Below the breast is the pectoralis major muscle. It is attached to the chest wall along the lower, inner portion of the breast, then along the entire side of the breast bone. The muscle spans across the chest like a triangle, and attached to the upper arm bone called the humerus. Below the muscle lies the chest wall, essentially the rib cage.

To place the implant under the muscle, a pocket is created by lifting the muscle off the underlying rib cage. The attachment of the muscle to the overlying breast remains undisturbed. To place the implant above the muscle, the breast is lifted off the underlying muscle. The attachment of the muscle to the underlying rib cage is undisturbed.

So, which is better? In either case, you have a pocket, and in that pocket you increase the size of the breast by inserting an implant. Theoretically, it should not make much difference. Theoretically yes, but in practice, quite the opposite. Consider the following:

1. The more soft tissue (breast and muscle are both examples of “soft tissue”) that is placed over the implant, the less visible and palpable the implant will be. If the patient has nice, thick, firm breast tissue, then it may not make too much difference which route you take. Certainly, if the tissue is naturally thin, or thinned out by atrophy after pregnancy and lactation, if will matter greatly which route of placement is utilized. Also, consider that with time, everyone (unfortunately) ages and that results in thinning (atrophy) of tissue.

2. The muscle is subject to less stretching that the skin and breast tissue. It acts like a stabilizer to prevent overstretching of the breast pocket (to some extent).

3. There is (according to my friends who are radiologists specializing in breast imaging) less interference with interpreting mammography when the implant is below the muscle. This statement is purely anecdotal and not based on any personal experience as I do not interpret mammograms.

4. It is no easier to place the implant above the muscle than below it, and probably requires a little more surgical effort, although not enough to make any difference to persuade the surgeon to choose below the muscle placement.

5. Despite the fact that the muscle is being partially cut with placement below the muscle, I do not believe that there is any more discomfort or downtime in using below the muscle placement. I utilize a rapid recovery method with below the muscle placement and my patients require no more than Advil for discomfort and are driving the next day.

So then, what is the reason surgeons choose to place implants above the muscle? There are a few reasons. The first may seem silly, but is in fact a reason surgeons choose to do what they do. The answer is “because that is what I was taught to do”, or “because that is how I have always done it and it works for me”. That is fine, but you cannot advance as a surgeon if you don’t keep yourself open to advances. Personally, I am always on the lookout for better ways to do things. It may take some getting used to when changing up to another technique, but if it is for the betterment of my patients, then why not? If I wasn’t progressive, then I would still be writing prescriptions for narcotics like Vicodin instead of just Advil after surgery, wrapping my patients is straps and bandages instead of just a small paper Steri-Strip and telling my patients they cannot raise their arms or drive for days or weeks instead of raising their arms high above their head while still on the recovery room stretcher and driving to their first follow up visit in my office the next day. That is a whole different story; my point is that a surgeon must be up to date on the latest techniques and methods.

There is one compelling reason why many surgeons place implants above the muscle. If you have a breast that has lactated, lost fullness in the upper portion and the glandular tissue is bottoming out (some of the breast tissue lies below the lower crease of the breast), then you have a special situation, one which is also very common. If you place an implant below the muscle, then the breast mound from the implant will lie up high, but the breast tissue will slide off the front of the implant and sag over the implant. From the side, this resembles the side view of the dog “Snoopy” from the Charlie Brown cartoons. The reason for this is that the muscle is preventing the implant from moving lower into the breast where there is some sagging. If you place the implant on top of the muscle, then you no longer have this problem. However, placing the implant above the muscle will result in some other potential problems: there is now much thinner tissue over the implant, so the implant will be more palpable and visible. Also, there will be less support of the shape of the breast without the muscle. Lastly, mammography may be more difficult.

A better solution is to place the implant under the muscle using a dual plane technique. In this technique, the muscle is repositioned superiorly in the breast pocket. There is a little less muscle coverage of the implant, but there still is muscle coverage of the upper portion of the implant nonetheless. The implant can now move into the lower pole (portion) of the breast and fill it out properly. All this with no need for a breast lift.

The dual plane technique will be the subject of a future blog on this website.

Body Sculpting Surgery: Technologies and Techniques

by William W. Cimino, Ph.D.

‘Lipoplasty’ is the all-encompassing term that refers to body contouring by sculpting or removal of fatty tissue. The major groups of different technologies and techniques for lipoplasty are described below, along with a short assessment of their respective advantages and applicable volume considerations.

Suction-Based Technologies

Liposuction or Suction-Assisted Lipoplasty (SAL)

• Power-Assisted Lipoplasty (PAL) Ultrasound-Based Technologies
• 
  Internal Ultrasound-Assisted Lipoplasty (IUAL)
• 
  VASER-Assisted Lipoplasty (VAL)
• 
  External Ultrasound-Assisted Lipoplasty (EUAL)

• Transdermal Ultrasound-Assisted Lipoplasty (TUAL) Laser-Based Technologies
• External Laser-Assisted Lipoplasty (ELAL)
• Internal Laser-Assisted Lipoplasty (ILAL) Chemical-Based Technologies

Mesotherapy

Suction-Based Technologies

Liposuction/Suction-Assisted Lipoplasty (SAL)

Liposuction, with all of its many variations, is the predominant form of body contouring surgery today. These variations include liposculpture, tumescent liposuction, suction lipectomy, syringe lipoplasty, and micro-cannula technique. All of these suction-based techniques can be included in a general category commonly referred to as Suction-Assisted Lipoplasty, or ‘SAL’.

SAL is a two-step process that requires the infusion of a wetting solution into the fatty tissues followed by the insertion of a suction cannula that is attached to a suction source. The cannula avulses (tears) and aspirates the fatty tissue fragments which are deposited into a waste canister.

This technology has been around in basic form for more than 30 years and has undergone improvement and refinement during that period. Major advances for the SAL technique include the introduction of the side-ported cannula, the introduction of wetting solutions with drugs for pain and control of bleeding, and overall reduction in cannula size.

Suction-based technologies are not tissue selective. Any tissues, such as nerves, vessels, or collagen structures in the fatty layer that get pulled into the ports on the suction cannula will be torn or avulsed. The technology is reliable, and has been used and studied extensively.

SAL has been used for small to very large volumes of fat removal in lipoplasty.

Power-Assisted Lipoplasty (PAL)

Power-Assisted Lipoplasty (PAL) is essentially a liposuction cannula (SAL) with the addition of a motor-driven reciprocating handle. The primary advantage of this technology is that it makes passage of the suction cannula through the tissues easier for the surgeon but represents no clinical improvement in outcomes or safety relative to SAL for the patient¹.

Surgeons may develop arthritis, ulnar palsy, or carpal tunnel syndrome as a result of the motor-induced vibration². Like SAL, PAL is not tissue selective – any tissues, such as nerves, vessels, or collagen structures, in the fatty layer that get pulled into the ports on the suction cannula will be torn or avulsed.

PAL is generally used for medium to large volumes of fat removal in lipoplasty as it may be too aggressive for smaller, more delicate areas.

