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Breast Augmentation

Breast augmentation is one of the most common and popular breast enhancement procedures in the nation. Board-certified plastic surgeon Gene Sloan, MD has experience with the many different incision techniques and implant options available for breast surgeries, and his qualifications and commitment to safety and satisfaction have resulted in many happy patients. Dr. Sloan can develop a customized treatment plan for breast augmentation that is designed to help you meet your goals with results that look both natural and beautiful.

What Are the Benefits of Breast Augmentation?

Women pursue breast augmentation surgery for many reasons. Most desire to look more feminine in certain types of clothing or swimsuits, and not limit clothing options. When a woman looks and feels her best, she often gains a boost in self-confidence. Typical candidates either never had a large enough breast to begin with, want to restore size and shape after breastfeeding, or are trying to achieve better symmetry due to a developmental condition.

Along with improving the shape and size of the breast, other goals are just as important. Every effort is made to maintain breast function, softness, and sensitivity. It is also important to minimize interference with breast cancer detection and not interfere with future breastfeeding.

There is an extremely high satisfaction rate with breast augmentation surgery; however, it is not for everyone. As with any cosmetic procedure, patient selection is critical. The keys to success in this procedure are good health and realistic expectations. When these goals have been met, many women say it’s the best thing they ever did for themselves.

Who Is a Candidate for Breast Augmentation?

Almost any healthy woman who wants to enhance her figure with breast implants may be a candidate. There are several reasons why women seek breast augmentation, including:

Never developing the breast size they desire
Looking to restore lost breast volume after pregnancy or weight loss
A noticeable difference between the sizes of the breasts and the desire to make them equal

For patients who are considering breast augmentation, it is important to determine readiness from three different standpoints: physical, emotional, and financial.

During the consultation process, Dr. Sloan will assess physical health and ask about previous operations and hospitalizations, presence of chronic diseases, medications, allergies, smoking history, pregnancies, and mammograms. It is also important that patients are emotionally ready for the stress of a surgical procedure and recovery. Cosmetic surgery generally should not be performed in close proximity to major life events. Dr. Sloan advises patients to only pursue the procedure for themselves and not because someone else wants them to do it. It is also best when patients have the support of family when seeking cosmetic surgery, especially during the recovery period.

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What Is the Anatomy of a Breast?

The size and shape of a woman’s breast is determined by the anatomy of the chest wall, the amount and quality of skin, and the volume of fat and glandular tissues. Additional factors include the effects of gravity, aging, hormonal, and environmental influences. The ideal shape is generally conical with breast volume in proportion to the woman’s frame. The nipple ideally sits an inch or more above the crease at the bottom of the breast, with one third of the volume sitting above the nipple and two thirds sitting below. From a side view, the upper portion of the breast may be slightly convex, flat, or concave.

The breast has a vast network of blood vessels and nerves that essentially enter the breast from all sides. The circulation allows the breast to heal after surgery and the nerves enable the breast to maintain variable degrees of sensitivity after surgery. Blood vessels and nerves are located at the periphery of the breast and can be damaged with very wide implants.

The quality and quantity of skin is an important factor in determining results after breast augmentation. Younger patients tend to have thicker, tighter skin with greater amounts of collagen and elastic fibers, and the skin and underlying tissues become thinner and less elastic as women get older. This is due to the natural aging process, genetics, pregnancy, and environmental factors such as sun damage and smoking. As the amount of skin increases and the volume of the breast decreases the breast tends to sag more.

Underneath the breast skin is a mixture of breast gland and fat. In younger women, there is typically more gland and less fat and the breast is firmer. With age, the amount of fat relative to the breast gland increases and the breast becomes softer. Exiting from the glands are the lactiferous (milk) ducts that eventually converge and arrive at the nipple via multiple tiny openings. These ducts communicate to the outside and are also an entry point for bacteria. This is an important consideration in the development of infection and capsular contracture after breast augmentation.

When a plastic surgeon describes putting implants “under the muscle”, they are referring to the pectoralis major muscle. One end of this muscle attaches to the collarbone, breastbone, and ribs. The other end attaches to the upper arm. The free edge of this muscle can be felt just in front of the armpit.

