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Breast Augmentation FAQ's

By http://www.epsteinplasticsurgery.com/blog/author/
January 13, 2014

Introduction – read this only if you are serious about breast augmentation and want to learn more…

Breast augmentation is probably the most common cosmetic surgical procedure performed today. There are many options to consider: type of implant (saline or silicone gel), conventional silicone gel or highly cohesive (“Gummy-Bear”) silicone, shape (round or anatomic “teardrop”), surface texture (smooth or “textured”), placement of implant (above the muscle or below it), implant size, technique (dual plane type I, II or III), whether or not a breast lift (mastopexy) is also needed and whether or not it should be performed at the time of surgery or later.

Most women who present to me for breast augmentation are good candidates for this procedure. There are some limitations; as the surgeon, I can only work with the tissue I am given. Some patients have issues that may compromise the results or make the surgery a little more difficult. This includes differences in breast size, shape and position on the chest; chest wall (rib cage) asymmetry; overstretched tissue from pregnancy or weight loss; drooping of the nipple (ptosis); asymmetry of the nipples/areolae, and drooping (“bottoming out”) of the glandular tissue.

I define a successful outcome in breast augmentation surgery as one in which the patient goes into surgery with realistic expectations, and a surgical result is delivered which meets or exceeds those expectations. As I go to great efforts so that the patient has been properly educated as to what is a likely outcome, and that outcome is met, then both the patient and I are more likely to be satisfied with the final outcome.

Vectra 3D - Learn about our three dimensional computerized simulation of surgical results

The key to success is education and proper decision making. Proper decision making in plastic surgery is a joint effort between the patient and surgeon. The patient is presented with many options and decisions to make. If the patient is not properly educated as to how to consider all factors and how to make the necessary decisions, then there is no assurance of a good outcome.

 

The purpose of this rather lengthy, detailed Frequently Asked Questions (“FAQ”) for breast augmentation is not to “wet the prospective patient’s appetite” for breast augmentation. Instead, it is for the patient who is serious about breast augmentation and wants to learn more. The more you, the patient, educates yourself, the more you will derive from your consultation, and the better your ability to make all the right decisions to ensure that you obtain the result that you so desire and deserve. Although not all inclusive, this set of FAQ’s should well prepare you for your initial consultation with the surgeon of your choice.

What is Breast Augmentation?

Breast Augmentation surgery involves the placement of a prosthesis (commonly known as a breast implant) underneath the breast. Breast Augmentation surgery can give women with small or unevenly sized breasts a fuller, firmer, better-proportioned look through the placement of saline or silicone implants in the breast. Women may elect to undergo breast augmentation for many different reasons, including increasing or balancing breast size and compensating for reduced breast mass after pregnancy or surgery, or possibly to correct a congenital breast defect. The procedure may be combined with others such as a breast lift to correct drooping (ptosis). According to the American Society of Aesthetic Plastic Surgeons, Breast Augmentation surgery is one of the most commonly performed cosmetic surgical procedure in the United States. In 2014, 313,327 breast augmentation procedures were performed. Under my expert care, patients can enjoy great-looking, natural-feeling and looking breasts that are one or more cup sizes larger after the operation.

Fully Customized Breast Enhancement

Every woman is unique in both her desires and her body shape. With that in mind, I take the time during the pre-operative consultation to learn what is important to each patient, as well as what she hopes to gain from breast augmentation surgery. Patient education is absolutely essential so as to make the proper decisions regarding which implant type, size and placement is best. In this way, each patient enjoys a completely customized treatment designed with her specific goals in mind.

During your consultation with me, you and I will make decisions together about the type, size, incision and placement of your implants. Your anatomy, as well as the tissue characteristics of your breasts, play a major role in these decisions. I will discuss with you the available options for breast augmentation surgery.

What is the difference between Saline and Silicone Gel Breast Implants?

Implants are silicone shells filled with either saline (salt water) or silicone gel (approved by the FDA November, 2006). There are two primary types of fillers used in breast implants: saline filled and silicone gel filled implants. Saline implants have a silicone shell filled with sterile saline (salt water) liquid. Silicone gel implants have a silicone shell filled with a viscous (cohesive) silicone gel. Saline implants are firmer than silicone gel implants. Silicone gel implants better resemble the texture and feel of natural breast tissue. There are also silicone gel highly cohesive “Gummy Bear” implants that provide a more long lasting natural shape to the breast. Not every woman is a candidate for this type of implant. Both implant types are very safe, and each offers its own specific advantages. I will help you decide which kind is right for you. For additional information on silicone breast implants, please see:

An advantage of saline breast implants is that, if ruptured, the saline (salt solution) is absorbed by the body. A disadvantage is that saline breast implants are firmer than silicone gel implants and natural breast tissue, and are subject to many times the amount of rippling and wrinkling as seen with a silicone gel implant. Also, saline implants have a valve used to fill them during surgery (they arrive deflated from the manufacturer), which is another potential point of failure (leakage) not found in silicone gel implants, which arrive pre-filled from the manufacturer. This is especially important for very thin women who have little breast tissue to cover the implant, or for women who have a breast injury or need breast reconstruction.