Ultrasound-Based Technologies

Internal Ultrasound-Assisted Lipoplasty (IUAL)

Internal Ultrasound-Assisted Lipoplasty (IUAL) uses an ultrasonically vibrating cannula to emulsify (liquefy) adipose tissue during the aspiration process. IUAL technology was introduced with the promise that the ultrasonic technology would provide a level of tissue selectivity due to the emulsification process and thereby improve outcomes relative to those obtained using SAL. However, clinical experience and outcomes with IUAL vary considerably. Some surgeons report no significant clinical change in outcomes^5,6. Some surgeons report an improvement in outcomes^3,4. Others report increased complications or tissue damage relative to SAL⁷. This wide variation in results is in large part explained by the design of the technology which aspirates protective fluids/ tissue while the ultrasonic energy is active, by application of excess power to the tissues, and by the initial insufficient clinical understanding of the technology, all of which prevented consistent and uniform effectiveness⁹.

IUAL is called internal UAL to differentiate it from external UAL (EUAL, explained below). Most IUAL is a two-step process similar to SAL: infusion of a wetting solution into the fatty tissues followed by a combined emulsification and aspiration phase using a hollow ultrasonically powered cannula.

IUAL has been used generally for medium to very large volumes of fat removal in lipoplasty as it may be too aggressive for smaller, more delicate areas.

VASER^®-Assisted Lipoplasty (VAL)

VASER-Assisted Lipoplasty (VAL) represents a third-generation internal ultrasound system that incorporates significant design improvements over the previous two generations of internal ultrasound devices.

VASER technology is the ultrasonic component of an integrated lipoplasty system. The VASER System uses small-diameter, solid, multi-ringed probes to deliver a minimal level of ultrasonic vibrating energy to specifically target and emulsify fatty tissues. Smaller diameter probes and pulsed delivery of the ultrasonic vibratory energy further reduce delivered energy by as much as 50% compared to continuous wave ultrasound used in first and second generations of internal ultrasound-assisted lipoplasty⁸.

By emulsifying the fatty tissue prior to extraction, aspiration can be performed with less avulsion, and hence less tearing of the tissues. The VAL procedure does not utilize standard SAL to remove the emulsified tissues and fluids -rather, specially designed aspiration cannulae, call VentX^® Cannulae, are used to remove the emulsified fluids and minimize avulsion and other tissue trauma associated with standard SAL aspiration devices.

This third-generation ultrasound technology was specifically designed to preserve and spare as much of the tissue matrix as possible, yet still remove the desired amount of fatty tissue. This approach helps minimize post-operative pain and bruising and also addresses the limitations inherent in earlier generation IUAL devices^10,11. VAL was compared to IUAL in a clinical study and found to significantly reduce potential complications relative to the earlier generations of IUAL⁹.

VAL has been used on volumes from the very smallest (face/neck) to very large volumes.

External Ultrasound-Assisted Lipoplasty (EUAL)

External Ultrasound-Assisted Lipoplasty (EUAL) is the application of non-focused ultrasonic energy in the 1-3 MHz range to the skin of the patient prior to the use of standard SAL techniques. The theory is that the externally applied ultrasonic waves disrupt or soften the fatty tissue so that subsequent suction aspiration is easier. However, there has been no scientific substantiation that this additional step, prior to SAL, improves outcomes or safety.

Because SAL is used to remove any fat targeted by the EUAL technique, the outcomes are generally consistent with SAL outcomes. EUAL surgery may involve significantly more time if larger volumes are to be pre-treated with the EUAL device. This technology is not in widespread use today, primarily because the combination of EUAL and SAL has not been shown to be clinically superior to SAL alone.

Because SAL must be used in conjunction with the EUAL device, addressable volumes are the same as SAL, from small to very large, strictly a function of the SAL step.

Transdermal Ultrasound-Assisted Lipoplasty (TUAL)

Transdermal Ultrasound-Assisted Lipoplasty (TUAL) is the application of focused ultrasonic energy directly to the skin of the patient to disrupt the fatty tissue below the skin and does not require removal of the ruptured cells with a suction cannula (SAL). This technology is not currently available for use in the United States, as it has not yet gained Food and Drug Administration (FDA) clearance.

Transdermal ultrasound is a single-step process which involves application of the ultrasonic energy directly to the skin without the prior infusion of wetting solution as required in all other techniques. The body’s natural processes remove the damaged tissues over a period of time after the ultrasound application.

This technology is used to treat only small volumes in a single patient visit, on the order of 250–300 milliliters (cc’s) per treatment. The treatable volume is limited because this approach requires that the patient’s body remove or process the dead or damaged tissue. Because the treated fatty tissues are not removed at the time of surgery, results are not seen until several months after the procedure. Many treatments are required over an extended period of time if more significant volumes are to be addressed.

Laser-Based Technologies

External Laser-Assisted Lipoplasty (ELAL)

External Laser-Assisted Lipoplasty, also called Low-Level Laser-Assisted Lipoplasty, is the application of low-level laser energy to the skin of the patient prior to the use of standard SAL techniques. The theory is that the application of the low-level laser energy causes the fatty cells to produce a transitory pore in their cell membranes, which allows the fat inside the cells to pass to the outside of the cells¹². This claim was subsequently studied for validation, and results showed that the ELAL therapy did not influence the fat cell structure as reported¹³. This technology is not in widespread use today, primarily because the combination of ELAL and SAL has not been shown to be clinically superior to SAL alone¹³.

Because SAL is used to remove any fat targeted by the ELAL technique, the outcomes are generally consistent with SAL outcomes, as are addressable volumes, from small to large, strictly a function of the SAL step.

Internal Laser-Assisted Lipoplasty (ILAL)

Internal Laser-Assisted Lipoplasty (ILAL) uses a small-diameter laser fiber to deliver laser energy directly to

the fatty tissues through an incision in the skin. The laser is reported to operate through photomechanical and photothermal effects¹⁵. In short, these processes cause destruction of cells via coagulation and vaporization due to localized heating and rapid thermal expansion. ILAL was first introduced in the mid to late 1990’s¹⁵ and did not gain wide adoption or use. It has been reintroduced and is marketed as SmartLipo™ and Cool Lipo™.

A contra-lateral study comparing SAL on one side of the patient to ILAL (SmartLipo) on the other side of the patient showed no significant difference in outcomes¹⁴. The American Society for Aesthetic Plastic Surgery issued a guidance statement for this technology stating “Although SmartLipo received FDA clearance in late 2006, alarm bells rang for many experts when discussing this procedure based on the recent publication of data showing that this procedure was no better than traditional liposuction, and that it may present some risks to the liver and kidneys due to the way it releases free fatty acids when destroying the fat cells”¹⁶. The surgical technique for ILAL is a three-step process: (1) infusion of wetting solution followed by (2)application of the laser energy to the fatty tissue then (3) aspiration of the emulsified tissues using SAL. It has been proposed that the suction phase is not required for ILAL but surgeons are generally not willing to risk leaving the laser-affected volumes of damaged or dead tissue in the body. ILAL is therefore applicable only to small volumes as a standalone technology if no SAL step is used. If ILAL is combined with SAL to remove larger volumes, then outcomes consistent with SAL can be expected¹⁴. In this case (ILAL with SAL) the laser is used to treat only a small percentage of the removed tissues.

