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Breast Enlargement



Overview

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Before & After

Breast augmentation is one of the most common procedures performed for good reason. When performed by a competent plastic surgeon the results are dramatic with little scarring, and little down time. Many women want their breasts enlarged because they know it would make them feel more self-confident, more attractive, and fit into clothes better. Often, they have thought about it for a long time. Others seek augmentation because their breasts have begun to sag, either due to age or childbirth. These women wish to regain that youthful perkiness and cleavage they once had. Some wish to return back to the shape they were in their early twenties. Others, when given the option, want a more dramatic enhancement. The effect of augmentation in the saggy breast is impressive as it raises the nipple, fills out the sagginess, creates significant breast projection, as well as cleavage.

For those who are interested, here is a little history on breast augmentation. In 1895, Czerny transplanted a benign fat tumor from a woman's back to fill a breast defect created by removal of a breast cyst. Other accounts of fat transplantation for breast augmentation have been documented. All these early attempts led to disappointing results.

In the 1950s, many materials were injected into the breasts for augmentation purposes. This uniformly caused severe local reactions that left the breasts hard, painful, and distorted.

The modern age of breast augmentation began in 1962 when plastic surgeons for the first time started placing silicone gel implants under the breast tissue. This was a significant advance but it still caused an unacceptably high incidence of breast hardening, otherwise known as capsular contraction.

In the 1980s, it was found that by placing the implant under the pectoralis major muscle, capsular contraction could be greatly reduced. Today, this is where the great majority of breast implants are placed.

In 1992, the FDA banned the use of silicone gel implants. This left saline implants (a.k.a. salt water implants) as the only option for implant material. What we have found is that saline implants, when placed under the muscle, have even a lower rate of hardening than silicone implants. Silicone implants, however, have a more realistic feel. Since the ban, several major studies have shown rather conclusively that silicone implants are safe and soon will return as an option for breast augmentation. It should be pointed out that the shells of the current implants are still silicone. Silicone implants currently are available to certain patients. These patients include those who dislike their saline implants and those undergoing concurrent breast lift.

Plastic SurgeryIncision for Breast Augmentation

There are three incisions that most plastic surgeons use for breast augmentation. Typically, the decision of incision placement is made during the consultation. Important considerations are the patient's lifestyle, typical clothing and general preference.

    The three incisions are:

    1. Within the crease at the bottom of the breast.

    2. Exactly at the margin of the areola where the lighter skin meets the darker skin.

    3. Within the axilla (armpit).

All 3 incisions can provide excellent results. It really is up to you during your consultation to decide what is best for you. The incision along the margin of the areola typically leaves the most imperceptible scar and is usually the best choice. The incision within the fold at the bottom of the breast is the best choice when future breast feeding is absolutely necessary or when a secondary surgery is expected. The axillary is best when the patient absolutely does not want an incision on the breast. The tradeoff is a scar within the axilla.

A 4th option for the incision is through the naval. Some plastic surgeons use this incision but the results, when compared to the standard incisions, are not as predictable. This is because it is impossible to visualize the pocket where the implant will be placed. This is not to say that this incision cannot produce good results. If you elect to have your breast augmented via this approach, make sure your plastic surgeon routinely does it this way.

Breast AugmentationBreast Enlargement and Mammogram

Breast implants make mammograms slightly more difficult to obtain. With today's advances in mammogram technique, however, they can still be done effectively. This is especially true when the implant is placed below the muscle. Notice in the pictures below the differences between implant placement above and below the muscle. When placed below the muscle, there is a separation between the implant and the breast tissue. This separation makes it easier for doctors to get a good look at the breast tissue during mammography.

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Implant above muscle

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Implant below muscle

Breast implants require more X-rays during mammography in order to see around the implant. If you have a strong family history of breast cancer and/or significant fibrocystic disease you should be sure to discuss this during your consultation. It should be pointed out that breast augmentation does not increase the likelihood for breast cancer; also breast feeding is possible after augmentation. Be sure to discuss this during your consultation if you plan to breast feed as it may affect where the incision is made. The safest incision to ensure breast feeding is within the breast fold.

Plastic SurgeryBenefits

There are many benefits to breast enlargement. These range from the way clothes fit you to how you feel about yourself. In general, there are two categories of women who benefit most from breast augmentation. The first is naturally small and has always wanted to have larger breasts. Typically, she is very secure with herself. She just knows she would feel more self confident with larger breasts.

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Example of a woman with naturally small breast. She wanted to be more proportionate with the rest of her body. Also notice correction of wide gap between breasts.

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Same woman from the side.

The second type is the woman who has developed saggy breasts. Often, this occurs because of child birth, aging, or weight loss. She wants her breasts to be perky like they used to be. She may even choose to be a little bigger than she used to be. The choice is up the patient. Both of these patients are dramatically helped by breast augmentation.

