| Dr. Paul Faringer is a plastic surgeon certified by the American Board of Plastic Surgery. Here the Doctor has answered some of the common questions bizymoms visitors have about Breast Augmentation.
Q. What is Breast Augmentation?
A. Although this surgery is called a breast augmentation, actually we do not touch the actual breast gland at all during this surgery. Most breast augmentation procedures involve making a skin incision and then tunneling around or under the breast gland to create a pocket to place an implant which will give the breast mound more projection and in certain patients, a slightly larger base diameter. Occasionally I perform a breast lift procedure in conjunction with a breast augmentation and this does involve manipulating the breast gland itself, but otherwise most surgeons avoid touching the gland itself during routine breast augmentation surgery.
Q. How is a breast augmentation surgery performed?
A. Breast augmentation surgery can be performed by a variety of methods and there is no one method which is best for all patients. In my practice, each patient makes the decision on which approach is the best for them and I offer 3 common approaches and a variety of alternatives. Like everything in life, there are advantages and disadvantages for each procedure or option. I encourage each patient to discuss the various options with me at length to find out which option is best for them. For the purpose of this interview, I will review a few common options and some of the advantages and disadvantages of each option. First of all there are several incisions used for this procedure. The most common incision used for breast augmentation is still the inframammary crease incision and is made under the breast mound in the crease or fold of the breast and chest wall. The advantage to this incision is, it offers very good access to the implant pocket regardless of whether the pocket is above or below the pectoralis muscle (more on this later) and is quick direct access for any additional procedures which may be necessary in the future such as capsulectomy or capsulorhaphy (manipulating or removing the capsule that forms around the implant). The disadvantage is the scar, which may be noticeable if the patient doesn’t have a well defined crease under her breast or when lying down. The peri-areolar incision is another very popular incision and is made between the colored portion of the areola and the adjacent skin. This scar is in the most conspicuous place but often times is barely perceptible because the scar is camouflaged because of placement within the existing natural color change of the areola. This incision also allows excellent access to the implant pocket and for any revisions of the capsule in the future. There has been speculation that this incision may have higher incidence of injury to the nerves of the nipple/areola, but this is not necessarily true if the surgeon does not go through the breast gland but instead tunnels around it in the subcutaneous plane as previously mentioned. This method has an advantage for the release of inferior breast gland tissues from the skin envelope which can sometimes aid in slightly lifting thebreast in certain cases where minor breast sagging occurs but isn’t severe enough to require a full breast lift surgery (mastopexy). The other incisions used for breast augmentation are a distance away from the breast mound and because of this, they may compromise some of the access to the capsule and implant pocket. The axillary incision is still very popular and has the advantage of being away from the breast mound in terms of scarring on the breast. The axilla has important blood vessels, nerves and lymphatic tissues which can increase potential risks and this incision can be slightly more painful following surgery. Some surgeons, like myself, will leave drains following an axillary approach as the lymphatic drainage may increase the risk of fluid collections. The umbilical approach is the furthest away from the breast mound and it would be very difficult to do anything else aside from placing an empty saline implant which can then be filled in the pocket. As in all the procedures I perform, I offer my patients a choice and spend time educating them on the pros and cons of each option, so they can make an informed decision. I perform an equal amount of inframammary crease and peri-areolar incisions and very few axillary incisions in my practice based on my patient preferences. I do not perform umbilical incision breast augmentation.
Patients also have a choice as to whether they want their implant placed above or below the pectoralis muscle and the advantages and disadvantages to this depend mostly on each patient’s individual anatomy. Placing the implant below the muscle allows more of the patients own tissue to cover the implant and look more natural. It also can cause more distortion of the breast mound with muscle movement. Most sub muscular procedures are only partially under the muscle as the lower border of the breast mound is below where the muscle would attach to the rib cage and this is released during the surgery. Each patient will need to discuss their anatomy and physical characteristics with their surgeon to decide which placement is best for them.