Silicone gel-filled implants may provide a more natural feel and are the implant choice of the majority of my patients. In November 2006, after fifteen years, the U.S. Food and Drug Administration (FDA) had re-approved silicone breast implants for breast augmentation surgery. I am proud to offer patients the option of silicone gel-filled breast implants, since they are much softer and feel more natural than saline-filled breast implants.

What is the difference between round and teardrop shaped implants?

When choosing breast implants, shape is an important consideration. The two basic breast implant shapes are round and teardrop. Breasts differ greatly from woman to woman, so the ideal breast implant shape for each patient must be determined with care.

Round Breast Implants. Of the two breast implant shapes, the round breast implant is the most common type used by most plastic surgeons for breast augmentation. Round implants are easier for the surgeon to work with. If a round implant is turned, it is still round. Many women choose round implants because they believe that they tend to provide the greatest amount of lift, fullness, and cleavage. This is in fact, not entirely true. When the implants are overfilled, they may see these characteristics, but there is loss of the naturalness to the overall look of the augmented breast. Some women, however, feel that the results produced with round implants appear artificial, so they seek out more natural-looking alternatives (anatomical or “teardrop” implant). Some women may prefer the "artificial look" and want to look like they have implants - this is the minority of my patients. A round breast implant can have a smooth or textured surface. Due to a round implant’s symmetrical shape, the shape of the breast is not compromised should the implant rotate. If the implant should rotate, the shape is still exactly the same, round. Round implants come in four different variations of shape: low, medium, high and extra-high profile. The higher the profile, the narrower the base width for a given implant volume.  A higher profile can enhance the forward projection of the breasts, which would otherwise require larger breast implants with wider bases. However, such devices are associated with greater thinning of the breast tissue, chest wall deformities and creation of uncorrectable deformities. I find that the medium profile implants seem to give the most consistent, natural results.

Teardrop Breast Implants. As the name indicates, a teardrop breast implant, also known as a contoured or anatomical breast implant, is shaped like a teardrop. Breasts attain a more gently sloping contour with teardrop breast implants. Teardrop implants better resemble the natural shape of the breast. There is greater preservation of the contour and fullness of the upper portion of the breast, and less overstretching, also known as "bottoming-out". They require much more care in placement. When inserted, they are often tilted to better follow the natural contour of the breast. The degree of tilt requires more attention if the degree of symmetry is to be optimized. The teardrop-shaped implants often provide greater projection by volume. For women who want more naturally shaped teardrop breasts, these implants may be the ideal choice. Breasts with teardrop shaped implants typically excel in appearance in women who have loss of fullness and stretching secondary to pregnancy and lactation.

Round vs. Teardrop Implants – Which gives the breast a better shape?

A generally held belief is that round implants give more fullness in the upper pole (part) of the breast. This couldn’t be further from the truth. If one takes a saline round implant, and a saline teardrop shaped implant, and inflates it (outside the body) to the manufacturer’s recommended fill volume, and you hold it in the palm of your hand so that the bottom of the implant is against your palm (simulating the position the implant will have in the body when a woman stands upright), the round implant will exhibit more collapse at the top than the teardrop shape. The teardrop shape was specifically designed to retain its fullness at the top. So why do so many people believe round implants have more upper breast fullness? The answer is that the women who have round implants with very prominent upper pole fullness have implants that are over-filled with saline past manufacturer’s specifications. If you examine the shape of these breasts out of clothing, they will not look as natural as a breast with a properly filled teardrop implant. It is my opinion, based upon critical review of my own cases, that in the case of SALINE implants, that teardrop shaped implants give a more natural shape than round implants in the vast majority of cases. It is important to note that in some women, particularly those with an adequate amount of good quality breast tissue, that the shape of the implant may be less important to the overall aesthetic result. I utilize use both types of saline implants in my practice. As of February, 2013, highly cohesive teardrop silicone gel ("Gummy Bear") implants became available in the U.S. (although they were in use in other countries for about 15 years prior). Again, when you compare them out of the body, or in the body, there is much more preservation of upper breast fullness with the teardrop "Gummy Bear" implants than with the round silicone gel implants. As of this writing (September 2014), about half of my patients are selecting round silicone gel implants, and the other half selecting "Gummy Bear" implants.

What is the difference between smooth and textured implant surfaces?

Breast implants also are available in two surface types: smooth and textured. Textured implants were originally developed to reduce the chance of capsule contracture (see below).

Smooth implants do not attach to the surrounding tissues, while textured implants do attach to the surrounding tissue. The two different surfaces give the surgeon some additional choices in optimizing the breast augmentation results. In the case of a patient with better quality breast tissue, with good thickness, a textured implant will attach to the chest wall and the underside of the breast tissue or muscle, and may result in less stress on the lower portion of the breast because all the weight of the implant isn’t sitting on the bottom of the breast. This is somewhat theoretical. In the case of a patient with very thin tissue, a textured surface will attach to the underside of that tissue, and may be more likely to demonstrate visible rippling as when the implant ripples; it pulls the breast tissue in with it, causing a visible ripple in the breast surface.

