a similar size with a less than 5 % difference in size.
6. Deflation: Deflation of the implants can occur and in gen at 1% per implant per year. So in 10 years there is a 10% chance of the implants deflating. Deflation is felt to occur when the shell (or cover) of the implant rubs against itself. In saline implants, this occurs when the implant is under-filled. For example, if you chose a 360 cc implant, then this implant is usually overfilled to 380cc so that there are no creases in the implant. Detection of deflation in saline implants is easy since they deflate like a flat tire. Detection of deflation in silicone implants is more difficult since the silicone implants tend to ooze and minimally deflate. Often a ultrasound or MRI is needed to confirm a break in the silicone implant shell.

1. Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period which pools into a pocket. When less than 10 % of the breast volume, the hematoma is left to resolve on its own. When larger than 10 % most surgeons will recommend a trip back to the operating room so that this hematoma can be removed. There are two reasons why the hematoma must be removed. First, the hematoma is a perfect medium for harboring growth of bacteria. So if you have an infection anywhere in your body, the bacteria will travel through the blood stream and grow in the hematoma; this can lead to an infection of your implant(covered below). Second, the presence of a hematoma is felt to promote capsule formation (covered above).
2. Infection: An infection is probably the worst complication that can occur following breast augmentation surgery. An infection will require you to remove the implant and get on 1 month of antibiotics. You will have to wait approximately three months before having your implants replaced. This 3 month interim can be quite discomforting for you since you will have to wear a falsy(bra) to make your breasts symmetric.
3. Pneumothorax: A pneumothorax refers to the inadvertent puncturing of the lining that covers your lungs. This is a rare event but can occur since most implants are placed under the pectoralis muscle. Once you are dissecting under the muscle, there is only a few millimeters of tissue between your pocket and the lung lining. Regardless, if this does occur, then the surgery is more complicated as you might assume. The surgeon has to place a catheter into the lung, has to seal the hole created, and then pull the catheter after the case following an X-Ray to confirm proper placement. This will probably mean a trip to the hospital for the X-Ray and an overnight stay.
4. Assymetry of breast shape: Assymetry in shape is very different than asymmetry of size (described above) and occurs when the implant pockets have not been dissected accurately. This is why preoperative marking is so critical (see below). In fact, if the breast pockets are dissected too medially, this can lead to the breast pockets connecting together leading to a condition called symmastia. This can be a difficult complication to fix and will require revision surgery.

Breast augmentation surgery has always been a popular procedure. According to the statistics published by the American Society of Plastic Surgeons, nearly 300,000 women undergo breast augmentation each year. On average plastic surgeons perform 2 to 5 breast augmentations per week.

Breast implants are made of a solid silicone shells which may deflate with time. The degree of deflation has been described as a “bleed “(least leak) and as a “rupture” (complete deflation). Saline implants will completely deflate over time even if there is only a bleed; this is in contrast to silicone implants which may look and feel normal when bleeding. Over all, the deflation rate for an implant is 1 % per year. This means that over a 10 year period there is a 10 % chance of your breast implant deflating.

Breast implants are not a risk to your body. This was proven as a result of multiple clinical studies that were initiated following the silicone scare in the late 80s. As a result of the “silicone scare” of the late 80s, the FDA moratorium in 1992, and subsequent research and development, far superior implants have been developed. Today implants are made stronger yet they feel softer and more natural than those we were used to in the past.

The age gap for breast augmentation has begun to spread. Plastic surgeons are seeing patients as young as 18 and as old as the 60s. The popularity of cosmetic makeover shows has prompted younger patients, even in their teens, to seek cosmetic surgery. In contrast, surgeons are also seen older patients in their 60s desiring breast augmentation since patients are living longer and wanting to look younger.

The medical term for “sag” is PTOSIS. According to a recent study, regardless of the implant size, at most patients can expect to improve their sag by 1 to 1.5 cm i.e. a finger breadth. In a nutshell, you can only improve minor degrees of sag with a breast augmentation alone.

First, you need to examine where your nipples lie relative to the breast crease by placing your index finger underneath the breast. If the nipples lie below the breast crease, then you need a lift.