How Should Breast Cancer Risks Be Considered?

It is important to understand the relationships between breast implants and breast cancer diagnosis and treatment. In the United States, the risk of a woman developing breast cancer during her lifetime is 1 in 8. At age 30, the risk is 1 in 2,000, 1 in 200 at age 40, and by age 50, the risk increases to 1 in 50. The presence of breast implants generally does not interfere with the detection of lumps on breast self-exam. Women should have a mammogram by age 40 and those with a family history should have a mammogram earlier.

If a patient has breast implants, they should inform the mammogram technologist as implants may interfere with mammography to some degree. Since the breast is squeezed during mammography, it is possible for an implant to rupture, although this is exceedingly rare.

Where Are Breast Implants Placed?

Breast implants may be placed over the muscle or under. When placed “on top of the muscle”, they are placed between the pectoralis major muscle and the breast gland, and all the breast tissue is still in front of the implant. When placed “under the muscle”, implants are placed between the pectoralis major muscle and rib cage. The technique is also called dual plane, as the muscle is only large enough to cover the upper inner half of the breast and the lower outer half is covered by the breast gland.

Above the muscle
When placed above the muscle, there is often no distortion with muscle contraction. The implants are less likely to displace laterally with certain rib cage shapes and have a more rounded appearance. On the other hand, this technique often presents an increased risk of capsular contracture, and patients may see more implant wrinkling and edges. There is also a greater chance of interference with nipple sensation and a mammogram.
Under the muscle
The dual plane technique often results in a more natural shape and appearance, and there is less of a chance of capsular contracture and implant wrinkling. Disadvantages of placing the implant under the muscle include increased distortion with muscle contraction and the temporary weakening of the muscle.

Where Are Breast Augmentation Scars Located?

The most common incision techniques used during breast augmentation include:

Inframammary
This common approach involves an incision made along the crease underneath the breast. The technique typically takes less time, there is less risk of implant contamination, and offers the best exposure for secondary surgery.
Periareolar
A periareolar scar is often concealed at the edge of the nipple; however, there are some drawbacks. The technique cuts through breast tissue and increases the risks of infection and capsular contracture. It also can lead to decreased nipple sensation and interference with breastfeeding.
Transaxillary
The transaxillary method involves an incision made in the armpit as opposed to the breast. This approach limits visible scarring, but often can’t be used for many secondary operations, increases risk of implant contamination, may cost more, and does not correct sagging as efficiently.

What Are My Breast Implant Options?

The two most popular breast implant types are saline and silicone. Saline implants are delivered empty and are filled with saline at the time of surgery. Silicone gel implants are pre-filled to a specific volume. Current silicone gel implants are manufactured with fill ratios to reduce risk of rupture and rippling and to provide more upper pole fullness. Implants are also available in low, medium and high profile. Low profile implants will have the widest diameter and the least projection, while high profile implants will have the narrowest diameter and the most projection. Additionally, high profile implants give a more rounded upper breast, which may or may not be desirable for a particular patient.

What Factors Can Affect Breast Augmentation Outcomes?

Many factors affect the outcome of breast augmentation surgery, with the first being what a patient’s breast looks like before surgery. The new postoperative breast will be the sum of the size and shape of the implant, plus the size and shape of the existing breast. Factors that may limit outcomes include:

A tall and narrow or short and wide chest
The circumference of the chest may be a barrel shape or wide and flat due to the way the ribs are curved
The breastbone may be flat, depressed, or protruding

The quality of the skin over the breast may vary in appearance, pigmentation, and in how it heals. It may be thick or thin, and its elasticity will vary. Additionally, the nipple areola complex varies greatly in its size, shape, color, and position on the breast. While achieving symmetry is one of the goals of surgery, patients do not typically start out with perfectly symmetrical breasts, thus making it difficult to fully achieve complete symmetry. Another factor that is critical is the amount of soft tissue coverage over the implant. The thickness of this tissue determines its strength and how well it will hold up the implant over time. It also determines whether there will be visible wrinkling, how easy it will be to feel the implant through the tissue, the final breast shape, and how natural or unnatural it looks.