My patients also must decide which type of implant they want and, once again, there are advantages and disadvantages to both saline and silicone gel devices. Although both devices were initially used in the early 60’s, the silicone gel devices are the implants, which have undergone the most amounts of change and controversy in the past 40 years. The first generation devices were thick shelled and fairly durable but soon gave way to the second generation devices which had a very thin outer shell and very thin liquid silicone inside. These devices were not originally regulated by the FDA and in the late 80’s came under extensive public scrutiny due to the relatively high rate of rupture which was complicated by the practice of closed capsulotomy common during that era (a process in which the surgeon would squeeze the breast capsule very hard in an attempt to break the patient’s tissue capsule but not rupture the implant inside). Due to a variety of problems, including mounting public pressure, the FDA ordered all of the silicone gel devices off the market in 1991. Saline devices soon controlled the market and to this day remain a very safe alternative. Some of the disadvantages of the saline devices involve the feel of the saline filled bag. Although your body is 60% salt water, most of this is in your muscles and organs. Your breast tissue is mostly fatty tissue and this is why it has a unique soft feel (although the fat percentage may change over the years and there is a lot of variability amongst patients). The silicone gel feels much more like natural breast tissue because of it’s density and consistency. The current implant market uses the fourth and fifth generation devices which have a thicker outer shell and a thick, viscous inner gel. Although all of the gel implants use a cohesive inner silicone gel, some devices use an extremely thick inner gel which is form stable. These devices are called form stable cohesive gel devices (sometimes referred to as "gummy bears") and are currently not available in the United States outside of specific research studies. Both plastic surgeons and the implant industry are hopeful the FDA will approve these devices for clinical use sometime in the relatively near future. After a thorough examination of your anatomy and tissues, your plastic surgeon can recommend which device may be a better fit for you. Ultimately it will be your decision based on the pros and cons of each device and your confidence in that implant. Of note is that it may not be possible to place the form stable cohesive gel devices (gummy bears) through an axillary or umbilical incision. As you can see from this discussion, it is important to go to a surgeon who has the requisite training and experience to offer a variety of procedures such that the surgery can be tailored to the individual patient. I strongly recommend patients look for a board certified plast ic surgeon who is a member of the ASPS and/or ASAPS in their area. This can be done online through either the ASPS or ASAPS websites.
Q. What are the possible immediate post-operative effects in breast augmentation surgery?
A. The immediate effects of breast augmentation surgery are a breast mound with more projection and possibly slightly larger base diameter. I use total intravenous anesthesia (TIVA) technique which wears off relatively quickly and has minimal side effects such as nausea. Various anesthetic agents affect patients differently and will dictate the patient’s recovery. I incorporate extensive local anesthesia into the tissues I am working on and almost all of my patients wake up pain free. The local anesthesia will begin to wear off in 3-4 hours and most patients tell me they feel "very tight" at this stage. Some relate the sensation to that of engorged breasts when their breast milk came in (the difference of course is you cannot breast feed
and relieve the engorgement). I have found that most patients will have this sensation for a few weeks as it gradually subsides and they will use pain medication to relieve this. If the patient chooses to have her implants placed under the muscle, they may have discomfort with raising their arms overhead for 3-4 weeks. There are no specific restrictions following breast augmentation surgery aside from no soaking for a week (patients may shower the following day but no Jacuzzi’s, swimming or soaking in the tub for a week). I usually want to see my patients back in the office 5-7 days after their surgery to examine their incision and implant position. I will instruct them on implant manipulation exercises and scar care at that time. There are no sutures to remove (I use absorbable sutures which melt on their own within a few months and the outer skin is sealed with skin glue which flakes off in a few weeks). One of the potential risks of surgery is infection and this usually manifests itself around 5-7 da ys after surgery if it occurs. This is usually effectively treated with oral antibiotics if caught early but can be devastating if advanced or involves the implant which may require removal of the implant. The risk of this is less than one in a thousand but is one of the more serious risks of implant surgery. Other risks of breast augmentation include anesthesia problems or adverse reactions, scars, bleeding, hematoma (blood collection), implant malposition, contour irregularities and hardening of the implant capsule. I will go over all of the potential risks and complications with each patient prior to surgery so that they can make an informed decision regarding the risk to benefit equation for their surgery.
