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Breast Augmentation

breast augmentationThere are many different reasons why a patient may consider breast surgery. Some patients find their breasts flatter after having children. Some need some reconstruction to correct deformities or disfigurement from congenital defects, trauma or cancer. Others simply want to have larger breasts.

Breast augmentation or augmentation mammoplasty is the procedure for changing the size, contour, texture and shape of breasts using a prosthetic device or autologous fat.

In terms of cosmetic surgery, breast augmentation has a very high satisfaction rate among patients. The usual problems encountered with the procedure are most commonly the scar and contractures. The surgeon has several options where to hide the incision. The typical areas are the inframammary fold (IMF), periareolar and transaxillary approaches. The decision as to the location will also depend on several factors including the size of the implant to be inserted, the anatomic lie of the breast, the size of the areola and whether the patient scars well. For example, if the implant to be used is large, and the patient has a small areola, using the Periareolar approach is not optimal since there would be additional incisions away from the areola in order to accommodate the implant. For this case, the better option would be the inframammary approach. On the other hand, contracture is capsule formation around the implant (inside the body). The effects of the contracture can range from nothing at all to slight pain, to unusual breast appearance coupled with breast hardness and more profound pain. Depending on the severity of the contracture, patients’ reactions and treatments vary. Of course, it is still best to minimize the occurrence of contractures during the surgery. These strategies include the choice of location of the pocket, minimizing bleeding within the pocket, lessening the manipulation of the implant by various members of the surgical team, and ensuring an adequately sized pocket and implant. The implant itself also plays a role in contracture formation. Smooth implants carry a 20% risk of contracture formation compared to a 10-15% risk for textured implants. For a brief period, surgeons used a polyurethane-coated textured implant which decreased the risk of contracture further to 1-3%. However, it was discontinued due to the presence of 2,4 toluenediethyline (TDA), a carcinogenic substance, which was formed when the body reacted with the polyurethane. After several studies, it was found that the amount of TDA was so insignificantly small that surgeons were not even obligated to mention TDA when offering polyurethane coated implants. These implants are still used in South America and Europe but the manufacturers no longer sought any US FDA approval, hence they are not used in North America.

Your Consultation with Dr. Joel Nicdao

During the preoperative consult, apart from the implant type, size and incision site, another thing discussed is the location of the pocket where the implant will be housed to make breasts more natural-looking. For those who have very little or no breast tissue, under the pectoralis muscle is the location of choice. Over time, they are not expected to sag due to the sparseness of the original breast tissue. For patients with some breast tissue and just want more volume, above the pectoralis muscle is ideal. As the patient ages and her natural breasts start to droop, the implant and her own breasts will act as one unit. If in these patients, the implant is placed under the muscle, the implant will be kept in place by the muscle bulk, preventing it from sagging along with the natural breast. This will result in a “double bubble deformity”, which looks very unnatural.

Our surgeons want to make sure that patients are clear on why they are undergoing the surgery. Some patients proceed with the surgery in the hope of saving their marriage, or pleasing a partner, or improving their sex lives. When these are not met even after a technically successful procedure, patients are unsatisfied and may blame the failure in their expectations on the surgery.

The Breast Augmentation Procedure

Since breast augmentation is typically done under general anesthesia, patients are required to undergo laboratory workups and medical risk assessment prior to surgery. Patients are instructed to discontinue any blood thinners, alcohol, smoking and diet pills and drinks. The clearance will determine whether the patient has some infection or other co-morbidities that need to be addressed to optimize the patient’s condition.

The procedure can last anywhere from 1 hour to 3 hours. Although some surgeons do breast augmentation as an outpatient procedure, it is advisable to keep patients overnight while being monitored by a private duty nurse. With this setup, any problems such as hematoma formation may be identified early and addressed without any delay.

Risk & Recovery

Post-operatively, patients are advised to relax at home for a week. External stitches are removed at the end of that week. The earliest exercise is walking and stretching on the third week from surgery with care against moving the arms too much. Subsequent exercise will depend on the individual patient’s recovery.  In the long run, patients are advised to monitor their implants for any signs of rupture (one-sided deflation) by doing MRI starting around the 5th year post-surgery. Some studies have shown a low rate of spontaneous rupture at the 6th year mark, hence some surgeons advise the first MRI to be done on the 10th year post-surgery. During the time when most implants were saline-containing, the rate of spontaneous rupture at 10 years was high. Hence surgeons typically advise patients to have their implants replaced at around that time, However, with the advent of silicone-containing implants, they were more resilient to spontaneous breakage and leaks. Any leaks were not particularly disfiguring since the silicone gels were so vicious that they did not seep out of the pocket as saline implants did. Ruptured implants were changed. Contractures that formed over time were also addressed surgically with breaking (capsulotomy) or removing (capsulectomy) the capsule then replacing the implants.

