BREAST AUGMENTATION
By Robert Caridi, M.D.
Westlake Plastic Surgery
Overview
Now is a wonderful time for women to consider a breast enhancement. Breast enhancement is now the most commonly performed plastic surgical procedure among board certified plastic surgeons, and in my hands the surgery is safe and reliable. My patients have been extremely satisfied with their results.
Frankly, it’s uncommon to find women with natural breasts that are as attractive as those that can be created by using implants (sad but true!) An implant is a wonderful foundation to any breast–it doesn’t change with your menstrual cycle, weight fluctuations, or age, even though your natural breast does.
After performing breast enhancements for almost twenty years, I have compiled an overview of important information to consider when contemplating breast enhancement. The procedure does have its risks and potential for complications, and you should make yourself fully aware of these. For a complete list of the potential risks and complications, please review the implant manufacturers’ literature.
Your Initial Consultation
First and foremost, don’t be nervous about your consultation. This is your time to get to know your doctor, get a feel for his/her practice, and have your questions answered by an experienced professional. Visiting with several doctors is advisable, as it will help you make the most important decision regarding your procedure — whom to entrust with your care. Good care and good results come from good doctors.
I see several different groups of breast enhancement patients. The first group is made up of women who are considering a first time breast augmentation because of their small breasts. The second are women that are experiencing involution of their breasts, sagging, and a loss of superior fullness due to pregnancy and breastfeeding. The third group is composed of women who have had previous breast procedures and are not completely satisfied with their results. Finally, the fourth are women that have had their implants for a number of years and are ready for them to be replaced.
Most patients have “done their homework,” and are somewhat familiar with the issues involved in a breast enhancement. Unfortunately, much of their information is derived from the media and the Internet, both sources of tremendous misinformation, bias, sensationalism, and salesmanship. Because of this, I spend valuable time debunking myths and misconceptions. There is no better source for accurate and reliable information than your Board Certified plastic surgeon. The consultation process is your best investment in your outcome.
Goals
The first comment most patients make is that they don’t want to be too large. They also don’t want to look like they are wearing a push up bra, when they aren’t. They desire breasts that are in proportion to their figures. They certainly don’t want implants to make them look heavier. They don’t want their breasts to be the first thing people look at when they enter a room. Many women have made the comment, “I don’t want people to look at me and say, ‘Yeah, she has implants.’” They want their breasts to look and feel natural. The best result occurs when others see you and wonder, “Does she, or doesn’t she?” One patient described seeing a woman with attractive breasts the following way: “If those are hers – I hate her, or they did a good job!”
Most patients prefer to have natural looking breasts. When they hug friends and family, they don’t want people distracted by two firm objects on their chest. They desire more superior fullness. Cleavage is a huge bonus. Symmetry is important. They don’t want the size of their breasts to interfere with exercise or daily activities. They want to be able to wear clothing that will accentuate their breasts and shape, or even conceal them, if the situation warrants.
Ultimately, they are your breasts and you can choose the shape and size that you prefer. But, I will certainly chime in to keep you “honest,” and provide you with the feedback that comes from working with breast augmentation patients for many years. I am “the expert,” and I will share with you my medical and surgical judgment and my artistic eye.
Implants and body proportion
The beauty of breast implants is that the benefit extends well beyond the breast. Breast augmentation changes the appearance of your figure dramatically. For instance, if you have relatively wide hips or a full lower half (pear-shaped), enhancing the size of your breasts creates a more balanced figure. Your abdomen will look smaller, and you will look like you have lost some weight. Women with “broad” or “strong” shoulders often benefit from full breasts because their shoulders appear more balanced and less generous. The goal is sexier, perkier breasts that compliment your hips and shoulders. During your consultation you will try on various breast implant sizers to observe the impact that the different implants have on your appearance. I can’t imagine how patients can undergo a breast augmentation without first trying on sizers to determine what size is best for them. It is foolish to think you can just ask your surgeon to make you a “C” or “D”. This is a shot in the dark. Ultimately, the implant size that you choose is influenced more by how they change your figure, than how they change your breasts.
Silicone vs. Saline
Both Silicone and Saline implants enjoy wide popularity. As you can probably determine after visiting my website, the majority of implants chosen are silicone. This is absolutely a patient’s decision, which is only made after appropriate education regarding the “pros and cons” of the two implant types. Saline implants are preferable to patients who believe that silicone is dangerous.
Saline implants certainly ripple more than silicone, and they are more likely to stretch your breast with time (I’m working on proving this in the laboratory with my Engineering colleagues). Saline implants are water filled bags that behave like water balloons, whereas silicone implants behave more like a thick gel that it is.