Chemical-Based Technologies

Mesotherapy

Mesotherapy is the use of a large number of injections of non-FDA approved drug mixtures, most often including phosphatidylcholine. The drug mixture is injected directly through the skin and into the fatty layer using several hundred needle injections to distribute the drugs throughout the fatty layer.

The mesotherapy theory provides that the drug mixture causes the breakdown (cell rupture and cell death) of the fat cells, which are then absorbed by the body. The American Society of Aesthetic Plastic Surgery recently released a position statement on mesotherapy which warns patients, stating: “efficacy and safety are not known, the procedure and the drug mixtures are not approved by the FDA, and that the procedure is often offered by unqualified personnel”¹⁷. Mesotherapy is marketed as LipoDissolve^®, LipoStabil^®, and LipoShape^®.

1. Fodor PB, Vogt PA. Power-assisted lipoplasty (PAL): A clinical pilot study comparing PAL to traditional lipoplasty (TL). Aesthetic Plast Surg., Nov.-Dec.,23(6):379-85, 1999.
2. Shiffman, MA. Editor’s Commentary in Liposuction: Principles and Practice. Editors M.A. Shiffman M.D., and A. DiGiuseppe M.D. Springer-Verlag, Berlin, Germany, 2006; p 405.
3. Kloehn RA. Liposuction with “sonic sculpture”: six years experience with more than 600 patients. Aesth Surg. J. 1996;16:123-8.
4. Zocchi ML. Ultrasonic assisted lipoplasty: Technical refinements and clinical evaluations. Clin. Plast. Surg. 1996;23(4) 575-598.
5. Fodor PB, Watson J. Personal experience with ultrasound-assisted lipoplasty: A pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast. Reconstr. Surg. April 1998;101(4):1103-1116;discussion 1117-9.
6. Karmo FR, Milan MF, Silbergleit A. Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty. Plast. Reconstr. Surg. 2001;108(1):241-7; (discussion 248-9).
7. Cardenas-Camarena L, Andino-Ulloa R, Mora RC, Fajardo-Barajas D. Laboratory and histopathologic comparative study of internal ultrasound-assisted lipoplasty and tumescent lipoplasty. Plastic & Reconstructive Surgery. Sep. 2002;110(4):1158-1164.
8. Cimino WW. Ultrasonic Surgery: Power Quantification and Efficiency Optimization. Aesth Surg. J. 2001;21: 233-240.
9. Jewell ML, Fodor PB, De Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: A pilot clinical study. Aesth. Surg. J. 2002;22:131-146.
10. Cimino W.W. “Ultrasound-Assisted Lipoplasty: Past, Present, and Future”, Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 225-228.
11. Cimino WW. VASER-Assisted Lipoplasty: Technology and Technique. Liposuction: Principles and Practice, Editors M.A. Shiffman,

M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 239-244.

1. Neira R, Arroyave J, Ramirez H, Ortiz CL, Solarte E, Sequeda F,Gutierrez MI. Fat liquefaction: effect of low-level laser energy on adipose tissue. Plast Reconstr Surg. 2002 Sep 1;110(3):912-22; discussion 923-5.
1. Brown SA, Rohrich RJ, Kenkel J, Young VL, Hoopman J, Coimbra M. Effect of low-level laser therapy on abdominal adipocytes
2. before lipoplasty procedures. Plast Reconstr Surg. 2004 May;113(6):1796-804; discussion 1805-6.
2. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaete F. A Prospective, Randomized, Double-Blind, Controlled Clinical Trial Comparing Laser-Assisted Lipoplasty with Suction-Assisted Lipoplasty. Plast. Reconstr. Surg. 118(4):1032-1045, September 15, 2006.
3. Schavelzon, D., Blugerman, G., Chomyszyn, A., “Laserlipolysis”, Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 321-325.
4. ASAPS website commentary: http://www.surgery.org/press/news-print.php?iid=476&section=news-lipoplasty
5. http://www.surgery.org/press/news-release.php?iid=475

The current FDA recommendation is to obtain a MRI examination of the breasts three years after breast augmentation surgery and every two years thereafter. Does this make sense? To put it simply, there will be a certain amount of women who will experience device failure of a silicone gel implant. If you screen everyone every year, then almost all of these problems should be picked up by the MRI scan. If you screen no one, then of course, there will be none of these problems identified. So then, what frequency of examination makes sense? Just like screening for any disease or problem, you have to have an understanding of the actual frequency the problem, the severity of the problem (is it life threatening or a risk to quality of life or the health of the community vs. low health risk) and the costs of the screening program. Most likely, a screening program will not screen everyone each year, which leads to some problems going unrecognized. The other question is: What is the consequence of not recognizing the problem? Will there be a compromise to one’s life, health, livelihood or their family? In the case of breast implants, if a rupture is missed, there is most likely not going to be a significant risk to the patient’s health. Silicone is biologically inert and fifteen years of studying breast implants have demonstrated that they are not a causative factor in the development of any systemic diseases.

The first question is whether or not an MRI, which is an expensive test, is an appropriate first line screening test for breast implant rupture. In screening for cancer, mammogram remains the gold standard for initial screening. If there are any abnormalities seen, then it is ultrasound, not MRI that is used next to investigate further. This is not because MRI is inferior to ultrasound, but rather than ultrasound is a good second screening test and is much more cost effective then proceeding directly to an MRI. Should there still be some question after ultrasound, an MRI may be a good way to go prior to considering surgery in cases where there exists uncertainty as to whether or not a problem exists within the breast. I have found this process to be extremely useful in my cosmetic breast surgery patients (augmentation, lift, reduction) who require routine screening prior to commencing surgery. So why then, is MRI recommended as the initial screening tool for a silicone breast implant rupture? Is it better than less expensive tests?

In an excellent 1998 scientific study at the University of Michigan, Chung found that if ultrasound was the initial screening tool for a breast implant rupture and the ultrasound test was read as normal, the chance of a false negative, in other words, the chance that the normal interpretation of the ultrasound was incorrect and that there really was a rupture which was undetected was only 2.2%. On the other hand, if ultrasound did suggest a rupture, and an MRI was obtained afterwards which also supported a diagnosis of implant rupture, then there was an 86% chance that the implant was in fact truly ruptured. This is a high enough chance of rupture to support the plan of surgical exploration and implant replacement if a true rupture is actually found.

