Enhanced Recovery After Breast Augmentation
Dr. Pin is part of a nationwide movement to enhance recovery after surgery. The idea is to return patients to their normal routine more quickly and comfortably. Breast augmentation is the perfect setting for enhanced recovery. He chooses the term "enhanced" over "24 hour recovery," as the latter term misleads patients into thinking they will be back in the gym after 24 hours, which is never the case! While you will not be exercising for two weeks, by the next day you should be able to perform normal activities like lifting your children, bathing, shopping, or returning to work.
Explaining to a patient pre-operatively exactly what to expect after surgery is proven to reduce anxiety and postoperative discomfort. Dr. Pin loves to see his patients enter the operating room relaxed and smiling. Also, prior to surgery, patients are given Tylenol, one gram and Celebrex, 200 mg. Pre-treating a patient dramatically reduces their discomfort after.
The operating room is kept warm so patients can maintain their body temperature during surgery. Studies consistently show that patients who arrive in the recovery room at normal temperature recover faster, with less discomfort and have a lower risk of infection. Once the patient is asleep, Dr Pin injects the breasts with local anesthetic, as again, this block reduces post-operative discomfort. The surgery itself is done as precisely and as meticulously as possible. The goal is to limit tissue trauma and bleeding as each leads to more swelling, bruising and discomfort. Finally, the medications used for the anesthetic are very short acting so patients can easily walk on their own within an hour after surgery.
Post operative Measures
Dr. Pin tries to make the procedure as simple as possible. There are no bandages, no wraps, and no drains. A sports bra is supplied, but patients may choose not to wear it if they choose. Patients are encouraged to move their arms normally, as this prevents spasm and stiffness. Showering may proceed normally the next day. Patients are advised to take Aleve three times per day for discomfort. Some patients may need pain pills for the first 24-48 hours, and this are made available. Regular exercise is allowed 2 weeks after surgery.
Dr. Pin is constantly modifying his surgical care to make it as simple, and as painless as possible so patients can return to their lives quickly with a great result.
Breast Augmentation Overview
Every woman having breast augmentation wants to make sure she has the best possible operation so as to achieve the best possible result. Though the basic idea of breast enlargement is simple, there are many factors to consider, thus making a simple idea quite confusing. Obviously one wants to be bigger, but by how much? Alteration in shape is another goal, but what shape?
There is no one “perfect breast” for everyone, as every woman has preferences regarding size, shape and feel. Therefore, each operation needs to be tailored to meet an individual patient’s needs. There are six basic variables each woman should consider as part of her preoperative planning:
- Implant size
- Implant surface
- Implant shape
- Implant position (beneath the breast or beneath the muscle)
- Incisional approach
- 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 (300 cc equals 10 ounces). 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 larger woman.
There are numerous ways to select an implant size with a patient. These can involve simulating an augmentation by placing an implant in the patient’s bra, measuring specific dimensions of a patient’s existing breast to select an implant that matches these dimensions, or reviewing pictures of previously augmented breasts that the patient finds appealing in terms of size and shape. Usually some combination of these methods will ensure the patient’s result is to her liking.
Breast implant surfaces can be textured (rough) or smooth. Textured implants were designed to ensure breast softness after augmentation, and to maintain implant position in the case of a tear drop-shaped implant. Unfortunately, texturing has not worked well and many plastic surgeons 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 immobile and are more likely than smooth implants to cause ripples in a woman’s breast. (Such rippling can be treated only with additional surgery.) Smooth implants, conversely, are mobile, softer, and less likely to ripple than textured implants.
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 because when implants are held 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.
Round implants can be further divided by “profile,” which means how projecting the implant is for a given volume. Generally, implant profiles are low, medium, and high profile:
When a patient wants a small implant, a lower profile is normally employed to make sure there is enough width to match the native breast. Conversely, if a woman wants a large augmentation, a high-profile implant is used to limit the width so the implant does not extend too far laterally.
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. Additionally, implants in this position can cause thinning of the overlying breast tissue. The consequence of this is if the implant is ever removed, the center of the breast may appear sunken. For this reason, it is preferable to place the implant 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 farther from the skin. Finally, most radiologists feel mammograms are more accurate in patients whose implants are underneath the muscle. The downside of subpectoral placement is that some patients experience implant motion with pectoralis contraction.
Implants are generally placed through an incision in one of three places:
1. Inframammary (the fold under the breast);
This is the most commonly used incision as gives the best access to the sub- pectoral pocket, it does not disturb breast tissue as the dissection is completely behind the breast, and the scar is relatively inconspicuous. Additionally, the incision can be long enough that the implant is not damaged by insertion through too small an opening.