Saline implants don’t feel as natural as silicone — silicone is softer and feels like normal breast tissue. This is a BIG factor; after all, you want your breasts to look and feel wonderful. Having said that, I can tell you that in many patients (particularly in women who have a fair volume of their own breast tissue), I cannot tell, upon physical examination, which type of implant you have! This issue is more critical if you have small breasts with a thin layer of tissue, in which case it will be easier to see and feel your implants.
I have listened to many patients and I can tell you that there is a common theme among them all—saline implants are like a beach ball, while silicone implants are more like a bean bag. Patients are more aware of the saline implants than the silicone implants. Silicone implants actually ”feel better” on the inside than saline implants. Saline implants feel somewhat separate from the natural breast tissue whereas silicone implants feel like “one” with your breast tissue.
Another observation that simply can’t be denied is that patients who have had experience with BOTH implants, almost without exception, prefer the silicone variety. This is for the reasons that I mentioned above, and speaks volumes from the patients’ perspective.
In November of 2006, the Food and Drug Administration approved the use of silicone breast implants after having removed them from the American market 14 years prior. Their reintroduction to the market was due to the lack of any scientific evidence that silicone is associated with disease conditions or adverse affects to your health — there was none. The main reason not to choose a silicone implant is if you think they are associated with “funk,” and this may keep you up at night. If you are at all concerned about perceived health issues with silicone implants, don’t hesitate to choose saline implants.
Form Stable Breast Implants
These implants are referred to as “gummy bear” implants because they have the feel and consistency of gummy bear candy. They are not yet available in the United States. These implants have been used overseas since about 1992. They are currently undergoing trials in the United States, and after attending a plastic surgery seminar in August 2009, many of the surgeons who have been investigating these implants believe that they will eventually be approved by the Food and Drug Administration. They seem to be beneficial in a small subgroup of breast enhancement patients. The biggest plus for these implants seems to be that when the implant shell ruptures, there is less concern about possible migration of silicone material, as it is cross linked so heavily that the silicone does not flow like the less cohesive varieties used today. However, there is no study or evidence to support this belief.
Some of the positives noted are the stable shape of the implant, possibly less rippling, and less frequent capsular contracture. Some drawbacks with them include the rotation of the shaped implant (they are textured and tear drop shaped) and a larger incision for implant placement (the relatively firm implant cannot be “squeezed” into a smaller opening without damaging the implant.)
My professional opinion regarding these implants is that they will probably find a role in certain patients. But, in general, they will not be the “holy grail” of breast implants. In fact, I worry that the heavy marketing that is sure to follow the approval of these implants will result in a large amount of women requesting them. Then, these women may find out, first hand, that the supposed benefits are not significant, and the potential for complications and dissatisfaction are real. Only time will tell whether these implants find a role in today’s breast implant market. It’s important to remember that patient satisfaction with current breast implants is very high.
Size
This is the fun part. Most of the consultation time is spent choosing the size that works with your figure and your personality. Every patient has a preconceived notion of what size and shape they think they want. It must be understood that there are limits on implant choice based on the anatomy of your chest wall and your breasts. To provide you with an analogy, I can’t sit six people at a table for two. Large implants won’t work with a small chest. My primary goal is to make sure you make the best choice in implant size so that your results are long lasting and pleasing.
I generally hear two comments from almost all my patients considering breast enhancement. First, they tell me “they don’t want to be too big.” On the other hand, they tell me that they have heard from others who have had the procedure that “I should go larger than I think I should.” These statements are somewhat conflicting! What patients are trying to communicate is that they don’t want to look bizarre or fake to others, yet they don’t want to regret not having gone larger because of their initial hesitancy, and fear that they might look fake.
As a general rule, breast shape always “trumps” breast size. In other words, a larger breast with a poor shape is not as pleasing as a smaller breast with a better shape. Having a large and shapely breast is not common because of the negative impact that a larger (heavier) implant has on the shape of the breast over time. The ideal breast enhancement result occurs when the best size and shape is created using the smallest implant possible.
During your consultation you will try on silicone sizers and observe, firsthand, what volume works best for you. The A, B, C, D cup size system of breast measurement is imprecise and varies by manufacturer. By wearing different sized implants under your bra, you can get an exact idea of the appearance of both your breasts and your body, and how this changes with smaller or larger implants. This process removes much of the guess work and potential for choosing the wrong size implants.