In the case of teardrop implants, there really is no choice. One needs attachment to the surrounding tissues, or else the implant will rotate within the pocket and the breast shape will constantly change as the implant rotates. This is not an issue with round implants because if they rotate, the shape remains the same. The advantage to a teardrop implant, be it saline or silicone, is a more natural shape and, in especially the case of the silicone teardrop "Gummy Bear" implant, better preservation of that shape over time.

What is the difference between “above the muscle” and “below the muscle”?

The breast sits atop the pectoralis major muscle (the “pecs”). This muscle covers the upper portion of the rib cage or chest wall. Breast implants may be placed either below (submuscular) the pectoralis major muscle or above it (subglandular – below the breast). The pectoralis muscle is a triangular shaped muscle that has a broad attachment along the sternum (breast bone) and the medial (inner) side of the ribs near the sternum, then spans across the chest to attach on the humerus (upper arm bone).

Which is better: “above the muscle” or “below the muscle”?

When the implant is placed below the muscle, there is more soft tissue coverage of the implant, which gives the implant (if textured) more support and makes it less palpable. There is a more natural feel to the breast, as there is more tissue covering the implant. This advantage is especially important when saline implants are used, as they do not feel as natural as gel implants. Submuscular implant placement also pushes more of the breast tissue forward, resulting in less interference with mammography. When the implant is placed above the muscle, there is the possibility that some of the breast tissue may not be imaged as well with mammography, and that the implant may be more palpable and visible through thinner breast tissues. When having mammography performed, the mammographer will use techniques such as the Eklund breast displacement technique to better image an augmented breast. Lastly, submuscular placement may lessen the risk of capsule contracture following augmentation (post-operative tightening of scar tissue around the implant – see below). It is believed by many that the disadvantage of placement below the muscle leads to more pain and the possible need for drainage tubes due to more bleeding during the surgery. THIS IS SIMPLY NOT TRUE! See the “One Day Recovery Breast Augmentation” below for more on this.

The fact is that on the lower and lateral portions of the breast, there is rarely muscle coverage of the implant, and thus the implant may be more palpable and even visible in these areas particularly in those individuals with thinner tissue. This is not a contraindication to performing breast augmentation surgery, rather, it is just a point that the prospective patient needs to be made aware of. For those with thinner tissues, silicone gel filled implants may be a better choice.

What if my breasts are sagging? Should the implant be above or below the muscle?

Ptosis means drooping or sagging of the breast. There are two types of ptosis, and they can co-exist in the same breast. The treatment for each type, however, is very different. Women with no (true) ptosis (drooping of the nipple) or pseudoptosis (“false ptosis” or bottoming out of the breast tissue with loss of superior fullness and a drooping bottom contour to the breast), are candidates for either above the muscle (subglandular) or below the muscle (subpectoral) placement of the implant, assuming that they have good quality tissue to drape over the implant.

Women with pseudoptosis present a more challenging problem. Pseudoptosis is more common in women who have been pregnant, and often more pronounced in women who have breastfed their children. In pseudoptosis, the nipple may or may not be at appropriate height (at or above the level of the lower breast crease or inframammary fold). The loss of superior fullness of the breast with shifting of the glandular and fat tissue of the breast to the lower portion of the breast (drooping of the lower portion of the breast as manifested by a longer distance from the crease below the breast to the nipple) is more problematic if one wishes to place the implant below the muscle. In this case, implant placement below the muscle would result in a “double-bubble deformity”. The muscle with the underlying implant will project forward; however, the glandular breast tissue will “fall” off the front of the implant, leading to the appearance of a nice breast mound with a sagging wad of breast tissue at the bottom. It is in these cases that surgeons usually elect to place the implants above the muscle (subglandular). This better fills out the lower breast tissue, and lets the implant descend a little more within the breast envelope to yield a more natural look. However, all the disadvantages of a subglandular augmentation exist.

What is the Dual-Plane technique?

In my practice, many of my patients fall into the category of patients with pseudoptosis as described above. I also have not placed a breast implant into a subglandular location (excluding revisions of other surgeon’s work) in about over ten years. How is this possible? The technique of dual-plane augmentation, originally described by John Tebbetts, M.D. This technique involves the creation of a pocket below the pectoralis major muscle in which the implant will be placed. A second, smaller pocket is created between the muscle and the above glandular tissue, usually up to about the level of the nipple or upper border of the areola (the pigmented skin around the nipple). Nothing is placed in this pocket, but the separation of tissues serves to separate the tighter muscle with the overlying stretched breast tissue to permit the implant to better fill out the lower pole of the breast, thus preventing the “double-bubble” deformity as described above. The dual plane technique adds additional time to the procedure, but can make all the difference in obtaining a beautiful, natural augmentation as opposed to a poor, unnatural look, with breast tissue sliding downward over the front of the breast. The dual plane procedure does not eliminate the need for a mastopexy (breast lift) in those that need it. In my opinion, with the advent of the dual plane technique, there is no remaining reason to choose placement of a breast implant above the muscle over placement below the muscle. Some of the most natural looking results that I have attained were in women who presented with somewhat stretched breasts secondary to pregnancy with pseudoptosis. I have found that teardrop saline as well as round silicone gel implants yield wonderful results in these patients. There may be some increases risk for implant rotation if a teardrop shaped implant is used in these patients as the tissues are loose and the implant may be more free to turn.

