Breast Enhancement
Information by Dr. Epstein in Long Island
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What types of incisions are used?
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). The breast is then elevated, creating a pocket into which the implant is inserted.
There are advantages and disadvantages to each surgical approach. A transaxillary (armpit) incision is well hidden; however, this approach does not permit one to perform a dual-plane procedure. Furthermore, the dissection is completely blind and performed bluntly unless endoscopic technique is employed. In this case, a long, thin scope is introduced (like laparoscopic surgery) and the surgical dissection is performed through a small incision with direct visualization. Endoscopic technique is my preferred method when performing this type of surgical approach. I limit this technique to patients with minimal pseudoptosis.
A periareolar incision is made around the lower portion of the areola. A dual plane technique can be performed via this approach, although it is not as easy as when making an inframammary incision. The main advantage of the technique is that the resulting scar is usually thin and not easily visible. The main disadvantage is that as wound healing is somewhat unpredictable, if the scar is not ideal, it will lie on the most conspicuous part of the breast.
An inframammary breast crease incision is the most common incision used and the most versatile. 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. This incision allows for the greatest precision in aligning the bottom of the breast implants. 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.
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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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How are the wounds dressed?
The wounds are sutured and dressed with a paper Steri-strip. 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.
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What will my recovery be like?
Traditionally, breast augmentation surgery is considered my many to be a very painful experience. 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.
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Will I be able to breast-feed after breast enlargement surgery?
Yes. Breast Augmentation will not affect your ability to nurse.
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Do the implants have to be changed after several years?
As long as there are no problems with the implants, they never need to be changed.
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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 includes 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.
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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
Today's saline implants are more durable than ever. Although risk of rupture is extremely small, if this should happen, the implant deflates as your body absorbs the saline. There is absolutely no health hazard should this happen. The implant can be easily replaced with minimal discomfort. Under certain circumstances the manufacturer of the implant will pay for new implants and contribute towards the cost of replacement.
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. Many 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 (reoperations) over the course of their lives. Reasons for a breast augmentation reoperation may include the following: capsular contracture, wrinkling, asymmetry, rupture/deflation, and excessive tissue stretching as described above.
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.
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