What to Expect After the Surgery?

For those patients who are averse to having scars or using prosthetics, are only out to correct small contour defects in their breast due to a previous mass excision, or only want a modest increase in breast size, breast augmentation through autologous fat transfer may be their best option. Their fat is collected via liposuction typically from the abdomen, the front thighs, and/or the flanks which are then injected into the breast tissue itself. Although the results are acceptable, one major difference between fat transfer and implants is their relationship to the breast tissues. Breast implants are underneath the breast tissue and remain a separate entity. Autologous fat is placed within the breast parenchyma. This makes it quite difficult to monitor the breasts through Mammography since blobs of fat may appear as masses which may confuse the mammography reader as to whether they are worrisome masses (Cancer) or merely blobs of previously injected fats that have granulated or necrosed. In terms of texture, breast implants also feel more natural compared to lumpy breasts corresponding to fat injection sites.  In the unfortunate event of an infection, implants are very easily removed whereas fat injections that have fibrotic or scarred present a much more technically difficult removal without affecting a change in breast shape. Although it may appear that breast implants present as a better alternative to fat transfer, all options and risks must be thoroughly explained to the patients so that they can make well-informed choices.

Frequently Ask Questions

Where will the scar of the surgery be?

The surgery will always be tailored to the patient who needs it. The scar will be located depending on your anatomy, the size you want and the kind of implant to be used. The 3 common sites of the scar are (1) periareolar (around the areola), (2) inframammary (at the crease underneath the breast), or, (3) Transaxillary (in the armpit). The final decision on which incision to use will be made by both you and your surgeon.

What are the kinds of implant to be used?

There are essentially 2 kinds of implant. One is the Saline (water-filled) and the other is the Silicone (cohesive gel filled). Saline is no longer used due to its high risk of rupture leading to deformity between breasts and its need to be changed and/or maintained. Silicone implants, on the other hand are sturdy but soft, thus able to move cohesively with the natural breast.

Where will the implant be placed?

There are 3 possible spaces where the implant can be placed. The first is subglandular (under the breast), the second is submuscular (under the pectoralis muscle), and the third is biplanar (top part of the implant under the muscle, bottom part of the implant under the breast). The decision as to implant position will be made by you and your surgeon.

Why do some breast implants look and feel hard?

Breast implants that look and feel hard may be due to several factors. One may be that the implant was too big for the pocket that was created causing the implant to be squeezed into a tight space, making the skin above it shiny and taut, with the edges of the implant readily apparent. Another is that, there may be a contracture.

What causes a contracture?

Being a foreign substance, our bodies react to the implant by forming a capsule around it. In some patients, the capsule is so thin that its effects are imperceptible even to the patient herself. However, for others, the capsule is so thick and tough that apart from being obvious even to other people, it causes some pain and discomfort to the patient.

Can contracture formation be prevented?

Yes, it can. Implants are available in different textures. These differences in texture correspond to different rates of contracture. Patients who use a Smooth Implant have a 20% risk of developing a contracture. Textured Implants have a slightly lesser risk of contracture formation (15%), while Poly-Urethane or Brazilian Implants carry the least risk of contracture (1-3%). Also, placing the breast implant underneath the muscle can also lessen contracture formation.

Can I use my own fat instead of implants for breast augmentation?

Although some doctors use fat grafting to the breast as an option instead of implants, personally, we advise against it. First off, not all fat cells harvested will survive. So augmentation using mainly fat is not practical. Secondly, fat cells that die are sequestered in the breast, and calcify. Breast calcifications are mammographic clues to possible malignancies. Mammographic operators and interpreters may mistakenly identify these as cancers or mistakenly assume that they are calcified fat transfer granulation.

Is breast augmentation safe?

Any surgical procedure carries with it some amount of risk. However, breast augmentation is straightforward and technically easy. Minimal blood loss is expected. It is done under sedation with local infiltration of anesthetic solution for hydro dissection of surgical planes. It lasts for about 2 hours and is considered safe.

Can I go home after the procedure?

It is recommended that you stay with us for another day after the procedure. We’d like to make sure that everything is as expected before we send you home the next day. A private duty nurse will be with you to monitor how you’re doing and to assist you whenever you move around.

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