In a separate study in 2001, Cher found that in women with breast implants who have a specific complaint referable to the breast such as pain, capsular contracture or a change in the appearance of the breast, an MRI is better than 80% accurate in predicting an implant rupture. In the absence of such symptoms, the predictive value of MRI is much less, and was not felt to warrant use as a routine screening method for implant rupture in such asymptomatic women. The Royal College of Radiologists in the United Kingdom stated that ultrasound is 91% accurate if it demonstrates an intact implant, not too dissimilar to the results of the University of Michigan study discussed above. Furthermore, they concluded that the initial screening tool should be an ultrasound, followed by MRI (preferably one with a dedicated breast coil and a magnet strength greater than 1.5 Tesla) if the ultrasound suggests a rupture of the implant.

How often does rupture really occur? I use the rough rule of thumb of about 0.5 to 1% per implant, per year. Mentor’s core study of 420 patients demonstrated a 0.5% rupture rate at three years out from surgery, but there have been other studies that don’t show ruptures for even up to seven years (Sharpe and Collis- UK). Does it make sense to have 199 women to undergo MRI to find one rupture (assuming a 0.5% rupture rate)?

So, should one follow the current FDA recommendation and obtain an initial MRI examination of the breasts three years after breast augmentation surgery and again every two years thereafter?

- Consider that as third party payers (your health insurer) have strict clinical guidelines for the authorization of a breast MRI, it is quite possible that these routine MRI’s in an asymptomatic patient may not be paid for by health insurance.
- Consider the fact that a missed implant rupture is highly unlikely to represent a health risk to the individual.

- Consider that a normal ultrasound demonstrating an intact implant is better than 90% accurate

- Consider that the rupture rate is approximately 0.5% after three years.

My personal opinion, based on the information given above, is that the FDA guidelines represent overkill. In other words, I believe that these recomendations are not cost effective, and probably counterproductive. What I mean by stating that the FDA’s recommendations are not cost effective is that less expensive ultrasound is highly effective as a screening tool for implant rupture and given the fact that breast implant rupture occurs with such a low frequency brings into question the relatively frequent intervals that the FDA is recommending for breast surveillance for implant rupture. What I mean by counterproductive is that if the MRI’s are not covered by health insurance (unless there is a clinical problem, and even then possibly only after a mammogram and ultrasound have first been performed) I would not expect most women with breast implants to voluntarily follow these guidelines for cost reasons alone, as they may have to bear the financial burden of these costs. Therefore, less, if not more women will undergo such routine surveillance, which is the opposite of the FDA’s intended goals. I do not know what scientific rationale was used to develop the FDA recommendations, however, based on current scientific data, the FDA recommendations are not supported. The FDA’s recommendations are only just that, “recommendations”, not law and it is up to the individual patient to decide how to use this information. I feel that it is my obligation to present not only the FDA’s position, but my own as well.

The good news for women undergoing breast augmentation with silicone gel implants is is that breast ultrasound, a much less expensive option, is readily available for those women who are interested in routine surveillance of their breast implants. Breast ultrasound is also not “rationed” by third party payers as are breast MRI examinations.

I have been amazed that patients are still asking the question: When do I need to change my implants? Breast implants are mechanical devices and as such are prone to failure at some point in the future. The question is when. I remember several years ago removing a ruptured saline implant from a woman that was placed sometime in the mid-1970’s. I was amazed that this device, which looked like it was made out of a plastic baggie in comparison to today’s sturdily constructed implants (alright, a little bit of a gross exaggeration!), lasted twenty five years inside this woman’s body before it failed. The fact is, unless I can develop clairvoyant powers and predicts the future, I cannot answer this question. Let me explain. To put it very simply, and understand this is just my opinion, “if you are happy with your breasts then you do not need to change your implants unless you are having a problem.” The following is a list, not necessarily all-inclusive, but a list nonetheless of the reasons that I think a woman should consider revision breast implant surgery:

1. Deflation of a saline implant: If you have a saline implant, then any leak, whether in the silicone shell (the bag itself) or in the valve used to fill the implant, will result in a gradual deflation which will probably take about two days to occur. You will then notice a marked difference in the size of your breasts. No further diagnostic testing is required; you simply need to remove the implant. Your options are to replace it with a similar device, replace both implants with similar devices (if the implants have been in place for several years – this is arbitrary – maybe 8 – 10 years or so), replace the implants with saline implants of a different size if you are having issues with the size or replace both implants with silicone gel implants for a more natural feel to the breasts.
2. Rupture of a silicone gel implant: Rupture of a silicone gel implant is a bit harder to diagnose. With regard to the more recent implants, a small hole in the implant will most likely not leak any silicone gel due to the cohesive properties of today’s implants. If there is a tear in the implant shell, then the silicone will be contained by the natural scar tissue “capsule” that forms around all foreign bodies implanted inside us (a breast implant is a kind of foreign body). Silicone is biologically inert, which means that it won’t react with our bodies in an untoward and dangerous manner. Because the silicone is not absorbed by our bodies (nor does it travel elsewhere in our bodies), the breast will most likely look at feel the same even though the device is compromised. For this reason, the FDA recommends getting breast MRI’s at three years after surgery and every two years thereafter. Due to the infrequency of rupture, this may not be a very effective use of our health care budget and will be the subject of a future blog.
3. Capsule contracture: In this condition, the breast feels hard and may even be uncomfortable. The implant is not changing. Rather, the scar tissue envelope that forms around the implant thickens and contracts, causing the implant to feel firmer. Treatment involves re-exploring the breast, removing the scar tissue causing the problem and replacing with a fresh implant of the same type and size.
4. Asymmetry / breast deformity: If there is a shape issue of the breast that concerns you, and your surgeon believes that he/she can correct this surgically, then it may be reasonable to proceed. This can include issues relating to the first implant surgery such as improper pocket creation, improper implant selection, issues due to weight loss or pregnancy/lactation, malposition or displacement of the implant, palpability/rippling/wrinkling or visibility of the implant, ptosis (drooping) of the breast, lower (pole) breast over-stretching or changes in body habitus where your breasts now look too large or small for your frame.
5. Desire to change implant size: I am a firm believer that if you want to have the best breast (best looking, most natural in shape) for the longest period of time with the least probability of requiring a revision, then you need to subscribe to the belief that for every breast, there is a specific ideal implant volume that will result in a properly filled, natural appearing breast. If you have attained that now, but wish to go larger, then you are playing with fire. You will risk overstretching your breasts and creating a whole new set of problems, including the development of uncorrectable deformities. If you do not have the proper size implants for your breasts, then revision to a different size (larger or smaller) may be indicated. Your surgeon is best positioned to make that determination.

Capsule contracture and implant deflation/rupture are the most common reasons for implant revision surgery. Ptosis may require a mastopexy (breast lift) and palpability/rippling/wrinkling or visibility of the implant is usually best managed by replacement of the implants (if they are saline) with silicone implants.

Nationwide, the three year revision rate for breast augmentation surgery is about 25%. Who would want to undergo such surgery if there were 1 in 4 chances that you will need a second surgery to fix something in within the next three years? This is simply too high. In my practice, the revision rate is around 1 – 2%. Almost all of these cases are due to device deflation and capsule contracture.