Do breast implants need to be routinely replaced?

The answer is no. If your breast implants are doing well, you do not need to routinely replace them. However, it is important to understand that breast implants are not "lifetime devices" and additional surgery at some time in your lifetime is likely.

How is the size of the implant chosen?

If your goal is a natural appearing breast, then breast augmentation is not simply a matter of creating a pocket for the implant and then placing any size implant that you deem desirable. That is a “recipe for revision”. My goal is to perform a surgery that will not need a surgical revision for a very, very long time, hopefully never. The way to achieve this goal is to fit the implant to the breast.

If you think of the breast as a bag and you imagine filling that bag with water from above, then initially that bag will look under-filled, then properly filled with a nice shape, and then how further filling will distort the contours of the bag. The same holds true with breast augmentation. If you under-, or more commonly over-augment the breast, it will look unnatural. Furthermore, the risks of excessive tissue stretch, pain, loss of nipple sensation, and need for surgical revision will increase substantially if the breast is over-augmented.

My approach, which I credit to Dr. John Tebbetts, is a bio-dimensional approach coupled with an assessment of the tissue characteristics. First, the base width of the breast is measured. This is a starting point for selecting the base diameter of the implant. Next, a thorough analysis of the tissue thickness, and compliance (stretchability) as well as key measurements of proportion are assessed. A breast that has a tight skin envelope will require less fill volume than one with a normal skin envelope. Conversely, a breast with a lax skin envelope will require more fill volume than a breast with a normal or tight envelope. I can also precisely lower the breast crease, if necessary. Thus, this approach will allow me to produce an augmented breast with the most natural appearance, the least chance of undesirable overstretching, the least discomfort, least risk of loss of nipple sensation, least risk of atrophy of the breast tissue, and least chance of requiring a revision in the future.

How can I visualize the way I will look with implants before undergoing surgery?

Until recently, you really could not do this with any reasonable degree of accuracy. The commonly practiced method of placing an implant, bag of water, rice, peas or any other material in your bra or on top of your breast is not even remotely close to showing you how you would look after surgery.

In the past, there were some computer software applications that will allow you to alter a two dimensional photograph and allow you to see an augmented breast, but there are some limitations with this as well. The post operative images are the creation of the surgeon, based on what he thinks you will look like, but there is no accuracy here either. Also, the images are only two dimensional and cannot be rotated to show you how you would look from other visual angles.

In July, 2009, I added the Canfield Vectra 3-D system to my practice. This is an array of six cameras that will take your photograph from many different angles. The computer will then construct a three dimensional image of your torso. This image can be rotated and viewed from almost any angle. The software is pre-programmed with 3D models of several popular implant styles and sizes. The computer will then create a three dimensional image of how you will look after surgery. You can then view the before and after images, rotate and move them, and even compare the results with different implants…all from the comfort of the consultation chair. Understand that this is only a computer simulation. It is for demonstration only, and there is no guarantee that you will look as the computer portrays you after surgery, but this is most accurate method of visualizing how you might look after breast augmentation surgery that I know of. I am one of the first surgeons in the nation to use the VECTRA 3D system for breast augmentation simulations.

What are the choices for incision location for surgery?

Incisions are made in inconspicuous places on the breast to minimize scar visibility. These incisions may be located:

Armpit (transaxillary) – To perform breast augmentation with a transaxillary incision, the incision is made in the natural folds of the armpit tissue. A channel is then created up to the breast. When utilizing this operative approach, I prefer to use an endoscope, or a small tube with a surgical light and camera embedded in the end, to provide visibility through the channel. The biggest advantage of breast augmentation with a transaxillary incision is that the scar is not on the breast. This works well with saline filled implants because they may be inserted through the small incision deflated and rolled up. Silicone gel implants require a larger incision to prevent damage to them during insertion, and for this reason I prefer to use only saline implants when using this surgical approach. This technique is limited to those patients who have little or no pseudoptosis. It is generally recommended NOT to place silicone gel implants through an armpit incision.

Crease on the underside of the breast (inframammary) – An inframammary breast crease incision is the most common incision used as well as the most versatile. Breast augmentation with an inframammary incision is performed with an incision made under the breast in the inframammary fold. The incision is made here to secure proper placement of the implant, but also to reduce scar visibility. When it is placed within the breast crease, or slightly above, it is barely noticeable, as the breast lies on top of the incision in most cases. An advantage of breast augmentation with an inframammary incision is that the surgeon works close to the breast, allowing for optimal visibility while working, as well as having the greatest degree of precision in pocket dissection and implant placement and alignment. This is also the approach of choice for women who have bottoming out of their breasts after pregnancy and lactation. This is critical in ensuring that the breast mounds are at equal height. Also, if affords the greatest accuracy in placement of teardrop implants, ensuring that the degree of implant tilt is symmetrical. This approach can also be performed with the least amount of postoperative discomfort.