Whatever implant size you choose, I adjust the size up a bit because it will look smaller once it’s under your breast. I encourage my patients to be realistic when they choose the size. As you go through life, you will change the way you see yourself and your breasts, so it’s reasonable to assume that what works for you one day may be different later on. An interesting fact is that about twenty-five percent of my breast practice comes from patients that have had the procedure done elsewhere and now want them made SMALLER! When I ask them why they chose that size, they usually tell me that the doctor made the decision for them.
The days of large implants are over for sure. The first reason is probably style related. Women want implants that are proportional to their figures. Second, I believe that patients have learned (the hard way) that implant size is related to complications – the larger, and therefore heavier implant is associated with more long-term problems, such as stretching of the skin, drooping, rippling, and implant malposition. Implants also thin the overlying skin and breast tissue over time. Patients requesting larger implants should realize that their choice places them at a higher risk for poor long-term results and the need for corrective operations later on.
Incisions
The vast majority of my patients choose the inframammary incision (an incision in the crease below the breast). The inframammary incision is the gold standard of incisions, and is the location most frequently used by experienced surgeons. Not only does it provide ultimate visualization and control for the surgeon, but also involves the least soft-tissue trauma for access, the fewest potential nuisances, and the least chance for post-operative complications.
The axillary, or “armpit” incision, is more prone to potential problems. Many women believe they want this incision, as there is no scar on the breast. However, there is a higher incidence of implant malposition. Additionally, if you require an adjustment of your implant, it’s not uncommon to need a second incision in a different location to correct the problem. Only the smallest silicone implants can be placed using the axillary incision. Post-operative issues are also greater with the axillary approach. Also, operative and anesthesia times are longer than the inframammary incisional approach.
The periareolar incision (incision around the boarder of your areola) is not as common as it should be. It’s a wonderful approach if you have a large enough areola to accommodate the implants. There is no evidence that this incision, closer to the nipple, affects breast sensitivity compared to other incisions. Since there is a greater amount of dissection through the breast with this approach, it can lead to excessive scarring and a visible contour irregularity at times. This incision may also be associated with a greater inability to breast feed, by some reports.
Depending on the type of implant chosen, how the implant is inserted differs. A saline implant is placed under the breast and folded like a taco, with an incision about the size of my fingertip. A silicone implant is pre-filled, requiring a larger incision for insertion – three inches, or so. If you choose a saline implant, the laceration is so small that I would recommend the inframammary incision.
I do not recommend the TUBAor transumbilical (belly button) placement of breast implants (Click here to learn the reasons why I don’t recommend the TUBA). There is a higher incidence of breast asymmetries after this procedure, and this violates the cardinal rule of breast implants-BREAST SHAPE AND SYMMETRY IS THE ULTIMATE GOAL. For this reason, few board certified plastic surgeons in Austin offer this procedure to patients. Furthermore, silicone implants are not an option with this technique. Think long and hard about undergoing the TUBA approach, and make sure that your surgeon is Board Certified by the American Board of Plastic Surgery and a member of the American Society of Plastic Surgeons. “Buyer Beware” is very applicable to anyone considering this procedure.
Patients who have excellent outcomes, without complications or reoperations, rarely complain about the incisions. A skilled surgeon usually delivers excellent scar results.
Implant location: above or below the muscle
Choice of implant pocket location determines soft-tissue coverage for the patient’s lifetime and is the most important technical decision about your breast augmentation that you will make. I place the vast majority of implants below the muscle. First, implants are heavy, and the muscle helps support the weight of the implant (a 350cc implant weighs about 1.2 pounds!). I have seen less “bottoming out,” or implant malposition, when placed below the muscle. This occurs when the implant moves below the fold at the bottom of the breast and the nipples move up. Second, implants “behave” better below the muscle, and they are less likely to form a contracture. Third, the more tissue there is above your implant, the less likely you will observe implant irregularities. Fourth, implants placed below the muscle tend to feel more natural and have a more natural “take off,” or gradual transition (slope) between the chest wall and breast, which is preferred by most women.
The most common problem I see with implants placed below the muscle is that in some cases the muscle can cause unusual movement of the implant when the muscle is flexed. Typically, this would be upward displacement or excessive movement of the implant into the underarm area during exercise. Patients who have excessive “tension” in their chest muscles will experience this more frequently. In most cases, this can be managed with time and massage. However, in some cases, additional procedures are needed.
If you prefer the more “augmented” look, you may elect to have your implants placed above the muscle, which can enhance the “crease,” or rounded appearance of your breasts. I sometimes recommend implants above the muscle if the patient has particularly thick skin and firm breast tissue (seen frequently in Asian patients).
