Who are good candidates?
Breast Augmentation is a surgical procedure that enhances the size & shape of a woman’s breast. This is often desirable in patients that have lost significant volume after pregnancy and breastfeeding (involutional mammary hypoplasia). It is also beneficial in patients that have underdeveloped or absent breast tissue. This can be a genetic predisposition or in association with congenital deformities such as Poland Syndrome (absent chest wall muscle with or without upper extremity abnormalities) the procedure is also helpful in correcting breast asymmetries where the size and shape are different. Finally, it can be a balancing procedure in patients that have undergone mastectomy reconstruction to enhance the non-cancer side.
How is it performed?
The surgery takes about one hour. We perform this procedure in our office surgical unit under local anesthesia with sedation so patients are asleep but not on a machine to breathe. The implants used are saline (salt water) or silicone gel. Mentor or Natrelle prosthesis.
We prefer an axillary approach for Saline implants (a small incision in a natural crease of the armpit) or Inframammary for Gel implants (in the crease under the breast). We favor a submuscular position (behind the chest muscle) as this provides better shape, lessens the chance of hardening and provides an additional layer of soft tissue covering the implant, helping to obscure visible “wrinkling”.
How much time off do I need?
We suggest a week if possible, although many of our patients go back to work after an extended weekend (we usually perform breast augmentations on Thursdays). Since local anesthesia is used, there is not much pain for the first four hours after surgery, but after it wears off, there is soreness and tightness. We give a generous amount of pain medicine to make the recovery easier, so you will need somebody to oversee your care. The shape of the breast out of clothing is “artificial” for the first few weeks with tight skin and too much fullness at the top. Once the skin and muscles have relaxed, however, you can expect an amazing improvement in your breast contour.
What about cost & scheduling?
Because we perform 400-450 augmentations per year and use the office surgical unit instead of the hospital, we are able to provide surgery at a very affordable rate. We offer bilateral breast augmentation for $5,000 for Saline, $6,000 for form stable (“gummy bear”) Gel implants (procedure price may vary depending on the need for lifting or deformity correction). This global fee includes implant cost, facility, surgeon’s fee, anesthesia and all follow-up visits. We perform 4-10 pairs every Thursday so our schedule is flexible.
Can there be complications?
Any surgery carries risk. Fortunately, breast augmentation is extremely safe. Consult the Mentor or Allergan websites for their reported complication rates. We also have a detailed analysis of our surgery complication rates under “Breast Stats”.
1.) Deflation – There were 114 patients with deflation(Between July 1994 and May 2012. This is our most common reason to re-operate. All implants eventually deflate as they have a finite life span. If the implants are saline and one of them ruptures, that breast will lose volume rapidly. The need to replace it will be obvious. The exchange is usually simple and can be done under local anesthesia (if no pocket work is necessary) and the cost is covered by both manufacturers if it happens in the first 10 years. If the implant is silicone gel, rupture is usually silent (the patient will not notice any change) as most are intracapsular. Where the gel is outside the initial implant shell but contained by the capsule scar. The diagnosis is radiological (MRI, Mammogram) or clinical (pain, hardening, change in shape). The exchange of ruptured gel implant requires a total capsulectomy (removing the scar capsule) but no harm occurs from the gel to the rest of the body. We feel strongly that silicone gel is safe and we use it on all mastectomy patients and augmentation patients that are underweight and/or severely underdeveloped. In our saline experience we have had 148 deflations with the earliest at 8 months and the latest at 27 years. We have found that the textured saline implants deflate more often than the smooth, that the smooth McGhan (AKA Allergan, Naturel) deflate more at the valve while Mentor smooth deflate more at the peripheral fold (fold failure) but that both manufacturers’ smooth saline deflate at the same rate. In addition, a disproportionate number of deflations were either under inflated or had no added volume (i.e. minimum or less than minimum volume) so, in general, we add saline beyond the minimum, for example 325+25. The first number is implant minimum volume and the +25 is the number added beyond that. We also have measured all the implants volume of intact implants that we remove for revision and have found that they remain within 4cc of original volume even years later. So, over time they remain completely filled for years until the day the shell or valve weakens and the volume is lost suddenly.
The next most common reason to reoperate is;
2.) Change of Implant Size: upsize 72 (2.3%) / downsize 36 (1.2%)
According to our patient surveys (1 year post-operating), 89% think their breast size is correct.
3% think they are too big and 8% think they are too small. The latter group is typically divided into patients that were extremely conservative preoperatively and chose to be a B-cup and then realized a C-cup would have been preferable. These are good candidates for upsize and often proceed with a second surgery. The other group that thinks they are too small have what I would describe as a “mammary dysmorphic disorder”, where the augment is never big enough. Implants create a full D-cup and they still think they are too small. We generally advise them against upsize, as the surgery would be deforming and their breasts would become completely out of proportion with their body frame. The downsize patients are rare and tend to be patients that have gained some weight, causing a growth of their own gland tissue. Replacing the implant to a smaller size or removing it altogether and performing a lift will often correct the problem.
3.) Malposition (3.3% between 1994 and 2000) (1.2% between 2001 and 2012)
The third reason for reoperation would be malposition (where the pocket holding the implant needs to be corrected). This can occur either soon after the initial surgery or years later. The implant can be too high, too low, too far out or too close to the center or any combination of these. (See examples in REVISION section of photo gallery). The correction involves opening the pocket in certain areas and/or closing it in others with sutures. Malposition occurs more commonly if the breasts are significantly asymmetrical preoperatively or significant adjustment of the inframammary fold is needed as in constricted and tubular breasts or when an augmentation is performed in combination with lift procedures. Currently, our routine augmentations require pocket extension in less than 1% of cases.
4.) Correction of Capsular Contraction
The fourth cause of reoperation would be correction of capsular contraction (hardening of the breasts) (1.1%). Fortunately, this complication is rare when the implants are placed under the muscle. This is the most important reason we advise going behind the muscle even though the recovery is more difficult. This complication can be devastating as it can distort the breast shape and cause pain. If the capsular contraction is mild (Baker II firm but not shape distorting) massage can be helpful. Most contractures we see in the sub-muscular saline group are of this type. Some, about a quarter of our contractions, require surgery (Baker III, IV: distorted shape, painful). The surgery necessary depends on the severity of the hardness. Open capsulotomy is simple scoring of the scars to give the implants more room. Lower pole capsulotomy is when part of the capsule is removed and in severe cases total capsulotomy and exchange of implant is required.
5.) Infection and Bleeding
The more rare complications are infection (0.12%) and bleeding (0.03%). Infection can be acute (3 cases) within 2 weeks of surgery. Usually staphylococcus aureus is the bacteria responsible and can be treated with oral antibiotics and irrigation of the breast, but the implant may require removal for 4-6 weeks if the infection does not resolve. Infection can also be delayed (months or years after the original augmentation) and is usually caused by an infection elsewhere in the body (11 cases) such as sinusitis, pneumonia, breast abscess (at the time of breastfeeding). These have more insidious onset and always require removal of implants for 2 months or more (organisms include pneumococcus, strep, enterobacter, among others).
Bleeding is extremely rare with our large volume local anesthesia technique. No patient has required reoperation for bleeding in over a decade. Even more rare are extrusions (when the implant thins the overlying skin on the lower breast and becomes exposed) (1 patient), and medical complications such as deep vein thrombosis (1 patient with heterozygous factor 5 requiring 6 months of Coumadin and anticoagulation) and Bronchial spasms (1 patient).