Nipple (actually around the areola, the dark skin around the nipple - "periareolar") – The goal of breast augmentation with a periareolar incision is to place the incision in the transition area between the dark areola and surrounding breast skin where it can be hidden. As with the inframammary incision, this incision allows the implant to be placed in precise pocket formation and provides for absolute controlled bleeding. The advantage to this approach is the small, hopefully near invisible scar. The problem with this approach is that if the scar is not invisible, it is now on the most visible portion of the breast. Unfortunately, no one can control the way you heal and scar, which is in your genetic makeup.

After the incision, a pocket is created for the breast implant. The implant is placed through the incision and then centered behind the nipple.

Saline implants may also be placed endoscopically through an incision in the navel. This is often referred to as a "minimally invasive" breast enhancement technique and is known as a transumbilical breast augmentation or the TUBA approach. I do not utilize this approach because the pocket is made by blunt dissection (which is actually  in my opinion, a far cry from "minimally invasive") rather than by direct visualization. This technique is fraught with more problems such as pain, bleeding and lack of precision. Also, the implant is usually placed above the muscle, which is not my preference. Don't confuse the term "minimally invasive" from "small incision". A transumbilical breast augmentation technique uses a small incision, but requires a lot of blunt dissection on the inside, which is not the same concept as a truly minimally invasive procedure such as a laparoscopic gall bladder removal, where a small incision is created to avoid cutting through the muscles of the abdominal wall. There is a big difference here. In summary, if a small incision requires more ripping, tearing and pulling of tissues to perform an operation, then there is nothing "minimally  invasive" about it.

How long does the surgery take / what type of anesthesia is used?

Breast augmentation surgery usually takes about 45 minutes and is performed under general anesthesia. Although some surgeons perform the surgery under local anesthesia with sedation, it is my observation that patients will have less postoperative discomfort and a quicker recovery when muscle relaxation is used during the surgery. This requires the need for a general anesthetic. As the surgery is typically very short, postoperative nausea and vomiting is very rare. Most patients stay in the recovery room for about 45 minutes and then are discharged home.

What is "Awake Breast Augmentation"? Can breast augmentation be performed under local anesthesia?

"Awake breast augmentation" is a breast augmentation procedure performed using local anesthetic while you are awake. Some surgeons will also give you some sedation to relax you, some will not. This procedure requires injecting your breasts with a solution of local anesthetic ("numbing medicine"). The proponents of this procedure claim that you are "involved in the size selection" of your implants during surgery and that you will recover faster. While this might make sense on the surface, it really does not for several reasons:

1. You must be fully sitting up at 90 degrees to see how the implants will look and this is very difficult to do on an operating table.
2. For all breast augmentations, the result immediately after surgery looks nothing like the final result several months after surgery - so how can the patient judge the result? At surgery, it is best for the operating surgeon who is experienced and understands how the augmented breast shape will change with time to determine if a specific implant selection is correct for that particular breast.
3. If you are sedated, then how can you even begin to give input with a clear mind as to what you want to look like?
4. The principles of soft tissue based planning to determine breast implant size are not followed, and this will lead to errors in placing over-sized implants, leading to a much higher surgical revision rate.
5. If the local anesthesia is not providing complete relief of pain, you will not have the ability to be put to sleep to complete the surgery - essentially, you will have to "grin and bear it".
6. Any significant problems arise during surgery - again, you will not have the benefit of an anesthesiologist to manage them.
7. As for the recovery, a quick general anesthetic (about one hour) is out of your system very shortly after surgery. Therefore, recovery from the anesthetic is not an issue. In fact, if you require sedation during your procedure, it may take longer to recovery from your "sedative hangover" than from a short general anesthetic!
8. Post-operative discomfort - only a general anesthetic will allow the surgeon to perform the surgery with muscle relaxants. Muscle relaxants temporarily stop the pectoral muscles from contracting during surgery. Therefore, it is easier for the surgeon to divide and elevate the muscles during surgery to make the breast pocket. If the surgeon has to pull harder to fight the contraction of the pectoral muscles, then you will have much more post-operative discomfort. Muscle relaxants cannot be given except during general anesthesia, or you would not be able to breathe on your own. The end result is much less post-operative pain, 98% of the time eliminating the need for narcotic pain pills after surgery, as well as the nausea and vomiting that goes along with the narcotic use.

Have I performed the surgery this way? The answer is "YES", and furthermore, I would NEVER do it that way again!

How are the wounds dressed?

After the implants have been inserted and positioned, the incisions are closed. Dermabond glue is applied to the wounds as a watertight dressing. No additional bandages, bras, garments or other dressings are needed. Scars will begin to fade in a few months and will continue to fade for months or years.

What is the “One-Day Recovery™ Breast Augmentation™Technique?”