Can Breast Augmentation and a Breast Lift Be Combined?

One of the more common problems encountered in cosmetic breast surgery is sagging, or ptosis. The main problem is that there is too much skin for the amount of breast volume. This allows the nipple to sit below the inframammary crease and creates contact between chest skin and breast skin on the underside of the breast. It also creates a long distance from the collarbone to the nipple. Under these circumstances, the breast skin is thin and unable to hold up the weight of the breast.

The condition may be corrected by reducing the amount of skin, increasing the breast volume, or a combination of the two. Using an implant alone is useful only for very minor degrees of ptosis. If the ptosis is moderate, then a breast lift and breast implants may be combined in a single operation. In cases of severe ptosis, it is most predictable and has the least risk if the lift is performed first, then a breast augmentation is performed at least three months later.

The main problem in performing a breast lift at the same time as placing implants is the limitations of the skin. Sagging breasts often occur because the skin is too weak to hold up the weight of the breast. The additional weight of the implant will cause the breast to sag more. Also, in performing a lift the breast is further weakened by incisions at the bottom of the breast where more strength is needed, not less. Performing a lift at the same time also increases the risk of infection and capsular contracture because of the increased contact between breast tissue and the implants.

How Is Breast Augmentation Surgery Performed?

About two weeks prior to surgery, patients will come to our office for a pre-operative appointment. At that time, Dr. Sloan’s staff will go over detailed instructions of what patients need to do before and after surgery, including avoiding nicotine, medications known to thin the blood, and any herbs and dietary supplements for those two weeks before and after surgery. Patients will also be given instructions that help reduce the risk of blood clots in their legs.

Patients are instructed not to eat anything after midnight the night before surgery and should arrive at the Surgery Center one hour before the scheduled surgery time. Patients must arrange transportation to and from the surgery center and ensure someone will remain with them the first night due to the use of general anesthetic during surgery.

The surgery is performed at an accredited outpatient surgical facility with a surgical team that includes board-certified plastic surgeon Dr. Sloan, a board-certified anesthesiologist, a certified operating room technician, and registered nurses in the operating room and recovery room. After arrival, patients will be escorted to a private room to change into a gown. Dr. Sloan, the anesthesiologist, and the nurse will then meet with patients to confirm the surgical plan, mark the skin if needed, and answer any last-minute questions. An IV will be started and sedation administered. Most patients are unable to recall events of the day after sedation is given.

Patients will be taken to the operating suite on a stretcher and transferred to the operating table. Sophisticated monitoring devices will be connected to patients and anesthesia will be administered. Dr. Sloan will then proceed with surgery. A breast augmentation typically takes 40 minutes to perform and patients are under anesthesia for less than an hour. When surgery is over, a small piece of tape is placed over each incision and patients will be taken to the recovery room. Vital signs are constantly monitored and a specially trained recovery room nurse will take care of and remain with patients at all times.

How Is Recovery Following Breast Augmentation Surgery?

Recovery is the time it takes to get over the surgery and return to normal activities, while healing is the time it takes for all the tissues to get back to normal. The larger the implant and the more pressure it exerts on the tissue, the longer the recovery. The breast will attain its final postoperative shape in six weeks to six months. It may take up to two years for the sensation to return to normal.

Many patients have surgery on Friday and return to work on Monday. Light activities may be resumed in a few days and some patients may return to full aerobic exercise two weeks after surgery. Patients typically have very little bruising and pain is usually well controlled by a day or two of medication. No bandages, drains, or special bras are used. Patients can often shower, eat, and leave the house the day of surgery. The incision will be covered with paper tape and will stay on for a week after surgery. Usually, there are no sutures to remove.

Dr. Sloan sees patients at regular intervals after surgery. Follow-up appointments are scheduled one and four weeks after surgery, then three months after surgery.

What Are the Risks of Breast Augmentation Surgery?

Breast implants are not considered lifetime devices and there are potential complications to monitor and screen for. Patients should anticipate additional surgery and doctor visits over the course of their lifetime. Even though the implants are covered by a lifetime replacement policy, patients should anticipate additional expenses related to future implant surgery.

