Every woman having breast augmentation wants to make sure she has the best possible operation so as to achieve the best possible results. Though the basic idea of breast enlargement is simple, there are many factors to consider, and a simple idea can become quite confusing. Obviously one wants to be bigger, but by how much? Alteration in shape is another goal, but what shape?
When discussing breast augmentation with a patient, I try to limit confusion by helping each woman define her goals. There is no one “perfect breast” for everyone, as every woman has preferences regarding size and shape. Therefore, each operation needs to be tailored to meet an individual patient’s needs.
There are six basic variables I then discuss with each woman as part of her preoperative planning:
1. Implant size
2. Implant surface;
3. Implant shape;
4. Implant position (beneath the breast or beneath the muscle)
5. Incisional approach
6. Implant type (silicone vs. saline)
The issue of implant size is inherently tricky, as women naturally think about breast size in terms of cup size, while implants come in discrete volumes measured in cubic centimeters (30 cc equals 1 ounce). In other words, implant volumes do not directly relate to bra cup size. For instance, a 300 cc implant might result in a C cup size in a small woman but only a B size cup in a large woman.
To circumvent this issue, we go over pictures of augmented women, and I ask the patient to identify those most closely to her ideal as well as those that are unappealing. By knowing their body size and their goals, I can use my experience to select the appropriate implant size.
Breast implant surfaces can be textured (rough) or smooth. Textured implants were designed to ensure breast softness after augmentation. Unfortunately, texturing has not worked well and many plastic surgeons like myself avoid using textured implants. Not only do many patients seem to develop the same scar tissue around their implants texturing was designed to prevent, textured implants are stiffer than smooth implants and are easier for a woman to feel after augmentation. Due to the implants adherence to the patient’s tissues, textured implants are more likely than smooth implants to cause ripples in a woman’s breast. Such rippling can be treated only with additional surgery.
As with size, most women have a preference when it comes to breast shape. While some want a gentle slope to the upper part of their breasts, others want more upper breast fullness. To accommodate these preferences, breast implants are designed in “tear drop” (also known as “anatomic”) shapes for a more flat upper breast and a “round” shape for a more prominent upper breast. In actual practice, however, the shape of the implant does little to determine the ultimate shape of the breast. This is largely due to the fact that when the implants are upright, as they would be with an upright patient, teardrop and round implants have almost the exact same shape. Postoperative breast shape is mostly determined by where the implant is placed at surgery. If the implant is high on the chest, the upper breast will be full. If the implant is placed lower, the upper breast will be flatter.
I almost never use teardrop shaped implants due to the fact that they are all textured. I find I can reliably produce the breast shape the woman wants by careful implant placement, thus avoiding the negative consequences of texturing.
Breast implants are placed either beneath the breast (subglandular) or beneath the pectoralis major muscle (submuscular). Subglandular placement is easier for the surgeon and is associated with less postoperative pain for the patient. Unfortunately, placement of the implant under the breast is associated with an increased tendency for the body to form scar tissue around the implant, resulting in the implant and the breast feeling hard. For this reason, I prefer placement under the pectoralis muscle. Not only is the implant more likely to feel soft in this location, there are also fewer problems with visible rippling due to the implant being so close to the skin. Finally, most radiologists feel mammograms are more accurate in patients whose implants are underneath the muscle. For these reasons, I almost always place the implant under the pectoralis muscle.
Implants are generally placed through an incision in one of three places:
1. Inframammary (the fold under the breast);
2. Periareolar (beneath the nipple);
3. Through the axilla (or armpit).
Implant placement through the axilla obviously leaves no scarring on the breast. The problem with this incision is that it is the most difficult to ensure proper placement of the implant. Periareolar incisions usually result in an excellent scar; however, women frequently are intimidated by this incision being so close to the nipple.
The most common incision used in breast augmentation is an incision in the fold underneath the breast. While this incision is on the breast, it is extremely difficult for anyone to see once the breast is augmented because the breast covers the incision. This is the incision I use most commonly.
Breast implants consist of a soft rubber shell filled with either saline or silicone, each of which has its own advantages and disadvantages. Saline implants are less expensive and when they break it is obvious and the fluid is simply eliminated by one’s body:
Their downsides are that they feel less like a real breast, particularly in a thin patient, they are difficult to keep in proper position, and they cause more stretching of a woman’s breast overtime.
In 2006, after years of study, the FDA determined that silicone implants were safe and released them for general use in breast augmentation. Very simply, a breast with a silicone implant feels more natural than one with a saline implant. Silicone implants also stay in position better and cause less distortion of a woman’s breast. Though they seem to last longer than saline implants, silicone implants are more expensive. Additionally, when a silicone implant breaks, it can be difficult to tell as the silicone stays in the scar tissue formed around the implant. For this reason, a woman with a silicone implant should monitor her breast regularly for changes and, after consultation with her doctor, consider periodic studies such as an MRI or ultrasound to determine the integrity of their implants.
Though I feel silicone implants give a more natural result I recognize there has been too much controversy about their safety for all patients to feel comfortable with them. In these patients, I advise the use of saline implants.
These are the major issues involved with breast augmentation. After explaining each of these choices to a patient most generally have one clear preference, and this is the choice that is selected for them.
As you can see, there are many choices to make regarding breast augmentation. I strongly encourage patients to take the time to define their goals and make choices which seem most right to them. To me, patients who are the happiest with their breast augmentation are those who felt they helped select their final results.
Paul G. Pin, M.D.
American Board of Plastic Surgery Dallas, Texas
Breast augmentation is real surgery and involves risks such as bleeding, infection, and scarring. Results vary. Dr. Pin will be happy to discuss these and other risks of breast augmentation.
Tags: Breast Augmentation