I perform all of these operations with great care and precision, ensuring that my patients can enjoy a quick and healthy recovery. “One-Day Breast Augmentation Surgery” is my name for a technique based upon the pioneering work of John Tebbetts, M.D. Dr. Tebbetts was the first to describe a technique of breast augmentation with a recovery time of 24 hours and features dramatically less post operative discomfort, blood loss and downtime. One of the best parts about the technique is the fact that the reoperation rate (less than 2%) is far less than the national average (about 20% for silicone gel implants). Dr. Tebbetts personally taught me this technique in 2004.

With standard breast augmentation surgical techniques, women following breast augmentation surgery complain of a considerable amount of pain, swelling, and bruising. I employ the “One-Day Breast Augmentation Recovery Technique” in which the amount of swelling is minimal, bruising rarely occurs and post operative discomfort is dramatically less. Our patients can raise their arms up high over their heads before leaving the recovery room. Some of our patients have even brushed their hair and applied makeup before leaving the recovery room to go home!

You may have some soreness and minor discomfort, but in our experience you will most likely not need narcotic pain medicine. Patients typically describe what they feel in the first 24 hours after surgery as a “sense of tightness” rather than that of pain. We will give you a detailed set of postoperative instructions to assist and guide you through the first days after your surgery. When these instructions are followed, a 24 hour return to most activities of daily living (with the exception of heavy strenuous exercise) including driving and returning to work is anticipated.

Although there are no guarantees with any type of surgery, I can offer you information obtained from my extensive experience with this technique. Patients are asked to compete a brief survery 1-2 days following breast augmentation surgery. The most recent review of this data over the period 2008 - 2012  revealed that 97% of my patients required nothing stronger than ibuprofen (Advil) after surgery and 98% of my patients returned to normal activities the following day (except strenuous exercise), including driving in most cases. I continue to refine his technique.

Heavy lifting or straining should be avoided after breast augmentation surgery. You can typically return to work within a few days unless your work requires strenuous effort. The sutures are all dissolvable. There are no bras, bandages or straps required after surgery. Showering is encouraged the same day as your surgery! Any post-operative discomfort, swelling, and sensitivity will diminish over the first few weeks. Sensation in your nipples may be altered temporarily, but usually return to normal as your breasts heal.

After healing, some permanent scarring may remain, although scars from breast augmentation incisions will typically begin to fade in a few months and will continue to fade for months or years. Scars placed within the crease below the breasts are usually inconspicuous. It is my goal will be to make them as unnoticeable as possible. We even offer the use of lasers after surgery to help fade the scars!

How will I feel immediately after breast augmentation?

Your breasts will probably be mildly swollen, rarely bruised and there may be some discomfort for a few days but this will pass. There may be numbness in the breasts and nipples, and this should lessen as time passes. There may be some hypersensitivity of the nipples after this, but this too shall pass and is only a minor annoyance. Most patients do not need narcotics after surgery. In my experience using the “One Day Recovery” breast augmentation technique, there is no increase in discomfort with placement of the implant below the muscle. In fact, I place all implants below the muscle. Using the One Day Recovery technique, 97% of his patients require nothing stronger than Ibuprofen (Advil) after surgery. 98% of patients resume normal activities (except strenuous exercise) the very next day!

How long does recovery take?

Most patients feel tired and sore after surgery, but this usually passes in a day or two and many patients return to work within a day or two, many the very next day, although occasionally later. Any post-operative pain, swelling and sensitivity will diminish over the first few weeks. You should avoid strenuous exercise for the first three weeks.

Complementary Procedures

Breast augmentation can achieve dramatic and beautiful results on its own as well as in conjunction with other cosmetic surgery or non-invasive procedures. We sometimes recommend combining breast augmentation with other procedures such as a breast lift for more satisfying results. This is most commonly recommended to treat any sagging that has resulted from aging or pregnancy. During this combined procedure, breast skin is removed and tightened as well as lifting the breast, and an implant is inserted. Note that many women, even those with some sagging after pregnancy, do not require a breast lift concurrent with breast augmentation. I will evaluate you and discuss whether or not such additional surgery is indicated in your specific case.

Am I a good candidate for breast augmentation and mastopexy?

If you have sagging breasts and loss of fullness in the top portion of your breasts, you are likely a candidate for the breast augmentation. Depending on the degree of sagging, and whether the sagging involves the breast tissue alone or breast tissue and the nipples, you may be a candidate for a breast lift (mastopexy) procedure, either in concert with, or without, a breast augmentation procedure.  The need for a specific procedure is best determined during an in-person consultation.

When can I expect to return to work and resume my normal daily activities?

In my patients, I am not seeing much difference between breast augmentation alone and augmentation with mastopexy (lift) in terms of recovery time.. However, it is important to your recovery that you ambulate around during that time. I use a specialized “Recipe for Recovery” to hasten your recovery. After the procedure, it is often possible to return to work within a few days.

Strenuous physical activity should be avoided for at least the first three weeks following surgery. After that, you should be well-healed. If you have any questions about what you should or should not do, ask us.

What are the risks and complications of breast augmentation and mastopexy?