2. Periareolar (beneath the nipple);
This is incision heals great as the scar is at the junction of the areolar and the breast skin which renders it relatively imperceptible. This is an option in patients with relatively larger areolar. If the areola is smaller, the implant can be damaged by forcing it through a small incision. This damage can potentially shorten the life to the implant. Further, using this incision exposes the implant to breast tissue, which some believe results in a higher infection rate.
3. Through the axilla (or armpit).
Implant placement through the axilla obviously leaves no scarring on the breast. Though this incision normally heals great, if it does not, the resultant scar is very apparent in sleeveless apparel. The biggest problem with this incision is that the tunnel between the incision and the breast is narrow and the force required to place the implant can damage the implant.
Implant Type: Saline vs Silicone
Breast implants consist of a soft rubber silicone shell filled with either saline or silicone, each of which has its own advantages and disadvantages. Silicone implants can be further divided into Standard Silicone Implants and Highly-Cohesive Silicone Implants (“Gummy Bears.”)
Saline implants have the same outer shell as a silicone implant, but are filled with saline. Saline implants normally are inserted empty then filled during the surgical procedure.
- Less expensive.
- Allow for a short incision as they are inserted empty.
- When they break, your body absorbs and excretes the fluid.
- Peace of mind for those who worry about silicone gel. Though I feel silicone implants are safe and 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.
- More likely to show visible rippling.
- Easier to feel.
- Difficult to keep in proper position as they cause more stretching of a woman’s breast over time. This results in the implant being too far off to the side and too low.
- Shorter life span, about 10 years.
Silicone Implants Gummy-Bear Implants
- Much more natural feel than saline.
- Maintain position better.
- Less rippling.
- Longer life span, about 15 years.
- Difficult to detect breakage. 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 her implants.
- Higher cost.
Gummy Bear Implants
Highly cohesive gel implants maintain a given shape much better than saline or standard silicone. It is the perfect implant for those with with very thin tissues, such as a mastectomy patient.
- Maintain upper pole shape.
- Almost no rippling .
- More expensive.
- Require a longer incision.
- Feel much stiffer and are immobile.
Breast Implant Safety
1. Long-term Safety
In 2006, after years of study, the FDA determined that silicone implants were safe, caused no illnesses or cancers, and therefore released them for general use in breast augmentation. Most plastic surgeons prefer silicone implants as the result is more natural in shape and feel, and the implant position is more predictable, so revisional surgery is less common. Furthermore, silicone implants last longer than saline.
2. Life of Implant
General estimates for the life of breast implants is 10 years for saline and 15 years for silicone. Implants do not need to be replaced until they are broken.
The Breast Augmentation Procedure
Over the years, breast augmentation has been tremendously popular because the results have been predictably good. The only real way to improve this procedure was to make it easier on the patient. Small but significant changes in breast augmentation have achieved just that.
For years, breast enlargement was an operation performed under sedation or “twilight” anesthesia, where a breast implant was not so carefully inserted beneath a woman’s breast. Typically, the surgery took about two hours. Postoperative bleeding, often described as “swelling,” caused significant pain, which could last for several weeks. Long term, this swelling more commonly resulted in scarring around the breast or capsular contracture. This swelling was often treated by either placing drains or tightly binding the breasts, both of which generally added to the patient’s discomfort. To make matters worse, bathing was usually forbidden for the first week until the sutures were removed. In retrospect, it is amazing that this procedure gained popularity.
Twilight or sedative anesthesia has largely been abandoned in favor of general anesthesia, much to the relief of patients and surgeons alike. Patients no longer perceive the unpleasant sensations and sounds that are part of a breast augmentation. From the surgeon’s standpoint, the patient under general anesthesia is much more relaxed and the procedure usually goes more smoothly. This allows the surgeon to pay better attention to the surgery; and operative times for a breast augmentation are considerably shorter now than in years past, often well under one hour. Shorter operative times mean the patient receives smaller doses of drugs, which frequently leads to a faster recovery.
The technique used to create the space for a breast implant has also materially changed. Prior to this time, the space or the “pocket” was dissected bluntly. This was associated with more bleeding and swelling as described above. Today, more progressive breast augmentation techniques seek to prevent bleeding during and after the surgery. Rather than bluntly separating the tissues, a cautery or electrical device is used to coagulate blood vessels so they never have a chance to bleed. Similarly, tissues are cut rather than torn in an effort to minimize the trauma of the surgery and thus decrease pain and discomfort. Furthermore, many plastic surgeons use some type of local anesthetic in the breast during surgery to provide pain prevention and relief long after the procedure has been concluded.