Early Post-Op Risks

In the first month following surgery, there are a few potential risks patients should keep an eye out for. Patients may experience hematoma and postoperative bleeding. Infection may also occur and while most patients do not experience a great deal of pain after breast augmentation surgery, pain can range from mild to severe and may be temporary or permanent.

Later Post-Op Risks

A couple of months after breast augmentation, patients may notice some asymmetry as breasts usually heal at different rates and some degree of asymmetry is expected during healing. The pressure of the breast implant underneath very tight tissues may cause breast tissue or chest wall tissue to thin and shrink. Additional risks include implant wrinkling, implant movement, stretch marks, and thrombosed veins.

Long-Term Risks

There are potential risks that some patients may notice or experience down the line. There is a chance that saline implants may deflate and silicone implants may rupture. Patients could experience capsular contracture, or excessive breast firmness. An incision around the nipple for implant placement may reduce the ability to successfully breastfeed, and nipple and breast sensation may change. The larger the implant, the thinner the skin, and the older the patient, the more likely implants will sag over time and fall to the side when a patient is lying down. Breast implants also make it harder for the radiologist to see breast tissue on mammograms. Other long-term potential risks include Breast Implant-Associated Anaplastic Large Cell Lymphoma (ALCL) and Breast Implant Illness (BII). ALCL is an extremely rare type of lymphoma that has been associated with textured breast implants and caused one manufacturer’s textured implant to be pulled off the market. BIA-ALCL is not a cancer of the breast tissue itself and when diagnosed early, it is readily curable. If the disease is advanced, chemotherapy or radiation may be required. Textured implants have been associated with ALCL, so Dr. Sloan prefers to use smooth surface implants to avoid risk of developing the condition. The BII term incorporates a variety of symptoms, including chest pain, hair loss, anxiety, and more, and while the vast majority of breast augmentation patients do not experience the illness, it is believed to be caused by implants.

Rare Risks

There are some rare risks that patients should be aware of. Calcium deposits may develop in the scar tissue around the implant and it is possible for a breast implant to erode through the skin. Clear tissue fluid may occur around an implant and if implants are too close together, cleavage may be reduced or eliminated.

How Much Does Breast Augmentation Cost?

The original cost of breast augmentation surgery is only a portion of the cost patients will eventually sustain. In the event of a complication, there may be additional expenses. Additionally, breast implants are not lifetime devices, so patients should expect additional expenses in the future. While the vast majority of patients have breast implants that last 20-25 years, some women decide to have them removed after a certain number of years for various reasons. These potential future costs should be considered when budgeting for the surgery.

The cost of surgery often includes:

Surgeon fees
Anesthesiologist and anesthesia supply fees
Breast implants
Nursing staff
Lab tests performed at the surgery center
Use of the operating room for the estimated operating time

Surgery may run a little longer, but our practice does not charge extra for that. Outside fees such as pathology lab and prescription costs are a patient’s responsibility. The cost of hospitalization after a complication is also a patient’s responsibility and may not be covered by health insurance. Those instances are an exceptionally rare event.

Are There Alternatives to Breast Augmentation?

Women may seek alternatives to breast augmentation because of fear, cost, risk, or they have heard about someone who had a bad outcome or re-operations. Alternatives to breast implant surgery do exist; however, they have limitations.

Do Nothing

Breast implants are not for everyone. The reason for the consultation process is to get accurate information to find out if breast augmentation is right for each patient. Not getting breast implants is a perfectly acceptable option as it has a known outcome, no cost, and no risk.

Fat Grafting

Fat grafting has become a popular and standard procedure in both cosmetic and reconstructive breast surgery. The main limitation is the volume of fat that can be grafted at any one time, resulting in the need for multiple procedures. Another limitation is the availability of donor sites as many breast augmentation patients are thin. A 300 cc implant is on the lower end of implant sizes. Adding 300 cc of fat to the breast might require 3 or more operations.

Your Own Tissue

This is an effective technique for women who have lost a breast due to a mastectomy for cancer. However, the degree of scarring and the increased risks of the operations prevent it from being used for cosmetic purposes.

For more information about breast augmentation, please contact our office with any questions you may have, or to schedule a consultation with Dr. Sloan.