Complications following breast augmentation and mastopexy surgery are rare and usually minimal. The possible complications associated with breast augmentation and mastopexy include capsular contracture, swelling and pain, infection around the implant, a change in nipple sensation, wound separation (usually very minor when it happens) and breakage or leakage of the implant (implant rupture).

Many possible complications associated with breast lifts and implants can be avoided by choosing an experienced and well-trained surgeon. I perform all of these operations with the goal of minimizing all possible complications and ensuring my patients’ satisfaction.

Will there be scarring from my breast surgery (implants, lift or combination)?

Like almost every surgical procedure, incisions are a part of the breast augmentation and mastopexy process. In human skin, wherever you have an incision, a scar will form. Fortunately, breast augmentation and mastopexy scars, regardless of where they are located, tend to heal extremely well in the majority of patients. Scars can be hidden within a bra, bathing suit or low-cut top. During surgery, incisions are made in inconspicuous places on the breast to minimize scar visibility (in the armpit, in the crease on the underside of the breast, or around the areola, the dark skin around the nipple). A mastopexy does add additional scars such as around the areola, and usually a vertical scar from the bottom of the areola down towards the lower breast crease. In some occasions, an incision is made in this crease as well. It is important to remember that scar quality is not heavily influenced by your individual tissue biology of wound healing and that this factor is our of your control as well as mine. I can do my best to minimize the scars as much as possible, give you instructions in the aftercare for the scars, and even offer you laser treatments for the scars so as to minimize the visibility of the scars, but I cannot eliminate them completely. Scars do fade with time. The ultimate result is a combination of the plastic surgical techniques that I use to close the wound, your natural biology of wound healing, a factor that neither you nor I can control as well as the aftercare that you give the scar.

How will my breasts look and feel after a breast lift with implants?

Breast implants will add to the overall results of the breast lift procedure by lifting the breast and increasing your bust size in a single step. Some discoloration and swelling may occur initially after the procedure, but this will disappear quickly.

After recovery, many women equate the feel of their breasts implants to that of a teenage girl with young, healthy, firm breasts. And when you undergo the breast augmentation combined with a breast lift, your breasts will typically remain full and perky for longer. It is important to understand that no surgery will change the quality of your breast tissue, so you will be feeling the breast tissue on top of the implant. The more natural tissue that you have, and the firmer that tissue is, the less you will be able to feel the implant itself. As today's silicone gel implants are designed to mimic the feel of natural breast tissue, it becomes difficult at times to even feel the implant at all in some cases.

Can I breastfeed after the breast augmentation and mastopexy operation?

You will most likely be able to breastfeed after the breast lift with implants procedure, but it may depend on the kind of surgery you had and the type of incisions required.

Will insurance cover the breast lift with implant procedure?

Insurance companies do not usually cover breast implant (with or without a lift) surgery when performed for cosmetic reasons.

Is breast augmentation and mastopexy too much surgery to do on the breast at one time?

No, breast augmentation combined with mastopexy is not too strenuous on the breast, and in my experience the downtime is not much more, if at all, than if only one procedure was performed. Often, when mastopexy and augmentation are performed at the same time, less skin has to be removed, which may result in less scarring.

Should women who are pregnant or plan to be pregnant wait before undergoing breast augmentation surgery?

I will not perform any cosmetic breast procedure on a woman who is pregnant, lactating or planning to become pregnant in the very near future. Many of my patients have undergone breast implant surgery and then became pregnant at a later date with no significant deleterious effects on the results of their implant surgery from the pregnancy. If you do undergo breast augmentation, and then become pregnant, it is possible, although not very common, that you may desire to undergo a breast lift later after you have completed childbearing. As for breast lift surgery, most women seeking this procedure wish to correct sagging of their breasts following pregnancy, therefore, such surgery is generally postponed until such a time that the woman no longer desires to bear any more children.

What is out of the surgeon’s control?

There are two things that the surgeon cannot control: wound healing and tissue stretching.

Despite the most meticulous wound closure, a scar may be raised, thickened, widened or pigmented. The final appearance of the scar is due to a combination of factors, most importantly including the way the surgeon closes the wound AND the patient’s biologic tendencies towards wound healing. Some patients just naturally make great scars, and some make less than ideal scars. In my extensive experience with breast augmentation, I have found that in the vast majority of patients, the scars are thin, fade nicely and are not an issue for patient and partner. Occasionally, a scar may be hypertrophic (thick and raised). Fortunately, this is considered rare. Treatment for such scars includes intralesional injections of steroid preparations, scar massage and avoidance of sun exposure. Recently, we have found that treatment with lasers can reduce both the redness and thickness of the scars.

Any time a foreign material is implanted into the body, a scar tissue “capsule” forms around it. Breast implants are no exception to this rule. Most of the time the capsule is thin and pliable, and is neither visible nor palpable and does not affect the aesthetic result of the augmentation in any way. Textured implants were developed to try to minimize scar tissue capsule and subsequent contracture from occurring. Occasionally, the scar tissue capsule may thicken and contract. This will cause the breast to feel firm and hard. Occasionally, in very rare instances, the breast may be painful. The problem is not the breast. It is not the implant. It is the scar tissue contracting tightly around the implant. Treatment consists of removing the implant and the scar tissue, either in whole or in part, and then replacing the implant. In very rare cases, if a woman has this problem happen twice to the same breast, I would recommend removal of the breast implants and not replacing them. So far, I have never been in a position to make this recommendation.

