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   BREAST AUGMENTATION    POSSIBILITIES



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Pre: 36 year old professional athlete. No intereference with muscle activity permitted.
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Post: 425cc smooth moderate saline. 2 day after recovery.
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Pre
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Post: Breast augmentation with 300cc smooth moderate gel implants.
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Prel: 40 year old with loose skin in need of fullness.
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Post: 475cc subpectoral gel implant.
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Pre: 38 year old with a desire to look fuller.
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Post: 475cc prepectoral gel implant
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Pre: A 26 year old before having children with a tubular breast deformity
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Post: 375cc moderate profile saline placed subfascial, prepectoral. She subsequently fed 2 children.
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Prel: 23 Year old thin athlete not wanting to be too big.
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Post: 275cc gels placed subpectoral.

WHY DO BREAST AUGMENTATION?

Small breasts, tubular breasts, breast asymmetry, congenital lack of breast growth, symmetrizing after breast biopsies, or  after breast cancer, minimally lower breasts.


ANATOMY

The breast consists of internal tissue surrounded by a skin envelope. The internal tissue consists of breast glands, ducts, nerves, lymph nodes and cooper's ligaments. All of this rests on top of the pectoralis major muscle and the serratus muscle laterally. The ratio of volume of the breast ribs give the breast its shape.

On the surface, you see the nipple, the darker surrounding areolar skintissue versus skin, the condition of cooper's ligaments, the muscle and the  and the breast tissue. Laterally, there is the "tail" of the breast towards the axilla or armpit. This contains the lymph nodes.
The ducts radiate from the areola into the breast tissue. See the attached diagram.

Note that the pectoralis muscle does insert on the middle of the chest, but where the ribs meet the central breast bone. This has importance for sub, or under, the muscle implants.

An important part of the anatomy is that the pectoralis major muscle does not cover the entire anterior, front, of the rib cage and thus does not cover a subpectoral implant completely. Thus rippling can occur there regardless of the plane of placement.

The ratio of volume versus skin plays a role in placement, amount of lift, the amount of superior or upper half fullness and implant visibility. Having some subcutaneous fat masks implant visibilty, helps hide rippling, alllows for the implant to be place pre pectorally.

EFFECT ON MAMMOGRAPHY

The implant may interfere with mammography and you will require "eklund" views afterwards. If you are about to be 35 years, I recommend a pre op, baseline mammogram.



Key Points To Discuss Before Breat Augmentation -

  how much breast tissue is present?
  how much forward projection?
  what is the width of the breast, chest wall and hips?
  how much subcutaneous fat is present?
  are there any abnormal masses?
  what is the muscle shape and thickness?
  what is the condition of the ribs?
  what is the status of droop (or ptosis in plastic surgery terms)?
  how is your height?
  what is your weight?
  what is your skin elasticity?


SURGICAL CORRECTION

Some factors involved in choosing the optimal surgical option. Please note that no one procedure fits all, i.e. not all implants should be  subpectoral or pre pectoral.

What Size Breast Implant??

I have seen from around the globe implant sizes from 3000cc to 125cc. Bringing photos, morphing and wearing bra insert helps. Nonetheless converting your desires to cc's, on varying ribs, soft tissue at that particular point in time requires some estimation and some art.

Age. The older you are, especially after the late 30's, causes changes on the skin envelope that may make a pre pectoral placement more advantageous and lifting.

If you are in your early to mid teens, the breast may not have developed and surgery could interfere with final growth (however I am a little skeptical of this particularly since sub and most pre pectoral implants do not interfere with vascularity. The youngest patient that has had an implant was 1 year but fully grown.)

Pregnancies. The changes from hormones and cooper's ligament stretching change the considerations for placement. It may be more advantageous to place the implant above the muscle or do lift at the same time.

Body weight. Implants look and feel the best if they are not seen nor felt. This requires some subcutaneous fat to mask the borders. Very thin women, i.e. pilates instructors, pro atheletes need the implant more disguised and may do better with the implant below the muscle. Also, women who have lost a lot of weight or undergone large weight changes can take a larger implant but may also need a lift.

Exercise level. Serious exercisers, pro atheletes, and ballerinas frequently need the pectoralis muscle in a totally pristine condition. In these woman, the muscle may also distort the implant and push it laterally. So above the muscle may be better, balancing that decision with body weight.

Family history of breast cancer. Breast implants may interfere with mammograms but the cancer effect seems to be zero as several studies of women with implants who develop cancer, develop it at an earlier stage and have a better survival.