The best way to decide what size implants to get is to try out the sizer implants available at your surgeon’s office. Implant sizers range from 200 cc’s to 500 cc’s and go up in 50cc increments. If the client still has a difficult time choosing the implant size, then we recommend that they use sandwich bags filled with sand placed in their bra. When the desired size is determined, then we can calculate the appropriate size by measuring the amount of sand in the bag.

Currently there are three options for inserting breast implants. These include: 1)Inframammary fold (under the breast), 2)Nipple/Areola (underneath the pink portion of the areola), and 3)Trans-axillary (through the armpit). Breasts are an intimate part of a female in that this decision needs to be made together with your doctor. There are pros and cons of each approach and they should all be discussed with patients. Most plastic surgeons prefer the approach from under the breast. This avoids loss of sensation of the nipple, less interference with mammography, avoids a potentially ugly scar on the center of your breast mound. In the event that you don’t scar well, this is the ideal site for a scar; it will be hidden in the shadow of your breast and it can be treated with laser and scar management therapies.

The consensus among surgeons is that this approach is still in an experimental stage. When more cases have been performed, then we can evaluate whether this approach is more effective than the above options mentioned. From the limited experience gathered, it seems that there may be a slightly higher incidence of asymmetry of breasts associated with this approach due to the fact that dissection of the pockets for placement of implants is performed far from the pocket, i.e. the belly button.

Special plastic surgical techniques for closure of the incisions are utilized to minimize scarring including:

• closure in multiple layers so that the tension is taken off the skin
• specialized sutures which will stabilize the incision line for several months
• specialized bandaid dressings which create a pressure effect on the incision line, thus preventing scar formation.

In the event that individuals do develop prominent scarring, we can offer laser therapy, steroid injections, and even medical tattooing.

Squeaking of the breasts after surgery is rare. There are two reasons why this occurs:

1) If you had saline implants, it is possible that your implants were underfilled so that the water within the implant is swishing around, but this is probably not the case.

2) The more likely cause is that the dissected pockets are larger than the placed implants and so that the implants are able to move around in the pocket. Within 2 weeks following surgery, the pockets will tighten down around the implants and the squeaking will resolve on its own.

It is easy to pick a qualified surgeon by making sure that he is a plastic surgery trained physician. Unfortunately, there are a few organizations that will give you an impressive certificate claiming that you are a “cosmetic surgeon” but only after a limited amount of training. What clients have to look for is a certificate of completion from a “plastic surgery” training program.

There are currently several indications for having your implants replaced due to the hardening that you are concerned about. This hardening is nothing to get worried about since it is caused by the body’s own response to having a foreign material implanted in it.

If your breasts are being distorted by the hardening or if you are having pain associated with the hardening of your breasts, then you should be evaluated by a plastic surgeon.

If your implants are silicone and more than 10 years old, your implants are considered older generation implants which have a higher propensity for leaking and hardening. Hardening of the implants is due to the development of a thick scar which surrounds and squeezes around your implants; this scar as well as the implants need to be removed in order to return your breasts to the soft and aesthetic appearance that you once had.

Plastic Surgeons can fix breasts that are different in breast volume, mound shape, or nipple position. It is critical to assess the reason for the asymmetry so that the proper surgical revision can be performed.

When you put an implant under the muscle you benefit from three things. First there is less scar formation around the implant, this is because the muscle continuously messages the implant and breaks up any large scar depositions. In addition, implants tend to tether the overlying skin which is caused by the implant sticking to the skin; The muscle gives a protective layer that prevents tethering of the skin, especially over the upper pole of the breast mound. In addition, going under the muscle gives you a bigger cushion so that you are less likely to feel the implant. But most importantly, by placing the implant under the muscle, you avoid dissection through the breast tissue and subsequently improve detection of breast cancer.

It used to be that deflation rates were 1% per year per implant. That meant that you could tell a client to expect a 20% chance of one of their implants deflating over a 10 year period. However, due to the wonderful improvements in implant technology that we have witnessed over the last couple of years, the most current statistics have shown a 3 to 7 % rate of deflation over 10 years. These studies have been performed by the Mentor and Inamed Corporations, both of which provide extended 10 year implant warranties.