Whenever a breast is augmented with an implant, it stretches. The degree of stretch is usually appropriate for the size and shape of the implant. Occasionally, the lower pole (portion) of the breast may stretch more than is desired. This makes the implant look like it has been placed too low. When I have seen this problem, in the vast majority of cases, the amount of excess stretch is minor and not of concern to the patient. In very rare cases, it may require a surgical revision to be performed in the operating room. Excess tissue stretch, although rare, is somewhat unpredictable. Although one may expect the opposite to be the case, I have seen this occassionally happen with good quality tissue and not happen with poor quality tissue as well as with smaller breast implants, but not with larger implants. A general rule of thumb is that as you go larger than the recommended size implant, or if the tissue quality is compromised, you will run an increased risk of excess tissue stretch occurring.

Complications That May Arise

Complications following breast augmentation surgery are uncommon. They may include capsular contracture, swelling and pain, infection around the implant, a change in nipple sensation, and breakage or leakage of the implant. Some other complications that may arise from breast augmentation surgery are described in more detail below:

Rupture

As breast implants are mechanical devices, they will eventually fail. When saline breast implants fail, they often deflate quickly and can be easily removed. Device failure rates are approximately 1 – 2% per year, which is small. In the case of saline implants, the valve used for inflation is a common reason for device failure. Silicone gel implants do not have a valve. If an implant shell cracks, saline or silicone gel may leak out. Your body will absorb the saline with no untoward effects on your health. If a gel implant should rupture, the scar tissue capsule described previously in this article will usually contain the gel. The gel is biologically inert and poses no threat to your health, either. Today’s breast implants are made much more durable than previously. A silicone gel implant is made to withstand a compressive force equal to twenty five times that sustained during a mammogram. Over the course of your lifetime, a breast implant may fail and require replacement. Replacement is usually a very simple surgery.

Alterations in Nipple and Breast Sensation

The most common alteration in nipple sensation is a reduction in sensitivity, which can range from slightly diminished to no sensation at all. The good news is that in the vast majority of these cases, the sensitivity returns, although it may take days, weeks, or even several months. In rare cases, loss of nipple sensitivity can be permanent. Sometimes as the sensation is returning, usually a few weeks after surgery, there can actually be a heightened sensitivity which can be annoying. The good news is that this always seems to resolve, usually within a few weeks.

Infection

Infections after breast augmentation surgery are very rare. Many can be treated with oral antibiotics alone. Very rarely, should the infection involve the implant, the implant may need to be removed so as to allow the body to clear the infection. After six months, the implant may be replaced.

Need for Re-operation

Regardless of the type of implant, it is likely that women with implants will need to have one or more additional surgeries (re-operations) over the course of their lives. Reasons for a breast augmentation re-operation may include the following: capsular contracture, wrinkling, asymmetry, implant rupture/deflation, and excessive tissue stretching as described above.

Capsular Contracture

Occasionally, the scar tissue capsule that forms around the implant thickens and contracts. This makes the implant and the breast feel hard. When this happens to a mild degree, nothing needs to be done. When the breast gets hard, there is pain or distortion of implant shape, then the capsule needs to be removed and the implant replaced. The exact cause of this is unknown, but two theories are: 1) accumulation of blood around the implant after surgery. I use a near bloodless technique when performing the surgery, which helps to minimize the risk of this problem, 2) low grade infection around the implant. Again, I pay great attention to sterile technique during surgery, incorporating not only two different intravenous and post-operative antibiotics but also a triple antibiotic irrigation during surgery and a special way of draping the surgical field so as to minimize contamination of the wounds. Also, as my preference is to use an inframammary (breast crease) incision, there is a lower risk of capsule contracture than if a periareolar (nipple) incision were used.

Complications

Complications following breast augmentation surgery are uncommon and usually minimal. Although rare, some complications that may occur include capsular contracture, swelling and pain, infection around the implant, change in nipple sensation, decreased milk production while nursing, and breakage or leakage of the implant (implant rupture) as a result of injury. Regular monitoring of breast implants after breast augmentation surgery is recommended to ensure continuing breast and implant health.

Summary

Breast augmentation surgery is one of the most commonly performed cosmetic surgical operations. The surgery is brief, the recovery fairly unremarkable and complications are uncommon. Breast implants are not lifetime devices. Depending on your age at presentation, you may need to undergo an additional procedure on your breasts at some time in your lifetime.

Recently, women have been given the ability to choose between saline and silicone gel filled breast implants. The latter often produce a surgical result with an unparalleled natural feel to the breasts.

Most women who have undergone breast augmentation have a high degree of satisfaction with their surgery and often enjoy a greater sense of self-confidence and pleasure with their new body contours.

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