Breast Doctor

Example of a mother of two who has lost a significant amount of breast tissue resulting in sagginess. See text below for details.

Breast Surgeon

Profile of same mother of two. Notice breast sag and loss of upper breast fullness in the before, and its correction in the after.

The above example shows a common problem after childbirth; saggy breasts with loss of upper breast fullness and loss of cleavage. This is caused by several factors including skin stretching and breast tissue descent. A third significant cause is loss of breast tissue known as breast tissue atrophy.

Breast augmentation can correct only minor amounts of breast sag. However, if there is too much sag then a breast lift is required. This can be done with or without an implant. This depends on how much breast tissue is left and what the patient wants. If the sag is minimal then a breast augmentation alone can provide the necessary breast lift. By increasing the breast volume with an implant the nipple/areola complex will elevate slightly. This is demonstrated very well in the profile Before and After above.

Breast AugmentationWhen Is a Breast Lift Necessary?

This is one of the most commonly asked questions. The answer is not simple. There are many variables but we will try to make it as clear as possible.

In general, if the nipple is above the Infra-Mammary Fold (the fold below the breast tissue) then a breast lift is not usually necessary. If the nipple is more than 2 centimeters (about one inch) below the Infra-Mammory Fold (IMF) then a breast lift is most likely required.

What about the nipple that is less than one inch below the IMF? With this situation, the need for a breast lift depends on two things:

  • How big will the implant be. It stands to reason that a bigger implant will create more of a lift.
  • What bothers you more; low nipples or scars around the areola. The scars are not very noticeable but they are still scars.

Remember, if you elect not to have a breast lift, you can always have it done later on.

There are many more reasons for breast augmentation. Here is a summary of just a few:

  • If you are self-conscious about your small breasts size.
  • If you feel that larger breasts would make you feel more attractive and improve your self-confidence.
  • If you have a hard time finding clothes that fit because of discrepancy between your breasts and your buttocks.
  • If you have saggy breasts due to age or childbirth.
  • If you desire more cleavage.
  • If you recently lost weight leaving you with smaller, sagging breasts.
  • If there is a significant difference between one breast and the other.
  • If you feel unable to wear sexy clothes because of your small breast size.
  • If you feel disproportionate because your hips are much larger than your breasts.

Plastic SurgeryAre you a good candidate?

To determine whether or not you are a good candidate just look above and see if any of the scenarios apply to you. Most women who consult for breast augmentation have known for quite a while that they want their breasts enhanced. Often, they know of friends or family that have had it done. The most important consideration is to do it for the right reasons! Do it for yourself! Don't do it for a boyfriend or a husband or anyone else. Do it because you feel that you would be more self-confident, your body would be more proportional, and you would just feel better about yourself.

Breast AugmentationPossible complications

The most common complications of breast augmentation are:

  • Wrong choice of implant size. Sometimes it is too big but more commonly too small. This can be markedly reduced by a proper preoperative evaluation as well as experience. This is always discussed with the plastic surgeon during preoperative evaluation.

  • Asymmetry and/or implant malposition.

  • Capsular contracture. This is where thick scar tissue forms over the implant making the breast feel hard.

  • Nipple sensory changes. This is common right after surgery but usually goes away. Often, the nipple is hypersensitive for the first 6 weeks after the procedure and may be quite erect. This will go away with time.

  • Infection. Because an implant is a foreign body, infection is always a consideration. To avoid this, plastic surgeons use antibiotics during and after the operation as well as meticulously sterile technique. If it does occur it is possible that the implant may need to be removed.

  • Implant rupture. If this happens the saline leaks harmlessly into the body tissues. The implant company, will pay for a new implant.

  • Implant rippling. This is markedly reduced when the implant is placed under the muscle.

Plastic SurgeryDo's and Don'ts prior to surgery

  • Medications. Certain medications thin blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should be discontinued 3 weeks before surgery.

  • Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your plastic surgeon for something to help you sleep.

  • Smoking. You must not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood of infection, wound healing problems, and scar formation. It also affects your airway, which makes anesthesia much more difficult.

  • Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your plastic surgeon and anesthesiologist.

  • Arrival. It is important to arrive on time so everything goes as planned. By law, you must have someone else drive you home.

  • State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned. If you think it is necessary, ask your plastic surgeon to prescribe something to calm you down the night before and the morning of surgery.

Breast Augmentation Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you. He/she will take into consideration your medical history, the procedure, and your personal wishes.

Normally, breast augmentations is done under general anesthesia.

