Breast Enhancement
Information by Dr. Epstein in Long Island
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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. 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. The procedure may be combined with others such as a breast lift to correct drooping (ptosis). According to the American Society of Plastic Surgeons, Breast Augmentation surgery is the third most commonly performed cosmetic surgical procedure in the United States. In 2005, 291,000 breast augmentation procedures were performed.
What types of Breast Implants are used?
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.
Breast implants are produced in two shapes: round and teardrop (also known as “shaped” or “anatomic”. Round implants are easier for the surgeon to work with. If a round implant is turned, it is still round. 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.
Breast implants also are available in two surface types: smooth and textured. 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.
Textured implants were originally developed to reduce the chance of capsule contracture (see below).
Which is a better choice of shape?
That depends on the patient’s individual anatomy. Many patients specifically request round implants because they would like to have a fuller look, especially at the superior pole (upper portion) of the breast. If round and teardrop implants are filled to manufacturer’s specification with saline, and then placed on their side to simulate their position in the body when the chest is upright, the teardrop implant will exhibit less loss of superior pole fullness and collapse than the round implant. Why then do some round implants give such fullness in the superior pole of the breast? In these cases, the round implant is often overfilled above manufacturer’s specification. 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 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.
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.
Where is the implant placed?
Breast implants may be placed either below the pectoralis major muscle or above it. 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).
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 (see below).
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.
Women with no 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. 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.
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 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 implants yield wonderful results in these patients.
More Breast Augmentation photos »
Read More about Breast Augmentation »
Contact us for more infromation on Breast Augmentation »
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