Shaped Implants
A “shaped implant” refers to a “tear drop” looking implant. These were originally designed for the small subgroup of patients who prefer less fullness at the top and more at the bottom. They are not commonly requested. I rarely use them since all breast implants are soft and form a tear drop shape when placed under the breast. Most patients also benefit from the superior fullness associated with a round implant. After all, this is one of the main reasons augmentation is sought – filling in the upper pole of the breast that becomes flatter with pregnancies and advancing age. Shaped implants are textured and tend to have a more “stuck on” appearance. In addition, shaped implants can rotate, causing an unpleasant breast appearance. The new “highly cohesive” breast implants yet to be approved by the FDA are shaped implants.
Textured vs. Smooth Implants
“Textured” means that the outer shell of the implant is rough, and it feels like very coarse sandpaper. These implants were originally designed to reduce the rate of capsular contracture. They have not really enjoyed the theoretical benefits. I rarely use them since they are not as mobile and have a higher incidence of failure and “traction type” rippling. I don’t see much of a need for them, overall, except in isolated cases where I prefer the breast to be more firm and less mobile.
Implant Profile
An “implant profile” refers to the difference in the projection of the implant, relative to the diameter of the base of the implant, for the same volume (tall and narrow vs. wide and short). I usually prefer moderate profile implants, meaning they are neither too high nor too flat. High profile implants often look “stuck on” and unnatural in appearance, particularly in small-breasted, thin women. The most natural breast appears to gradually rise from the surrounding chest wall area, not abruptly, as can be seen with high profile implants. High profile implants often work very well in cases where the breast is fuller sized and wide in appearance. The projection of the high profile implants narrows the breasts and provides for very significant projection, which makes the breasts appear more youthful and perky.
Breast Lift
How do you know if you need a breast lift? This is not always easy to determine. It can be quite obvious when your breasts are hanging down to your belly button. However, that is unusual, and in most instances your breasts fall into the “gray zone.” Sometimes, an implant used alone will “lift” a breast for a more youthful appearance. In others, an augmentation without a lift may result in the breast actually hanging from the implant, creating a less than ideal appearance. You can tuck your breasts into a bra and make them appear attractive but they won’t look inviting when you are naked. In general, my goal with all my procedures is to make you look your best naked, as most patients would agree!
A mastopexy-augmentation procedure is a very complex undertaking, even in the hands of experienced surgeons. It involves not only the tightening of the skin, but expanding the breast with the implant. These two opposing forces maycompromise the healing of your tissues, which can lead to wound problems, possibly diminishing the blood flow to the nipple-areola complex which could lead to tissue loss. Smoking is an absolute contraindication to this procedure.
A BAR procedure (Breast Augmentation and Reduction) is similar to an augmentation mastopexy, but breast tissue is removed at the time of the procedure. This procedures is unparalleled in it’s ability to shape and elevate the breast for the ultimate achievement of “higher, tighter and perkier” breasts. This was invented and popularized by me. Instead of attempting to “lift” poor quality, hanging breast tissue, this is simply reduced and the breast implant becomes the new building block of the breast.
There are scars associated with a lift. Most scars will follow a “lollipop” pattern, with an occasional extension of the scar in the breast crease. Scars look worse in post operative pictures than in person. With rare exceptions, the benefits of the improved shape and appearance of your breasts outweigh the perceived downside of the scarring. Women who are candidates for a lift essentially have “scars,” in the sense that they are unhappy with the appearance of their breasts. Substituting a surgical scar, but with a huge improvement in the shape and appearance of your breasts, is usually well worth it.
Most men do not have a problem with a scar on the breast if the breast is shaped beautifully. They tend to see the “big picture” and not the details. It’s the fullness, the improved shape, and the fact that the nipple-areola complex is properly positioned on the breast mound that makes the greatest impact. To summarize, a beautiful breast with a scar is better than one that is natural, but not particularly attractive.
It is always preferable to choose a moderate size implant when considering a lift and augmentation. This is critical because too large of an implant mayresult in significant complications. If you tighten the skin too much, and place too large of an implant, you may compromise the blood flow to the tissue. This may possibly lead to wound healing problems, or worse, the partial or complete loss of your nipple-areola complex. Judgment and skill is paramount to a safe and predictable result.
We can also choose to stage your breast reconstruction. If I don’t think we can safely perform your reconstruction in one procedure, or if I believe your results will be much better if it’s staged, I will recommend that we split the two procedures up, with several months in between them.
Implant Longevity
We are now performing breast augmentations using fourth generation implants, and like most manufactured goods, they are better than previous generations. However, you must understand that ALL IMPLANTS WILL FAIL OVER TIME. It’s not a matter of if, but when.