Plastic SurgeryAfter the procedure

The procedure itself will take 1 to 2 hours. Of particular note is that for the first month or two you may feel that your implants are too big and are not naturally appearing. This is normal. As the swelling goes down and your skin accommodates your new breasts they will develop their desired shape and volume.

  • Immediately. You will immediately notice a big difference in breast size. Right after the operation you will be nursed for 1 to 2 hours and encouraged to walk around. You most likely will have a surgical bra on.

  • That evening. It is recommended that you take it easy. You can walk around, eat, but not much more. It is very important to avoid movements of your arms so that the implants are not displaced. Aggressive arm movements should not be done within the first 6 weeks after the procedure. You should take as much pain medication as necessary and try to go to sleep early. Be sure to take your antibiotics. Do not take aspirin or aspirin containing products and do not smoke for the first 2 weeks. It is best if you sleep with your head and chest slightly elevated to promote proper lymphatic drainage.

  • First Week. During your first postoperative visit you will be instructed on how to perform breast massage. Massaging is necessary because the implants will want to move upward. Massaging allows the skin to accommodate the implant quicker so that the implants stay exactly where they are supposed to. The bruising and swelling will go away in about 2 weeks.

  • Beyond. Swelling will not completely resolve for about 6 months but the majority of it will be gone by 3 weeks. You can start moving your arms aggressively at 6 weeks, at which time you can start doing gentle upper body workouts. Lower body workouts and brisk walks (no running) can be done as early as 1 to 2 weeks. A good rule to go by is if it hurts-don't do it. The scar will look its worst at 6 to 8 weeks after surgery but it will fade over time and usually becomes very difficult to see by 6 months.

Breast AugmentationRecovery time

Some people with sedentary jobs go back to work as early as 3 or 4 days. If your job, however, requires aggressive arm movements it may take as long as 4 weeks to return to work. You should discuss this with your doctor. Most people return to work after 1 week.

Plastic SurgeryConsultation

We have outlined below what you can expect from your breast augmentation consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to a plastic surgeon what it is you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used, but also applies to local anesthesia. Breast augmentations are usually done under general anesthesia. Rarely, if the implant is placed above the muscle, local anesthesia can be utilized. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are five areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

  • General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will the plastic surgeon do if I have medical problems?

In short, he/she will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating that you are able to tolerate surgery.

Be sure to let your plastic surgeon know if you have ever had a blood clot.

  • Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With breast augmentation it is especially important to mention all breast surgeries including breast biopsies.

  • Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 10 days before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

  • Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

  • Smoking, Drinking and Drug Use

These three will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

Breast AugmentationSpecific Breast Issues

During your consultation you must be very accurate with breast problems. Of particular concern is a history of breast masses and/or breast cancer. If you are over the age of 40, your plastic surgeon will require that you have a mammogram. Bring the results with you to your consultation so it can be documented. If you or a family member have a history of breast cancer then this age may be moved up to 35 or even 30. Breast augmentation has no effect on breast cancer. The only potential problem is mammogram screening. Mammograms are harder to read when there is an implant. This problem is minimized by taking special mammogram views called Eckland views. Eckland views show the breast tissue in multiple planes to see around the implant. It works very well but there still is a small (less than 10 per cent) amount of breast tissue that remains unseen. Mammograms work better when the implant is placed under the muscle. This allows better visualization.

Boob JobsWhat Do You Want To Change?

It is important to understand the goals of breast augmentation and to make sure your plastic surgeon understands what you want. Do you want to be subtle or dramatic. A subtle augmentation varies from geographical region to geographical region. Breast augmentations are somewhat larger in warmer climates. It is helpful to bring a picture to your consultation of the type of breasts that you like. Be sure to choose someone with a similar body type as yours. Things to look for are:

  • Size

Implants sizes are measured in cubic centimeters or (cc's). One ounce is about 30 cc's, therefore, a 12 oz can of Coke is close to 360 cc's.

Below is a chart that will give you an idea of what a woman close to her ideal body weight can expect from augmentation based on the size of the implant. The categories are broken up into Subtle and Dramatic. Remember, subtle and dramatic are subjective but it at least gives you an idea.

Height
Size of Implant
 
Subtle
Dramatic
5'0'' - 5'3''
<180cc
>280cc
5'3'' - 5'6''
<220cc
>320cc
5'6'' - 5'9''
<260cc
>360cc
5'9'' - 6'0''
<300cc
>400cc

Women who are thinner must subtract volume. Likewise, heavier women must add volume to the above general guidelines.

If you live in a warmer climate you should add about 10-20 per cent more volume as geographical differences exist regarding what is subtle and what is dramatic.

Another variable is skin laxity. These volumes are based on youthful skin. If you have saggy breasts or have been pregnant then larger volumes may be necessary. You should read the section on Breast Lift as well.