Short of the above, if you are happy with the way your breasts look and feel, and are having no problems with them, then there is no reason to re-operate on them. I hope that this article helps to dispel some of the rumors that have circulated for years about breast augmentation surgery.

There are currently two systems available for computerized imaging and simulation of breast augmentation surgery. Portrait 3D manufactured by AxisThree, a company funded by Siemens and started in 2002. AxisThree claims to use technology developed by Siemens in the Portrait 3D product. Other than the Portrait 3D system, I am unaware of any other products that the company produces. The other system, Vectra 3D, is manufactured by Canfield Scientific, a company specializing in medical imaging with a long history of many successful products including imaging software, which has been in existence about twenty or so years. Canfield is known for its work in standardizing medical photography, so that images can be taken with consistent lighting, positioning and exposure parameters. Their systems are well known to the dermatology pharmaceutical industry, which contracts with them to produce imaging systems for various drug studies. Both systems were released very recently in the past year.

Let’s start with the physical capture device itself. They are pictured below:

(Photos of Vectra 3D on the right, Portrait 3D on the left)

The camera system of the Vectra 3D consists of six 12 megapixel cameras arranged into three pods. The pods use mirrors to permit the imaging of subjects from the side without having to have physical extensions to mount the cameras off to the side. The Portrait 3D system has three cameras of 3 megapixels each. The cameras are mounted on extensions out to the side.

The lighting system of the Vectra 3D consists of high powered flash. This permits imaging without the use of additional lighting. The very bright flash emits much more light than the ambient room light, therefore the room light will not affect the exposure and the room lights can be left on during the imaging process. The Portrait 3D uses LED (light emitting diode) technology. On the Portrait 3D, the LED lighting system requires the user to shut off the room lights to prevent interference of the exposure by the room light.

The software for both systems is sophisticated. Both systems are pre-programmed with various implant styles (saline and silicone) and the available sizes within a style of implant. However, neither system has the Allergan 468 style anatomic saline textured implant. The software takes the captured image and “inserts” an implant under it, then re-paints the breast tissue over the implant to show the final appearance of the implant. The systems use various algorithms to make these estimations of appearance, and the surgeon is able to manipulate the final result to what he believes the final surgical result might resemble. The Vectra 3D comes with two software packages in addition to the capture software and modeling software: an analysis program which is very powerful and great for research purposes. It also has the “sculptor” software, which is the application that performs the surgical simulation. There are great “bells and whistles” to both software systems, and I think that any surgeon could be happy with either. The Portrait system is perhaps a little easier to use at the outset, but with a little training and practice, the more robust Vectra software is also very easy to use. I think that both systems can do a great job of “simulation”.

I had the opportunity to try out the Vectra 3D system on several patients prior to purchase. I found the system easy to use, added no more than perhaps five or ten minutes to the consultation process and that this time was well spent. The patients really loved seeing their images appear on the system. For the Portrait 3D system, the company has an online demo which lasts about an hour, so I had a fairly good opportunity to see what it can do. The sales representative and the Vice President of Sales then came to my office for a second demo; I thought that they were going to bring the capture (camera) system, but they showed up with a laptop only. This demo gave me further opportunity to look at the software.

The sales experience was very different between the two companies. Canfield Scientific has a much laid back approach. Maybe a little too laid back. They are easy to contact, and respond in a timely and appropriate fashion to inquiries. They are unobtrusive, in other words, they do not email or call me frequently, and rather there approach is “we will provide you with whatever information you wish, demonstrate the product, and let us know when we can help you. AxisThree takes a different approach. While the sales force seems equally knowledgeable about their product as the competition, they are much more aggressive. The approach taken was to let me know that I could be the first with their system in this county, as I am sure they told other sales prospects. They told me that if I am left out, I may not stay competitive in obtaining surgical consults, which may or may not be the truth, but I perceived it a little bit of a scare tactic to put pressure on me. When in my office, the Vice President of Sales demonstrated the software and answered all my questions. He then said to me “so what s holding you up from purchasing the system”. Again, a little high pressure for my taste. I guess if the answer was “nothing is holding me up”, then I would have purchased the system.

So what was the factor in my decision as to which system to purchase? It comes down to a couple. First, the minor factors: Canfield has been in business a lot longer than AxisThree. (20 + vs. 7 years). Canfield has a known track record in medical imaging products and I know from personal experience with them, both with camera systems and software (I use Mirror software), they are reliable, give phenomenal technical support and stand behind their products. AxisThree is funded mainly by Siemens, and has no other products that I could find. Is this a venture capital project that might not be around in a few years? I do know. However, if I am going to invest $35,000 - $40,000 in an imaging system, I don’t want to find the company gone when I need support such as hardware maintenance and software upgrades.

Now for the main reason I chose the Vectra 3D over the Portrait 3D. I was first approached by AxisThree last fall. I looked at their web site and the quality of the images. Quite frankly, I just wasn’t that impressed with the image quality. The image manipulation was great, but the images I thought looked dark and with poor detail. The skin tones looked unnatural. At this point, I really did nothing further. I figured I would wait until I found a system I liked, as this was not on my “wish list” but rather I looked at it because I was solicited by email and it looked like an interesting piece of equipment. Quite by accident, I was at the American Academy of Dermatology meeting with my wife, who is a dermatologist. I struck up a conversation with Doug Canfield, the founder of Canfield Scientific. I asked him if he was familiar with the AxisThree Portrait 3D and did he have anything like it. With great surprise, he responded “yes, but I guess I ma not doing a great job of marketing it if you haven’t hear of it!” I then looked at the Vectra 3D at their booth and was intrigued by it. They imaged by face. The images were so life-like, so perfect. So much detail that it was like looking at yourself in a 3-D mirror, (if there was such a thing!). I then took a ride to Fairfield, NJ which was not far from my home, to look at the system further and get a better demonstration. I even was introduced to the developers. Being that I have a computer hardware as well as software background and currently develop software for my own use in my practice, I found this a unique opportunity to really “biopsy” the system.

If you compare the images produced by the two systems side by side, I think that you will agree that the Vectra system produces life-like images with excellent color and tone reproduction. Due to the high resolution cameras, the images are very sharp, even after software manipulation. The images produced by the Portrait 3D on the other hand, are dark, have poor skin tone color reproduction and are not nearly as sharp.

(Sample images shown here, Vectra on the left, Portrait 3D on the right – or maybe just a link to the Portrait 3D images on their web site)

In summary, I believe that there is a place for three dimensional imaging and surgical simulation in breast augmentation. I think that the user could obtain great use from either the Vectra 3D or the Portrait 3D system, but the Vectra system produces a far superior image quality.

Disclaimer: I purchased a Vectra 3D computerized imaging system. I do not have any financial interest in its success, or any financial interest in the manufacturer of this system, Canfield Scientific of Fairfield, NJ. I am a voluntary member of the advisory board at Canfield for this system, the purpose of which is to provide feedback and assist the manufacturer in the further development of this system.