A quick return to normal life is one of the goals for the breast augmentation patient. To facilitate this, dissolvable sutures are substituted for standard sutures making the discomfort of suture removal unnecessary. Since there are no drains, bindings, or sutures, normal bathing can commence the first day after surgery. Most surgeons place limited activity restrictions on their patients; rather, early motion is encouraged to prevent stiffness and muscular spasms. Patients can return to office work and resume driving in a few days, and return to an active lifestyle usually well within two weeks.
Breast Augmentation with Galaflex
The goal of breast augmentation is to enhance the breast in a straightforward manner and to create a durable result. Some patients have physical characteristics that make a durable result less likely; the most common patient in this category has a chest that is sloped towards the side. These patients frequently find their implants rolling off their chest and this problem requires surgical revision. Another group that can expect lateral implant displacement are patients with larger implants (over 400cc.) Beyond this size, the average patients tissues are not reliably strong enough to maintain implant position. In both of these instances, I recommend Galaflex be used to augment soft tissue strength. Other patients who benefit from using Galaflex in a primary operation are patients who have massive weight loss and those patients who are droopy and are undergoing a mastopexy.
Galaflex is excellent at maintaining implant position. Galaflex is an “organic” mesh that works as a scaffold for new tissue growth, and becomes fully integrated with adjacent tissue. The lattice that is formed acts as an “internal bra” to support the new implant position. Then, unlike other surgical mesh, Galaflex dissolves over 1-2 years. Galaflex does add some cost to the augmentation procedure, but cost is dramatically less than the cost of revision surgery.
Some patients are self-conscious about how far their nipples project forward. Due to modesty considerations, this can limit clothing choices. As a breast augmentation can make a nipple more obvious, some women choose to have a nipple reduction. A standard nipple reduction can result in complete and permanent loss of sensation and the ability to breast feed. A newer version practiced by doctor Pin, preserves these functions and has little visible scarring. If excessive nipple projection is a concern of yours, please discuss it with Dr. Pin.
Before and After Photos
Breast Augmentation with Silicone Implants
This 28 year old was 5'5", weighed 110 pounds, and wore an A cup prior to her surgery.+ See Full Case
Breast Augmentation - Saline Implants
This 29 year old was 5'2′, 110 pounds and wore a B cup, which was slightly too large.+ See Full Case
Breast Augmentation with Silicone Implants
This 31 year old was 5'5" and weighed and 135 pounds, and wore a small B cup. Following her augmentation with 450cc round, smooth silicone implants she wore a D cup.+ See Full Case
A Cup to C Cup
This case is a good example of just how much fullness can be achieved from a breast augmentation, yet still result in a natural look. Despite the shift in size from an A cup to a C cup, the augmented breasts are neither too close, nor too far apart on the chest. The nipples still point forward, providing the larger breasts with a fuller, youthful appearance.
B Cup to C Cup
This case, on the other hand, shows that even a small increase in breast size can have a dramatic effect. Despite only going from a B cup to a C cup, this patient’s breasts still look fuller and natural. As with the previous case, the nipples still point forward, giving them a perky appearance.
Breast Augmentation after Weight Loss
This case is noteworthy because this patient underwent breast augmentation following dramatic weight loss. In many cases, the breasts may be one of the first areas of the body to show reduction in size after weight loss because the breasts are made up mainly of fatty tissue. Here, a breast augmentation allowed this woman to regain size in her breasts without sacrificing her weight loss goals.
Breast Augmentation for Asymmetry
This case is interesting because the breast augmentation was to correct for noticeable asymmetry, or difference in breast size. In this case, a moderate profile implant was used in the right breast and a low profile implant for the left one. This allowed the breasts to be of approximately equal size.
Breast Augmentation with Galaflex
This 33 year old desired an augmentation revision. She felt her implants were too lateral and she wanted to be larger. Her revision consisted of removal of 270cc moderate profile saline implants and replacement with 345cc high-profile silicone implants. Her implant pocket was moved towards the middle (lateral capsulorrhaphy) and was reinforced with Galaflex to maintain her implant position.
Breast Augmentation with Nipple Reduction
This 39 year old was 5'6", weighed 118 pounds, and wore a 34B bra. She wished to become a small C cup and desired to reduce the projection of her nipples. She underwent a breast augmentation with a moderate-profile 255cc silicone implant on the right and a moderate-profile 240 cc implant on the left.
Breast augmentation is still surgery and definitely associated with some amount of postoperative pain. However, changes in the procedure have clearly lessened the impact of the operation on the patient. If you consult with a plastic surgeon about breast augmentation, make sure to inquire about how he or she seeks to minimize postoperative pain and enhance the chance for a rapid return to your normal lifestyle.