The failure rate is measured by the percentage of implants per year that fail, as reported to the manufacturers. This rate is about 1-5% per year and is cumulative, meaning that the longer the implant has been in place, the higher the likelihood of failure. Much like auto tires, the greater the miles on your tires, the more likely they will fail.
Saline implants will fail partially, or completely, rather rapidly. Silicone implants may not manifest a problem because they tend to be “cohesive”-the silicone stays within the pocket created at the time of your procedure (more or less like thick hair gel). You may not even know that a rupture has occurred until the implant becomes more firm, changes shape, or you experience pain. Just because your implant has ruptured does not mean that you have “dangerous” implants, though.
I suggest that after fifteen to twenty years, you would benefit from implant exchange, even though you may not be experiencing problems. I use implants from the Mentor Corporation. They offer an exceptional warrantee that will cover all silicone implants for ten (10) years and provide $3,500 dollars towards the cost of the surgery.
Keeping Your New Breasts Looking Their Best & the Proper Bra
Age, health status, gravity, weight loss and gain, hormones and pregnancies will have a profound affect on the breast. The female breast undergoes the most changes, during your lifetime, than any other organ in the human body. Your genetic makeup can profoundly influence the longevity of your breasts. This explains why some women who are older and have had children still have relatively youthful-looking breasts.
How can you ensure that your breasts will have their best shape and appearance over your lifetime? It is important to maintain a healthy lifestyle by eating well, not smoking, and not abusing your body. As discussed before, your initial choice of implant size and position above or below the muscle is extremely important because these decisions have the most impact on the future of your enhancement.
Posture is also very important when it comes to the appearance of your breasts after an enhancement. Breasts always look more youthful and lifted when your shoulders are back. Hunching your shoulders forward and down makes your breasts appear droopy. This is an easy way to make your breasts look their best.
A proper fitting bra is critical, in terms of the longevity of your results. Click here to see the features of an ideal breast augmentation bra. The main function of your bra is to minimize the influence of gravity by transferring the load of the implant from your skin and muscle to the bra. Experts say that about 8 in 10 women wear the incorrect bra size. Most women wear a band size that is too large. A more snug band size—going from, say, a 34 to a 32—increases the size of the cup.
I recommend that all my patients visit with an experienced, professional bra-fitter. You will never be one size in every brand of bra, and if a fitter tells you this, then that is a sign of an inexperienced fitter. You will need to try on several bras until you find the right one that gives you support AND is comfortable. Your breasts should fit completely into the cup, no spillage, no wire digging into your sides, and the band should fit snug, but not too tight on the first set of hooks. Don’t be afraid to ask questions, and walk out if they aren’t knowledgeable enough to give you answers, or blame you (it happens) for their own inability to find you a proper fitting bra.
Most high-end department stores provide this service, free of charge, in their lingerie departments. They will fit you correctly, so that you benefit from a bra that will not only accentuate the appearance of your surgical result, but provide you with the support and comfort that you will need to protect your investment. ”Working” bras can be sexy too!
Wear a bra that will move your implants up and in.If your breasts have the same shape and appearance when you are in a bra compared to how they look when they are not, your bra is not working. Your breasts need to move up to ensure the bra is doing its job. Make sure your bra has a lateral panel that moves your breast towards the midline. Only a bra with an underwirecan provide you with the support that you will need (it’s a myth that you can’t wear an underwire bra after your surgery). The underwire portion of the bra must fit your natural curve, and sit right at the inframammary crease, so that the implant can’t move below this natural barrier. I prefer that, when you are in the lying position, your breasts sit up on the chest and do not disappear under your arms, which is why I also recommend that you wear a sleeping type bra as often as possible at night.
Implant Complications
Thankfully, serious issues or complications with breast implants are very uncommon. However infrequent as they are, problems associated with breast implants are real, and you will be provided with literature from the manufacturer that details all of the potential complications.
I offer breast enhancements to my patients with little reservation because, in my hands, I see few complications, and patient satisfaction is very high. Most concerns that I hear from patients involve the degree of perfection that can be realized. Remember, no two breasts are exactly the same, so after your augmentation there will be differences side to side.
Summary
My patients report that their breast enhancement procedures were very satisfying, both physically and psychologically. Keep in mind, however, that breast enhancement, by its very nature, is imperfect. You must take care of your breasts post-surgery, and understand that you will have additional procedures, since implants do not last forever. First things first though, choose the correct size and the best implant positioning below the muscle. Choose your surgeon wisely. Above all, enjoy your investment!
Robert Caridi, MD