General health. If you have significant other issues, tell me. They may, or more likely, may not, impact the procedure.

Previous biopsies. These may play a role in how the skin heals and thus where the incision is placed. It might be better to have them placed subpectorally.

Your psyche. Fuller, more natural, more symmetrical breasts will improve your confidence. You must realize that true symmetry is difficult. If that is your primary goal - tell me.

PHYSICAL EXAMINATION




CHOICES

1 - IMPLANT TYPE
   what size implant?
   silicone gel or saline?
   moderate profile, high profile?
   base width/projection?

There is no perfect answer, but some generalities:

In thin women, gel has a more natural feel. In women with subcutaneous fat, it doesn't matter.

Saline implants are adjustable and can be placed deflated so require a smaller incision.

Wider ribs can take a lot larger implant due to a wider base.

The resultant tissue that develops around the implant, called a capsule, tends to make all implants have the same configuration so high profile might not matter after time.

 2 - TYPE OF IMPLANT SURFACE - textured or smooth?
  
I prefer smooth as my studies have shown that the textured surface breaks down over time.

3 - ABOVE OR BELOW THE PECTORALIS MAJOR MUSCLE?

 Above is better for older women,  women with sag or ptosis, post pregnancy, athletic women, tubular breast deformities, muscle deformities, many rib deformities, women who want maximal cleavage. 

Below the muscle is better for thin women, women with hard capsules from earlier implants, possible wound healing issues, family history of breast cancer, multiple previous biopsies and women who particularly like a fuller upper half.

 

4 - INCISION PLACEMENT?

Axilla? Areola? Inframammary? Umbilical?
 

Axilla:

Best for those who are having -

below the muscle placement
not large gels
saline implants
have a poor inframammary fold that would hid an incision

Not good if -

there are pigment issues
you have a history of axillary infections
are concerned about visibility in strapless dresses, bikinis, or in photo shoots



Areola:

Best for those having -

small gel implants
saline implants
who have a poor inframammary fold
have a tubular breast deformity
want some lift
require a small lift with a mastopexy

Bad for -

someone planning to breast feed
pigment issues
has a history of areolar infections

 


Umbilical:

Best for -

those concerned with incisions on breast
saline implants

Bad for -

those wanting a natural shape (causes a more ball-looking breast)
voids implant warranty
more bruising
longer recovery
those wanting gel implants

Obviously, each of the above has particular advantages on particular women. No one procedure is correct for all. The best plastic surgery requires picking from a menu of options and using the one that's best for you. The possibilities are vast. Some general observations from 25 years and many, many procedures-

• Most women pick implants that are too small. If you err, go a little larger.

• Asymmetry is more readily hidden with larger implants and ones that are saline (gels are not adjustable).

• Thin women look better with gels implants.

• Larger gel implants require longer incisions to allow the implant, the inframammar approach is the best.

• Areolar incisions can interfere with the ducts.

• I have not seen breast augmentation interfere with breast feeding. One of my patients has had the same set of implants despite countless boyfriends, 3 husbands and 3 healthy children

• Good radiologists get good results.


COMMON QUESTIONS

Where is the surgery performed?
Outpatient in our clinic

What is the anesthesia?
Non general iv sedation which allows for a rapid, less nauseous recovery

How long does the operation usually take?
1 hour and a half

Is there much bleeding?
Usually less than 10 cc's

What if there is a mass?
I am a university-trained plastic surgeon with general surgery training. Unlike many clinics globally, I check each patient for abnormal masses and  perform an intra operative bimanual examination. That has saved the lives of 2 women as I have detected intra op cancers which were undetected by pre operative mammography.

What is the pain?
For most with implants above the muscle, on a 0-10 scale a 2 for the first night. For below the muscle, a range of 2-6. We find that use of a support wrap or bra and our mini drains greatly reduces the pain.

When can I fly?
2 days

Should I massage?
Yes. Starting 5 days post op, gentle circular massage for five minutes a day allows for a softer breast. 

What are the follow up visits?
Ideally at day 3, day 7 and at 1 year. In addition, many email photographs and/or telephone.

What are some of the complications?
Reoperation to adjust the implant or increase size
Loosen a hardening or capsular contracture
Remove implants
Infection
Rupture

Websites that offer helpful information

www.mentor.com
www.nih.gov
www.americansocietyofplasticsurgeons.org










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