When I see a patient in consultation for breast augmentation, I inquire as to what the patient is looking to achieve. I examine the patient and make recommendations as to what implant I think is best for them. The exact details of how I do this are beyond the scope of this blog, but suffice it to say, I determine what I think is the best implant to fit a particular patient’s tissues. I then have a discussion with the patient about what implant I recommend. The next question is invariably “what will I look like?” I told them that it is very hard for me to answer that question. Due to the nature that the implants conform to the body’s contours, you cannot put an implant in your bra, or a bag of water or rice. In my opinion there really is no way to see how you will look. Maybe you can get a very cursory idea of size, but I caution them that this, too, is highly inaccurate. So it comes down to a matter of trust. The patient just has to trust me that I will take into account the cup size she wishes to be, mindful of the fact that cup size is not a standard volume as “cc’s” are. You don’t buy a container of milk in A, B, C, D, or DD size. You buy a half pint (for your coffee), pint, quart, half gallon or gallon. These all have defined numbers of cc’s in them. For instance, a quart is 948 cc’s. Implants come in cc’s not cup sizes. The actual cup size is the sum total of how much tissue you start with and how many cc’s of implant you add later. The same implant can look very different in three different women.

I have had the opportunity to be the first in Suffolk County, NY to have a computer system capable of three dimensional imaging and surgical simulation. I have since taken the liberty of introducing the system to my breast augmentation patients who have had their surgery performed prior to my having such technology available. I have posed the following question to many of these patients: Prior to your undergoing breast augmentation surgery, did you have any visual image in your mind as to what your surgical result would look like. Having spent a fair amount of time with my patients in consultation prior to surgery, and that included either reviewing photos of similar patients who underwent breast augmentation or having the patients view such patients on my web site, I was very surprised with what they all (and I mean ALL) told me: all of the two dozen or so patients I queried told me that they had absolutely no idea what they were going to look like after surgery. They told me that they just “trusted me”!

I have now been questioning my breast augmentation patients after surgery regarding their feelings about the usefulness of three dimensional computer imaging and simulation. All of my patients have given me very positive comments, and furthermore, believe that the system has been very helpful in allowing them to have some understanding before surgery as to how their post operative surgical results will appear. Some have even told me that although they really liked the results portrayed on the computer, they feel that their actual results are even better! None of my patients indicated that the system offered no benefit to them during the consultation and preoperative process.

I do wish to take this opportunity to clarify one philosophical aspect of my approach to breast augmentation. As breast tissues do not possess the infinite ability to stretch to any size without consequence to the breast tissues themselves, I believe that there is a very narrow range of breast implant sizes (one ideal size and sometimes up or down one size) that is ideal for any given woman’s breasts. This is based upon an assessment of the physical dimensions of the breast and the dynamics (stretchability or tightness) of the breast tissues themselves. (Again, an entire discussion of this is beyond the scope of this blog, so I encourage the reader to visit my web site www.epsteinplasticsurgery.com for a more comprehensive discussion of how I size a breast implant). In view of this philosophy, I do not use the computer simulation to select a particular size implant, but I do find that it is useful provide a woman with understanding as to how I believe they would look (approximately) after placement of what I consider the ideal size implant for their breasts. I then might hone the decision down to the specific implant if the woman wants to be a little fuller or less full by going up or down one size if necessary, based on that woman’s preferences. I preface this by saying that not all women have the latitude to do this based upon their tissues and I caution them if this is the case.

In summary, I believe that all my breast augmentation patients have found preoperative computerized imaging and surgical simulation of their breast augmentation to be an extremely valuable tool in the consultation process.

Disclaimer: I purchased a Vectra 3D computerized imaging system. I do not have any financial interest in its success, or any financial interest in the manufacturer of this system, Canfield Scientific of Fairfield, NJ. I am a voluntary member of the advisory board at Canfield for this system, the purpose of which is to provide feedback and assist the manufacturer in the further development of this system.

I have always enjoyed technology. Since I was a teenager in the early 1970’s, I loved electronics (computing wasn’t even a hobby back then). For my pre-med major in college, I studied Biomedical and Electrical Engineering at Northwestern. It was there that I obtained a strong background in computers and emerging biomedical technologies. During the latter part of my plastic surgical fellowship training, I saw the advantage to know not only how to operate computers and run software programs, but to learn how to develop tem as well. Several of the software applications I developed over ten years ago, are still in use in my practice today.

When I was a surgical resident, I remember visiting a young plastic surgeon that had a computerized imaging system. It consisted of an inexpensive, low resolution video camera, a computer (one of those early PC’s) and a monitor. He took a photo of my face and showed me how the software could change the image. He deftly demonstrated how he could take my nose, remove it from my face and replace it back, this time upside down. Kind of a cool curiosity, but is it worth it? That was about twenty five years ago. Over the years, I have seen a couple of such imaging systems that could take a two dimensional image (two dimensional means a flat image with height and width, but no depth) and manipulate it somewhat. I was pretty unimpressed by what I saw, until recently.

I practice plastic surgery in the same office as dermatologist Dr. Elyse Rafal, who also is my spouse. Dr. Rafal has always been involved in clinical drug trials with various pharmaceutical companies. These studies rely on high quality, consistent, reproducible photographic imaging. Over the thirteen years I know my wife, I cannot remember a single drug study that required imaging that did not have customized photographic equipment developed by Canfield Scientific, in Fairfield, NJ.

Last year, Canfield released the Vectra 3D Face and Body Imaging system. This consists of a group of six 12 megapixel cameras mounted on a movable frame. It is connected to a powerful computer with a monitor. Similar to what I saw in the past, definitely not!

The subject stands in front of the camera system and a powerful flash illuminates the body. The image can be of the face or torso, there is specialized software for both. The cameras capture six photos and the software combines them to match the three dimensional topography of your body. Next, a three dimensional image appears on the computer monitor. Because of the high resolution of the cameras, the image is also high resolution. My 12 megapixel Nikon camera makes two dimensional jpg photographic files that are about 2 megabytes in size. This three dimensional system (I’ll call it the Vectra from here on out) makes three dimensional images that are about 50 megabytes in size!

When you look at the image, it is so real and lifelike, that it is almost like the person is standing inside the monitor! The flesh tones are natural, every little detail of the skin displayed perfectly.

The simulation software allows the user to take the original three dimensional images and manipulate it. For the purpose of simplicity, I will restrict further discussion only to breast augmentation, although the system works well on the face as well and can do a great job simulating rhinoplasty.

Several popular saline as well as silicone gel breast implant styles with the dimensions of all the existing implant sizes available for that particular style of implant are pre-programmed into the software. The surgeon can now take an image of the breast, and “dial in” different implant styles and sizes. The software then does an amazingly well job of “simulating” what the augmented breast will look like after surgery. Is it exact, no. However, it is fairly close and gives the patient a reasonably good idea of what they might look like with surgery. I say might, because depending on the patient, the accuracy can vary, however, overall I believe that there is no other method that I know of that even comes remotely close to this.