  • Shape

The shape of the breast that you wish to achieve is dependent on your physique. There are three breast implants that are most commonly used. Each one is best utilized on certain body physiques. Below is an overview of these three most common implants.

    • Round

This implant is by far the most common. As the name suggests, the implant is round. Therefore, it can never be improperly . It can, however, on rare occasion flip. This implant is ideal for women of normal height and weight as well as women slightly overweight.

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Round Saline Implant

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Round Saline Implant Shape

  • High Profile

This implant is best for women who want a dramatic augmentation but do not want too much lateral fullness. It is especially useful if she has a narrow chest. As the name suggests, this implant gives more projection than the round implant without adding as much width.

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High Projection Saline Implant
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High Projection Saline Implant

     

  • Anatomic

This implant is best for tall, thin women who want more vertical height than width to their breasts. It is taller than it is wide. It is the least common of the three ecause it has the potential to rotate and be positioned sideways.

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Anatomic Saline Implant

Breast Surgeon

Anatomic Saline Implant Shape

  • Silicone Implant

Silicone Implants have a more gel-like consistency. They are less likely to show rippling and irregularities. They are recommended in patients with little natural breast tissue. Silicone Implants may have a higher rate of capsular contracture (getting firm) than saline.

Breast Doctor

Standard Silicone Implant

Breast Surgeon

Standard Silicone Implant Shape

High Projection implants are best for women who desire large silicone implants but have a narrow chest.

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High Projection Silicone Implant

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High Projection Silicone Implant Shape

Breast DoctorPhysical Exam

  • Height, Weight and Bra Size

Typically, your exam will begin with your height, weight, and bra size. You should be as accurate as possible. If you have been pregnant or have had a significant weight change be sure to let your plastic surgeon know.

Tell your plastic surgeon what you would like to be. For example, I am a 34 A and would like to be a 34 full C. While cup sizes are highly variable depending on manufacturer, this still gives the plastic surgeon an idea of what you are looking for.

Once again, a picture of someone with breasts that you like is helpful. Be sure that this person has a similar body type as yours. Point out what you like about the picture, i.e. I like her size, I like her cleavage, I like her fullness up high, or her natural appearance, etc.

  • Observation

The second part of the exam involves evaluating the breasts for size, shape, and symmetry. It should be pointed out that all breasts are asymmetrical. Some are extremely asymmetrical while others have only minimal differences. These asymmetries will persist postoperatively.

Common causes of asymmetry include size differences, sagginess, nipple location, areola size and shape, scoliosis, chest wall asymmetries.

  • Palpation for masses

Typically, your plastic surgeon will perform a quick breast exam. Monthly, self exams are extremely important and are the best way to catch early cancers that are easily treatable.

  • Measurements

Most plastic surgeons will take measurements. Some take notes mentally, others will measure and write everything down.

Here are the most important measurements:

This distance determines sagginess of the nipple. Normal distances are less than 21-22 cm. Over 22 cm usually means there is some component of sag. Minor sag can be corrected with augmentation but usually needs some type of breast lift in conjunction. See the section on Breast Lift for more information.

This distance determines if there is a bottoming-out of the breast. It increases as the breast tissue falls downward. Typical lengths are less than 8 cm in the ideal breast but may be more in large breasts and still be acceptable.

This is, perhaps, the most important measurement. It determines whether the nipple is on top of the breast or has fallen. The ideal breast has a conical shape with the nipple on the top. The nipple should be at least 1 cm above the IMF. When the nipple falls below the IMF it should be lifted. Nipples that are at the same level as the IMF may, or may not be, corrected by augmentation alone. This must be determined by your plastic surgeon.

Breast Doctor

Notice how the nipple is well below Infra-Mammary Fold. In this case, augmentation without a breast lift will cause a Double-Bubble appearance.

Breast Augmentation

This measurement is important in determining the maximal size of implant that will fit on the chest wall. This measurement can be anywhere from 11 cm to over 16 cm. If someone has a thin chest but desires a large augmentation she may need to use a high profile implant to accomplish this.

This is the distance between the breasts. Most people relate it to cleavage but cleavage also is dependent on breast size as well. Typical separation is about 3 cm. This distance can be made smaller by elevating the pectoralis major muscle along its medial border. Point this out to your plastic surgeon if this is important to you.

The areola is the colored area around the nipple. It often enlarges after pregnancy as well as changes shape. Ideal areola size is subjective. Areola reduction is often done at the same time as breast lifting, but not routinely, with breast augmentation. Reduction requires a scar that goes all the way around the margin of the areola.


Typical Incisions:
  • Peri-areolar
  • Infra-mammary
  • Trans-axillary
  • Umbilicus (Naval)

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