Dr. Robert Caridi
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 BREAST AUGMENTATION
By Robert Caridi, M.D.
Westlake Plastic Surgery
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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 aesthetically pleasing as those that can be created by using implants. An implant is a wonderful foundation to any breast-it doesn't change with hormones, diet and 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 be made fully aware of these. For a complete list of the potential risks and complications, review the implant manufactures' 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.
I see several different groups of breast enhancement patients. First is the group of women considering a first time breast augmentation because of their small breasts. Second, are those women that have experienced involution of their breasts, sagging and a loss of superior fullness due to pregnancy and breastfeeding. Third, there are the women who have had previous breast procedures and are not completely satisfied with their results. Fourth, are the 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.
Goals
The first comment most patients tell me 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 that "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 not to have unnatural 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 provide you with not only my medical and surgical judgment but my artistic eye as well.
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 fuller 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 and 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. 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 that are chosen are silicone. This is a patient decision that is made only after appropriate education about the pros and cons of these two varieties. Saline implants are preferable to those patients who feel that silicone is dangerous. They believe that these implants were removed from the market years ago because they were unhealthy (this was not proven and that is why the implants have been reapproved by the FDA).
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 is a water filled bag that behaves like a water balloon whereas silicone implants behave like a solid implant. This makes for wear and tear characteristics that I believe favor the silicone variety.
Saline implants don’t feel as natural as the silicone variety—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 enjoy a fair volume of their own breast tissue, I cannot tell on physical examination which one you have! This issue is more critical if you have small breasts with a thin layer of tissue. In this case it will be easier to appreciate and feel your implants.
I have listened to many patients and I can tell you that there is a common theme among them all—that saline implants are more like a beach ball and silicone implants are like a bean bag. Patients are more aware of the saline implants than the silicone implants. They actually feel better to the individual who has them—how it feels on your chest, particularly how they feel when you are moving about.
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 for the reasons I mentioned above—this speaks volumes from the patients’ experience.
In November of 2006 the Food and Drug Administration approved the use of silicone breast implants after having removed them from the American market fourteen years ago. Their reintroduction to the market is due to the lack of any scientific evidence that silicone is associated with disease conditions or adverse affects to your health — 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 recently (August 2009) many of the surgeons who have been investigating them believe that they will eventually be approved by the Food and Drug Administration and that 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 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 that 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 and then finding 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 body 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 breast. 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 wall. My primary goal is to ensure that your choice is reasonable, based on the dynamics of implants and my experience and judgment.
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 did you choose that size?" they tell me that "the doctor made the decision."
I believe that the days of the larger to huge implants are over for several reasons. First, probably a style related reason, 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 problems long term, such as stretching of the skin, drooping, rippling and implant malposition. Implants also thin the overlying skin and breast tissue over time. Patients requesting the larger implants should realize that their choice places them at higher risk for poor long-term results and the need for reoperations.
Incisions
The vast majority of my patients choose the inframammary incision (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 the ultimate visualization and control for the surgeon, it 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 under the breast using the axillary incision. Post-operative issues are also greater with the axillary approach. 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, at times it can lead to excessive scarring and a visible contour irregularity. This incision may also be associated with a greater inability to breast feed by some reports.
A saline implant is placed under the breast 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 incision is so small I recommend you use the inframammary incision.
I do not recommend the TUBA or 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 considering this approach and make sure you know that your surgeon is Board Certified by the American Board of Plastic Surgery and that they are 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 decision 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 500cc 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 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"-a gradual transition (slope) between their chest wall and breast-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 and create asymmetry of the breasts. Typically this would be upward displacement of the implant 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. 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 will sometimes recommend implants above the muscle if you have particularly thick skin and firm breast tissue (seen frequently in Asian patients).
Shaped Implants
"Shaped implants" refers to the "tear drop" shaped implant. They were originally designed for the small subgroup of patients who preferred less fullness at top and more at the bottom. They are not commonly requested. I rarely use them since all breast implants are soft so that they 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 flattened with age and pregnancies. Shaped implants are textured and tend to have a more "stuck on" appearance. In addition, shaped implants can rotate, causing an unpleasant breast appearance.