Once you have the before and after images, you can put them side by side, or you can overlap them, one on top of another so as to show the change in the contours after the surgery. And here is the really cool part: you can take the images and rotate them in any direction, almost as if you are holding a three dimensional model of your torso in your hand and looking it over from the side, the front, the top, bottom or whatever view strikes your fancy!

A three dimensional computerized imaging system is a very useful way to capture an image in three dimensions, and then alter the image to simulate surgical results to demonstrate how someone might look after cosmetic surgery. This is very new and promising technology and I anticipate this to one day play an integral part in the consultation process and planning for all breast augmentation procedures.

Disclaimer: I purchased a Vectra 3D computerized imaging system. I do not have any financial interest in its success, or any financial interest in the manufacturer of this system, Canfield Scientific of Fairfield, NJ. I am a voluntary member of the advisory board at Canfield for this system, the purpose of which is to provide feedback and assist the manufacturer in the further development of this system.

Cosmetic surgical procedures such as breast implants, breast lifts, tummy tucks, facelifts, rhinoplasty and liposuction are often seen as a luxury, maybe even frivolous. But when you think of it, it really isn’t. It may help you feel more secure and confident about yourself; more comfortable within your own skin, so to say. And unlike a vacation, a car, a boat, a new entertainment system, the results obtained with cosmetic surgery are longer lasting and appreciate with time. How do you place a value on feeling good about yourself, being more self-confident?

Let’s talk about Botox. An average treatment may run $600 for about 40 – 50 units of Botox. If the Botox treatment lasts, conservatively speaking 90 days (sometimes up to 120 days), the cost per day is about six dollars per day to look younger and more refreshed.

Cosmetic surgery is even more of a value. The most common cosmetic surgical procedure is breast augmentation. The approximate cost of breast implant surgery on Long Island is around $7300.00. Although you never need to change a perfectly good breast implant, device failure is about one percent per year. So at twenty years there is a twenty percent chance of needing to replace a breast implant. So let’s say the duration of the breast implant surgery procedure is twenty years. Twenty years is 7300 days. So for just one dollar per day, you can feel better about yourself. Isn’t that worth it?

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), 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 should it be performed at the time of surgery or later.

Most women who desire breast augmentation are good candidates for it. There are some limitations; the surgeon can only work with the tissues he is 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) 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 those expectations. Because the patient has been properly educated as to what is a likely outcome, and that outcome is met, then the patient (and the surgeon!) will be satisfied with the outcome.

The key to success is education and proper decision making. Proper decision making in plastic surgery is a joint effort between the surgeon and the patient. The patient is presented with many options and decisions to make. If the patient is not properly educated as to how to consider and 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 patients appetite” for breast augmentation, rather, 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. All though 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, and correcting 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 2008, 355,371 breast augmentation procedures were performed. Under Dr. Epstein’s expert care, patients 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, Dr. Epstein takes the time during the pre-operative consultations to learn what each patient hopes to gain from breast augmentation surgery and to decide which implant type, size and placement is best. In this way, each patient enjoys completely customized treatment designed with her specific goals in mind.

During your consultation with Dr. Epstein, you 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. Dr. Epstein will discuss with you the options available to you 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 silicone gel. Saline implants are firmer than silicone gel implants. Silicone gel implants better resemble the texture and feel of natural breast tissue. Both implant types are very safe, and each offers its own specific advantages. Dr. Epstein will help you decide which kind is right for you. For additional information on silicone breast implants, please see Silicone Breast Implants: What You Need to Know. (Attach link)

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 fourteen times the amount of rippling and wrinkling as 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 is the implant choice of most of Dr. Epstein’s patients. In November, 2006 after fifteen years, the U.S. Food and Drug Administration (FDA) have approved silicone breast implants for breast augmentation surgery. Dr. Epstein is 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).

A round breast implant can have a smooth or textured surface. Due to a round implant’s symmetrical shape, it does not pose the risk of implant rotation. If the implant should rotate, the shape is still exactly the same, round.

Round implants come in three different variations of shape: low, medium, and high profile. A higher profile can enhance the forward projection of the breasts, which would otherwise require larger breast implants with wider bases. Dr. Epstein finds 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 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. 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 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 Dr. Epstein’s opinion, based upon critical review of his own cases,  that in the case of SALINE implants (silicone are another story) that teardrop shaped implants give a more natural shape than round implants in the vast majority of cases. It is of 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. Dr. Epstein does utilize use both types of saline implants in his practice.

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; textured implants attach to the surrounding tissue. The two different surfaces give the surgeon some additional choices in optimizing the breast augmentation result. 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.

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” and “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 “Rapid Recovery Method” (editor – add link) 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, or sagging means drooping of the breast. There are two types of ptosis, and they can co-exist in the same breast. The treatment for each type, however, are 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 breast fed 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 patient 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 six years. How is this possible? The technique of dual-plane augmentation, originally was 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 an additional ten minutes to the procedure, but can make all the difference in obtaining a beautiful, natural augmentation as opposed to a poor, unnatural look. The dual plane procedure does not eliminate the need of 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.

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.

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, initially that bag will look under-filled, then properly filled with a nice shape, and then 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 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 at 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.

Dr. Epstein is proud to introduce the Canfield Vectra 3-D system. 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 the post-surgical result that we know of. Dr. Epstein is one of the first surgeons in the nation to use the VECTRA 3D system for breast augmentation simulations.

Breast Augmentation Surgery - Incision Techniques

The breast augmentation procedure lasts less than one hour and is typically performed with general anesthesia. Incisions are made in inconspicuous places on the breast to minimize scar visibility. These incisions may be located:

 · In the 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, Dr. Epstein prefers using 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 Dr. Epstein prefers to use only saline implants when using this surgical approach. This technique is limited to those patients who have little or not pseudoptosis.

 · In the crease on the underside of the breast (inframammary). An inframammary breast crease incision is the most common incision used and 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.

 ·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 minimally invasive breast enhancement technique is known as a transumbilical breast augmentation or TUBA approach. Dr. Epstein does not utilize this approach because the pocket is made by blunt dissection rather than by direct visualization, which is fraught with more problems with pain, bleeding and lack of precision. Also, the implant is usually placed above the muscle, which is not Dr. Epstein’s preference.

How long does the surgery take?

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.

How are the wounds dressed?

After the implants have been inserted and positioned, the incisions are closed. Steri-Strips are applied to the wounds. 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 “Rapid Recovery Technique”?

 Dr. Epstein performs all of his operations with great care and precision, ensuring that his patients can enjoy a quick and healthy recovery.

Most commonly, women following breast augmentations surgery complain of a considerable amount of pain, swelling, and bruising. Dr. Epstein employs a “Rapid Recovery Technique” (add link to Breast Augmentation - Achieving Better Results with less Discomfort and Downtime) in which the amount of swelling is minimal, bruising rarely occurs and post operative discomfort is dramatically less. With the rapid recovery techniques employed in our office, our patients can raise their arms up high over their heads before leaving our 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. We will give you a detailed set of postoperative instructions which is called “Recipe for Recovery”. When these instructions are followed, a 24 to 48 hour return to most activities of daily living (with the exception of heavy strenuous exercise) including driving and return to work is anticipated.

