Breast Augmentation

Saline or Silicone in a Marked Pocket

Breast augmentation enlarges the breast with a saline implant, a silicone implant, or both, so the breast is in proportion to the body. The devices used here are Natrelle implants, and the operation also limits itself to FDA-approved implants made by Mentor, by Allergan, or by both. Natrelle is a trademark of Allergan Corporation. The Food and Drug Administration regulates these implants as medical devices.

The American Society of Plastic Surgeons describes the same choice, saline or silicone, placed to change breast size. This account cites that society for a yearly volume near 300,000 women.

The Standing Exam

The exam records mound size and asymmetry, nipple and areola position, medial cleavage, lateral concavity, and inframammary crease position. It also records mound diameter, chest-wall width, the distance from the nipple-areola complex to the crease, skin and soft-tissue thickness, and pectoralis tone. Those measurements set the pocket.

Sizing uses sizer implants in the office so the look can be seen and felt. The range runs from 200 cc to 500 cc, in steps of 50 cc. If the size is still unsettled, sand goes in a sandwich bag in the bra, and the sand is measured and converted to an implant volume. A family member can come to that visit. Sterile sizers are tried again in the operating room before the final device, and a range of sizes and shapes is kept at the surgery center in case the findings change the choice during the case.

How Breast Augmentation Marks the Pocket

Markings before the incision include the midline of the chest, the incision line for the approach that was chosen, the inframammary crease, and the pocket that will be dissected to fit the implant. Pocket size follows the implant size. After the implants are in, the patient sits upright so symmetry can be checked. If the breasts do not match, she lies back down and either the pocket or the implant volume is adjusted until they do. The incision is then closed in several layers.

Three incisions are in use. The inframammary crease gives the best view of the pocket and the most direct return if another operation is needed. Most surgeons prefer the fold under the breast for breast augmentation. It avoids a central mound scar, it is less likely to numb the nipple, and it interferes less with mammography. The periareolar cut can hide, but it crosses gland, it raises nipple numbness, and reopening it tends to pull the scar into a line that distorts the areola. The armpit cut hides unless the arms must stay up. Pockets are harder to match from there, the arm can go numb, a large vein can be injured, and a revision usually needs another incision. Those implants usually sit under the pectoralis. A belly-button incision is still called experimental, because the pocket is reached from far away and asymmetry is more common.

Under the Muscle or Over It

Routine breast augmentation places the implant in a submuscular plane and uses general anesthesia. For specific patients the plane is subglandular, over the muscle, and conscious sedation through an intravenous line is enough. The muscle massages the implant and limits thick scar. The muscle is a layer between implant and skin, so the skin is less likely to tether, especially on the upper pole, and the implant is harder to feel. The dissection also stays out of the breast tissue, which is the reason given for easier later detection of breast cancer.

A bi-planar technique corrects a slight nipple-areola asymmetry or a slight mound asymmetry. Pectoral release follows anatomic landmarks so the pockets match. Protection of the implant includes IV antibiotics, extended drapes, nipple-areola shields, non-powdered gloves rinsed with antibiotic solution, antibiotic irrigation of the pocket and the implant, and minimal-touch handling. A breast band then holds the position.

Where the Operation Is Done, and How Long It Takes

Breast augmentation takes 1 to 2 hours. Because general anesthesia is the routine plan, it is done in a hospital operating room or an outpatient surgery center. An office room is used less often, and only with an accreditation such as AAAASF. Nothing is eaten or drunk after midnight, so food is not aspirated when anesthesia starts. A caretaker drives and stays the first night. Planning also asks for a responsible adult through the first 72 hours, and for help with small children, because lifting is sore at first.

Blood work is drawn at the first visit. A mammogram is required at 40 or older, and after tenderness, a lump, or nipple discharge. An implant is safer when there has not been tenderness, lumps, discharge, infection, or an unchecked family history of breast cancer. Smoking stops for one month before surgery and for six weeks after. Antimicrobial soap starts four days prior. Anti-anxiety medicine is given the night before and the morning of surgery.