Q. What are the possible longer-term, local effects in breast augmentation surgery?
A. Immediately following breast implant placement, most implants will appear high upon the chest wall with a very rounded upper pole. Over the course of a year this "implant look" will soften and the upper pole of the breast will develop a more natural slope with the breast mound assuming a more natural appearance as well. Occasionally the capsule around the breast doesn’t soften or becomes more firm and this is called capsular contracture. There may be some early treatment options for this and this will be discussed with your surgeon during your early postoperative visits. Some of the long term adverse complications from breast augmentation surgery include capsular contracture (previously mentioned) or implant rupture. Rupture of a saline filled device is easy to determine as the breast loses volume (the larger the leak the quicker the volume loss but could be as quickly as a day or slowly decrease over several weeks). The usual treatment of a ruptured saline implant is to replace the device. This should be done relatively soon after diagnosed to minimize the shrinking of the capsule which may require more work to expand if allowed to shrink too small. Rupture of silicone gel devices are much more difficult to diagnose. Often times patients will have a ruptured device for years and not note any difference in appearance or feel. Diagnostic imaging is notoriously inadequate as there is no good standard test which has a high sensitivity or specificity (low rate of false negative or false positive results). MRI scans are the most accurate but are only about 85 % specific for ruptured silicone gel and they are quite expensive. Mammography is excellent for detecting early breast CA but not very helpful in detecting ruptured silicone gel implants. Most clinicians would recommend replacing a known ruptured silicone gel implant but there is no proof or agreement of untoward sequelae from long term ruptured silicone gel causing physical symptoms or problems despite many anecdotal reports and junk science on the subject. Other long term potential complications are related to each patient’s own tissues and the loss of elasticity in those tissues. The amount of sagging which can occur in these tissues is also dependent upon whether the implants were placed above or below the muscle.
Q. Who is a good candidate for breast augmentation?
A. This is actually an extremely important question that only can be answered after the surgeon examines and talks with the patient in detail (not everyone is a good candidate for breast augmentation surgery). I perform specific measurements using the notch at the apex of the patient’s sternum as a fixed reference point to determine the amount of breast tissue, amount of breast skin, laxity of skin and sagginess (or ptosis) of the breasts. The ideal candidate for breast augmentation surgery is a patient who has no ptosis or droopineess of their breasts and desires more volume or fullness of their breasts. Some patients experience deflation of their breasts following breast feeding and these can be ideal patients for breast augmentation as well (It is recommended that patients wait at least 6 months following breast feeding cessation before undergoing breast surgery). Other patients have never had adequate breast volume or have uneven breast volumes and they are also excellent candidates for breast augmentation surgery. It is not uncommon for a patient to think they desire a breast augmentation when, more appropriately, that patient needs a breast lift procedure. It usually takes considerable time to explain to a patient with sagging tissues how an implant may not improve the sagging and in some cases make it appear worse. The scars for a breast lift (mastopexy) surgery can be a considerable deterrent for patients who want to improve the appearance of their breasts
and I allow considerable time for this discussion. Discussing how a mis-shapen breast is not aesthetically pleasing even if there are minimal scars and the trade off of an aesthetically pleasing shape to the breast with scars is still a difficult decision for some patients. The bottom line for all procedures I perform is the patient must decide for themselves if the benefits outweigh the risks. I include all of the surgical risks such as bleeding, infection, nerve injury, scarring, implant issues, anesthetic risks as well as the nonsurgical issues such as time off work, financial issues and social issues in the risk side of the equation. The benefit side of the equation is basically how much better the patient will feel about herself by doing the surgery. If the benefit side of the equation outweighs the risk side, she should have surgery. If not, she shouldn’t have surgery. Only she can know the benefit side of the equation, so only she can make the decision whether or not to have surgery (It doesn’t matter what the surgeon, spouse, family or anybody else thinks, it’s really up to the patient). It’s the surgeon’s job to educate the patient so she can make an informed decision.
Q. What is the recovery time for breast augmentation?
A. The recovery period from breast augmentation is usually at least a year and this involves a gradual softening of the tissues around the implant and time for the implant to drop into its natural position. A significant amount of the recovery occurs within 2-3 months but it will take the external scar a year to soften/mature and the internal tissues undergo similar softening.
Q. How much does breast augmentation cost?
A. The cost for breast augmentation in Hawaii ranges from $4,000 to $10,000 depending on the surgeon and where the procedure is performed. My patients pay directly to Kaiser "New Ventures" and costs can vary from approximately $6,000- $8,000, depending on if they are a Kaiser member or not and what type of implant they choose. This would include the cost of the initial consultation and all routine pre-operative and post-operative care as well as the anesthesia and operating room fees. A written cost quote is given to patients following the initial consultation.
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