Textured vs. Smooth Implants
"Textured" means the outer shell of the implant is rough and 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
"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 high 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
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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, this is unusual and in most instances your breasts fall into the "gray zone." Sometimes an implant alone can "lift" a breast for a more youthful appearance. Sometimes it cannot, and in some cases the breast tissue can actually hang from the implant and create a less than ideal breast appearance. You can tuck your breasts into a bra and make them appear attractive but when you are naked and don't look their best, you won't be satisfied. 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 tightening of the skin but expanding the breast as well with the implant. These two opposing forces can compromise the healing of your tissues that can lead to wound problems, possibly diminishing the blood flow to the nipple-areola complex which can result in tissue loss. Smoking is an absolute contraindication to this procedure.
A reduction augmentation procedure is similar to an augmentation mastopexy but breast tissue is removed at the time of the procedure. The idea behind this endeavor is that the low hanging breast tissue is of poor quality, especially compared to the consistency and reliability of a breast implant. This tissue is removed at the time of the procedure instead of simply lifted up onto the new breast. I tell my patients that it’s not possible to build a two story straw hut! Many of us believe that you cannot lift poor quality breast tissue as it will always eventually come down over time. This procedure is often recommended when a patient has an abundant amount of breast tissue. Women desire smaller, perkier and “higher and tighter” breasts. Youthful breast shape and higher positioning of the breasts on the chest wall is the ultimate goal.
There are scars associated with a lift as well. Most scars will follow a "lollipop" pattern with an occasional extension of the scar in the breast crease. Scars typically look worse in post operative pictures than in person. In all cases, the benefits of the improved shape and appearance of your breasts outweigh the scaring. 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.
Probably the biggest issues with patients considering a mastopexy are the added complexity and cost of the procedure and the resulting scarring. This needs to be put into perspective so that patients do not cheat themselves out of the huge benefits from a mastopexy. First, although I hear many questions and concerns about the scarring from a mastopexy before the procedure, I almost NEVER have any discussions about scars afterwards. The reason for this is simply that the benefits of the procedure in terms of the shape change and overall improvement is dramatic and very satisfying to patients. Would you prefer a Ferrari with a scratch or an old clunker of a car? Patients are offered the option of a mastopexy if an implant alone will not result in the desired change. Desirable and youthful breasts are HIGHER, TIGHTHER and FIRMER (the one’s that you had when you were younger or before kids). If the nipple-areola complex is not in the best position it can make your breasts look tired or sad.
Most men do not have a problem with breast scars if the breast is shaped beautifully. They tend to see the “big picture” and not the details. It’s fullness, the improved shape and the fact that the nipple-areola complex is properly positioned on the breast mound that makes the greatest impact. We all know that breasts are “sacred”, and that it is only natural not prefer to have scars on your breasts, but the fact of the matter is that in order to make the most desirable breast a scar may be necessary--if I am able to recreate a beautiful breast the scars are generally a non issue. Please also remember that photography of breasts generally makes the scarring look more significant than it actually is when seen naked. To summarize, a beautiful breast with a scar is better than one that is natural, but not particularly attractive.
There is a limitation on the size of your implants if you choose a mastopexy-augmentation. This is critical because too large of an implant can result 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 which 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 manufactures. 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 or so 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 $3500 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 of 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 result. 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 and placing it on the bra. Experts say that about 8 in 10 women wear the wrong size. Most often the problem is that the stretchy fabric band around the rib cage is worn too loosely for smaller frames. A more snug band size—going from, say, a 34 to a 32—increases the width and depth of a cup. Simply put, a woman who wears a 36A is also likely to fit into a 34B or a 32C.
I recommend that all my patients visit with an experienced, professional bra-fitter. When you get to the store seek out the most experienced bra fitter there and have them measure you. If they tell you that you are a “definite” size, run like the wind. You will never be one size in every brand of bra and if a fitter tells you this then this is a sign of an inexperienced fitter. You will need to try on several bras, in many different sizes, until you find the right one that gives you support AND is comfortable. Your breast 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. You should be able to sweep your hands from you collar bone across the bra without feeling any flesh bumps. 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. New 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 and medially 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 underwire can 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 set 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 that 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.
Implant Complications
Thankfully, serious issues or complications with breast implants are very uncommon. However infrequent 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.
Asymmetry can result from excessive muscle activity in submuscular implants that cause abnormal movement of the implant. In most cases this causes minor breast asymmetries. On occasion a minor "revisional" procedure may be performed. Just remember, "The enemy of good is better." This means that if you choose to improve on a relatively minor problem, you may wind up with a problem that is more significant than the original one! I will help counsel you as to whether making an improvement is worth it.
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 afterwards and understand that you will have additional procedures since they 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!
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