Dr. Epstein surveys his patients following breast augmentation surgery. His 2007 survey revealed that 92% of his patients required nothing stronger than ibuprofen (Advil) after surgery and 86% of his patients returned to normal activities the following day (except strenuous exercise) including driving in most cases.

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. There are one or two stitches which are removed 14 days after breast augmentation. Any post-operative pain, swelling, and sensitivity will diminish over the first few weeks. Sensation in your nipples may be altered temporarily, but should 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. Dr. Epstein’s goal will be to make them as unnoticeable as possible.

How will I feel immediately after breast augmentation? 

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 Dr. Epstein’s experience using the “Rapid Recovery” breast augmentation technique, there is no increase in discomfort with placement of the implant below the muscle. In fact, Dr. Epstein places all his implants below the muscle. Using the Rapid Recovery technique, 92% of his patients require nothing stronger than Ibuprofen (Advil) after surgery. 86% 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 week, 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, some breast tissue is removed, the breast skin is tightened and lifted, and an implant is inserted. Note that most women, even those with some sagging after pregnancy, do not require a breast lift concurrent with breast augmentation. Dr. Epstein 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..

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

It will take several days to return to normal activities after your breast augmentation and mastopexy procedure. However, it is important to your recovery that you ambulate around during that time. Dr. Epstein uses a specialized “Recipe for Recovery” to hasten your recovery. After the procedure, it is often possible to return to work within a week.

Atrenusous 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 Dr. Epstein.

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, 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. Dr. Epstein performs all of his operations with the goal of minimizing all possible complications and ensuring his patients’ satisfaction.

Will there be scarring?

Scars are a part of the breast augmentation and mastopexy process. Fortunately, breast augmentation and mastopexy scars, regardless of where they are located, tend to heal extremely well. Scars following breast augmentation are usually small and inconspicuous, and Dr. Epstein will make sure the scar is as unnoticeable as possible. A mastopexy does add additional scars such as around the areola, and occasionally 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.

 Does breast surgery cause scarring?

Yes, although scars can be hidden with 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). Scars do fade with time. The ultimate result is a combination of the plastic surgical techniques that Dr. Epstein uses to close the wound and your natural biology of wound healing, a factor that neither Dr. Epstein, nor you can control.

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 will 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.

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 implant surgery 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 the downtime is no more 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?

Women planning to have children do not need to postpone surgery, since breast implants should not affect your ability to breast-feed.

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 the way the surgeon closes the wound AND the patients 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 rare. Treatment for such scars include intralesional injections of steroid preparations, scar massage and avoidance of sun exposure.

Any time a foreign material is implanted into the body, 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 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, and I have not had this happen in my practice to date, if a woman has this problem happen twice to the same breast, I would recommend removal of the breast implants and not replacing them.

Whenever a breast is augmented with an implant, it stretches. The degree of stretch is usually appropriate and appropriate for the size and shape of the implant. Occasionally, the lower pole of the breast may stretch more than is desired. This makes the implant look like it has been placed too low. In my experience, 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. I have seen it happen with good quality tissue and not happen with poor quality tissue. I have seen it happen 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 may 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 the shell cracks then saline or 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 subsequently 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 heightened sensitivity, which resolves shortly. In more rare cases, nipple sensation may be diminished which is usually temporary, but can be permanent.

Infection

Infections after breast augmentation surgery are very rare. Mnay can be treated with oral antibiotics alone. 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, 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. Dr. Epstein uses a near bloodless technique when performing the surgery, this helps to minimize the risk of this problem, 2) low grade infection around the implant. Again, Dr. Epstein pays 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.

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 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. 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.

Traditionally, breast augmentation is associated with a considerable amount of pain and down time, but this no longer needs to be the case.
Breast implants may be placed either below or above the pectoralis major muscle (a muscle located just beneath the breast). The advantage to placing the implant below the muscle is that there is much less interference with mammography, as well as more soft tissue to cover the implant, making it less palpable and visible.

Pregnancy/lactation causes stretching of the breast tissue with loss of fullness and bottoming-out of the breast. Often, a decision is made to place the implant above the muscle to better fill out the breast-skin envelope; however, in these cases there is less soft tissue coverage of the implant and less support for it. Using a specially created technique called dual-plane augmentation, women with such breasts can enjoy the benefits of a breast augmentation with implant placement below the muscle.

A breast implant consists of a silicone shell (bag) filled with either saline (salt water) or silicone gel. Silicone gel filled implants were re-released by the FDA in November 2006 after extensive study. They have become increasingly popular. Saline implants are available in either a round or teardrop shape. The advantage of a saline teardrop implant over a round saline implant is that the overall breast shape will be more natural in most cases. Use of saline teardrop implants requires greater attention to detail in placement than a saline round implant. The advantage of saline round implants are that they are easier to use and less expensive. Silicone gel implants are available in a round shape only. As silicone gel round implants are more flexible in shape than a saline round implant, in my experience, I believe that the overall shape of a breast augmented with a silicone gel round implant is more natural than that obtained with a saline round implant.

Breast implants may be placed through incisions in the armpit, around the nipple or under the breast. The advantage to an armpit incision is that the scar is well hidden and there is no scar on the breast itself. Although most surgeons perform this procedure blindly, minimally invasive endoscopic breast augmentation (similar to laparoscopic surgery) provides enhanced visualization of the surgical pocket on a large television monitor, affording greater precision during the surgery.
A periareolar scar (around the nipple) is usually inconspicuous. The disadvantage to the technique is that wound healing varies greatly according to the biology of the individual and thus some women have a more noticeable scar, which would now appear on the most conspicuous part of the breast.

The most common surgical approach to breast augmentation is an inframammary (breast crease) incision. This scar is barely noticeable as the lower portion of the breasts often covers the crease and scar. This surgical approach provides the surgeon with the greatest visualization of the surgical pocket, and the ability to make internal modifications as necessary in a breast that has drooped secondary to pregnancy/lactation. The techniques best suited for you will be discussed at your consultation.

Using techniques specifically designed to reduce post-operative discomfort, the post-operative experience has been dramatically improved. Many patients return to normal activities of living within 24 hours. During the past 3 1/2 years, nearly all our patients have been able to raise their arms up high over their head before they left the recovery room. Some patients have even put on makeup and brushed their own hair before going home. Occasionally, patients have felt good enough after surgery to go out shopping or to dinner later the same day! Rapid recovery after breast augmentation surgery is the culmination of proper preoperative planning, delicate and precise surgical technique, refinements in anesthetic management, and postoperative care designed to promote a quick recovery with minimal discomfort. Average return to work is about five days, and often less. Most patients experience some mild discomfort after surgery, but overall, the average amount of discomfort and downtime after surgery have been significantly reduced while the quality and consistency of the aesthetic results have been greatly improved.

Dr. Mark Epstein is a dual board certified plastic surgeon specializing in breast augmentation, with a special focus on improving the patient experience before and after surgery.

Download PDF Version