FAQ's – Breast Augmentation

What is the difference between smooth and textured implant surfaces?

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

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

In the case of teardrop implants, there really is no choice. One needs attachment to the surrounding tissues, or else the implant will rotate within the pocket and the breast shape will constantly change as the implant rotates. This is not an issue with round implants because if they rotate, the shape remains the same.

What is the difference between "above the muscle" and "below the muscle"?

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

Which is better: "above the muscle" or "below the muscle"?

Breast Implants | Long Island | Suffolk County 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" (www.steristrips.com) below for more on this.

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

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

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

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

What is the Dual-Plane technique?

In my practice, many of my patients fall into the category of 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 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 for a mastopexy (breast lift) in those that need it. In my opinion, with the advent of the dual plane technique, there is no remaining reason to choose placement of a breast implant above the muscle over placement below the muscle. Some of the most natural looking results that I have attained were in women who presented with somewhat stretched breasts secondary to pregnancy with pseudoptosis. I have found that teardrop saline as well as round silicone gel implants yield wonderful results in these patients.

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

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

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

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

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

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 no pseudoptosis.
In the crease on the underside of the breast (inframammary) - An inframammary breast crease incision is the most common incision used as well as the most versatile. Breast augmentation with an inframammary incision is performed with an incision made under the breast in the inframammary fold. The incision is made here to secure proper placement of the implant, but also to reduce scar visibility. When it is placed within the breast crease, or slightly above, it is barely noticeable, as the breast lies on top of the incision in most cases. An advantage of breast augmentation with an inframammary incision is that the surgeon works close to the breast, allowing for optimal visibility while working, as well as having the greatest degree of precision in pocket dissection and implant placement and alignment. This is also the approach of choice for women who have bottoming out of their breasts after pregnancy and lactation. This is critical in ensuring that the breast mounds are at equal height. Also, if affords the greatest accuracy in placement of teardrop implants, ensuring that the degree of implant tilt is symmetrical. This approach can also be performed with the least amount of postoperative discomfort.
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 the 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.

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