The First Weeks

Patients wake with Ace wraps and a breast band. The wraps support the implant in the new pocket. For the first three weeks after breast augmentation, the implant tends to ride up on the chest wall against gravity, and the band counters that. High-riding implants are expected early and drop over 2 to 4 weeks, which is about how long the band is worn. Soreness lasts about 2 to 3 days and is limited by long-acting local anesthetic in the pocket. Lifting stays under 15 pounds for two weeks. Steri-strips seal the line for 36 hours, so the shower waits until the second day. Exercise waits four weeks.

Daily activity after breast augmentation usually returns in one week. A sitting job can resume as early as 4 to 5 days. When the job is heavier, the 15-pound limit for two weeks is the guide. Results are described as lasting several decades. Early revision follows deflation. Later revision follows a thick capsule that distorts the breast, or sag from aging and from the weight of the implants.

Deflation, the Capsule, and a Hard Breast

Two deflation figures are written here, from two eras. The older figure is 1 percent per year per implant, a 10 percent chance over 10 years for that implant, and a 20 percent chance that one of two implants deflates in that decade. Saline collapses like a flat tire. Silicone can bleed and still look normal, so ultrasound or MRI confirms a shell break. A saline crease is avoided by overfill. The example is a 360 cc implant filled to 380 cc. Mentor and Inamed later reported 3 to 7 percent deflation over ten years, with 10-year warranties. Early revision after breast augmentation follows the older 1 percent yearly figure.

A capsule is the scar around the implant. A thin capsule is expected. A thick capsule is capsular contracture. It is described as uncommon, more often with silicone than saline, and less often with newer silicone. It can appear years later. Pain, hardness, or distortion needs an exam. Silicone older than ten years is called an older generation here, with a higher chance of rupture and of that thick scar. When the scar is squeezing the implant, both are removed.

Ptosis, Age, and the 2007 Silicone Change

A small droop, up to 2 cm, can be improved by breast augmentation alone. Whatever the implant size, most patients are expected to gain about 1 to 1.5 cm, a finger breadth. Ptosis past that minor range needs a lift. An index finger under the breast is the check. If the nipple lies below the crease, a breast lift is required. More droop can be a lift alone or a lift with an implant. The first reported enlargement was Czerny in 1895, using fat from a lipoma. Paraffin is dated to 1899, Pangman's polyvinyl polymer to 1951, and the silicone gel implant of Cronin and Gerow to 1963.

In 1991 a moratorium limited silicone implants after concern about immune disease and breast cancer. The studies summarized here found no tie to immune disease, and a lower rate of breast cancer in women with silicone implants. Before March 2007, silicone was limited to replacement after silent rupture, to sag that needed a lift, to chest-wall deformity, to asymmetry or a tuberous breast, and to reconstruction after breast cancer. First-time patients otherwise received saline. In March 2007 silicone was approved again for women aged 22 or older. Patients seen for this operation range from 18 into the 60s. Indications include too little volume, delayed breast development, and surgery after breast cancer.

Bleeding, Infection, and a Pocket That Is the Wrong Shape

A hematoma is blood in the pocket soon after surgery. Under 10 percent of breast volume, it is left to resolve. Over that, a return to the operating room removes it, because blood can feed bacteria and because a hematoma is tied to capsule formation. Infection is treated by removing the implant, a month of antibiotics, and about three months before a new implant, with a prosthetic bra during the wait. A pneumothorax, a hole in the lung lining, is rare. It is possible because only a few millimeters separate a submuscular pocket from that lining. The repair described is a catheter, a seal, an x-ray, and sometimes a night in the hospital.

Different implant volumes narrow a pre-existing size difference, with a goal under 5 percent. Shape asymmetry is a pocket error. Dissection too far toward the middle joins the pockets, which is symmastia, and that needs a revision. A squeak while running is rare. The likely cause is a pocket larger than the implant, and the pocket tightens within two weeks. A thick skin scar is limited by a layered closure, sutures that hold for months, and a pressure dressing, with laser treatment, steroid injection, or medical tattooing if it stays thick. Nipple numbness is more common after a periareolar cut and is expected to fade over 2 to 3 months.

Fees are kept on the breast augmentation surgery price page and are not repeated as a dollar figure here.