As one of the top two cosmetic procedure performed in the nation, breast augmentation is a procedure that many women choose to undergo for countless reasons. One can admit they wish their chest was a little bigger and others will choose to get breast implants to achieve an improvement in the shape and increase the upper pole fullness, aka “cleavage.” Mothers are also common candidates for implants because breast feeding can lead to experiencing sagging and loss of breast tissue volume, with the desire to restore the breast to a more youthful pre-pregnancy/breast feeding state. An augmentation is often included in a mommy makeover, too.
Breast augmentation is most commonly achieved with the use of a breast implant. These are surgical devices invented right here in Houston, Texas. In fact, they were developed by a resident who trained in the same program as Dr Downey, herself. We have come a long way in the development of breast implants over the past 40 years to include 4th and 5th generation silicone gel implants. There are many choices when it comes to the selection of the type of breast implant as well as where and how the implant is placed. Dr Downey can help you decide what is best for your particular body and your goals.
SILICONE VS SALINE?
|What’s it made of?||SILICONE (gel)||SALINE (salt water)|
|How does it feel?||Softer, more natural||Less natural feel|
|Position||Sits slightly lower||May sit higher (more cleavage), more rounded appearance|
|Risk of capsular contracture (see fig 1)|| Lower (approx. 5% at 7 years)||Higher (approx. 10% at 7 years)|
|Rupture?||Higher (approx. 9% at 10 years) and not as easily detected.||Lower (approx. 7% at 10 years) and causes obvious deflation|
(4-5th generation gel implants)….
What happens if you cut a gummy bear in half? Its content stay exactly where they are. Squeeze it and it may pouch out temporarily then retract back into place. This is the quality of the highly cohesive gel available in today’s gel implants. This prevents the escaping of the gel and migration into the surrounding tissue that was common after rupture with the original gel implants. Here you can see a gel implant that has been cut in half. Notice there is no moving of the gel inside. Compare this to the old gel implants.
TEXTURED VS SMOOTH?
- ADVANTAGE: Textured implants have a decreased rate of capsular contracture (or scaring around the implant see fig 1). They tend to “stick” to the tissues better which is believed to withstand the forces of gravity better and possibly increase the longevity and lessen the chance of “bottoming out” (where the implant slips down below the breast over time). Dr Downey may suggest textured when performing a concurrent breast lift or if considering future pregnancy.
- DISSADVANTAGE: The textured implant have a firmer shell and are therefore not quite a soft and squishy as a smooth implant. They also tend to have a greater chance of rippling, and; therefore they should ideally be placed beneath the muscle if there is little native breast tissue.
- Anatomical or “shaped implants” always come only in textured option to minimize rotation and malposition
- ADVANTAGE: Smooth implants have a softer feel. They also have less rippling in the upper area of the breast and may be better for those with very little breast tissue coverage.
- DISSADVANTAGE: The smooth implants have a slightly higher risk of capsular contracture (see fig 1) and due to the fact that they are able to slide more in the tissues, may be more affected by gravity over time.
ROUND VS ANATOMICAL (SHAPED)?
Recently released and FDA approved in the United States is the shaped or anatomical implant, which rather than symmetrically round throughout, carries that “shape” of a “natural breast.” It may be preferred by patients who are looking for a softer more natural augmentation with less obvious upper pole fullness (cleavage). It also may be preferred when the breast has a less than ideal shape especially a “constricted lower pole” or narrow breast width. You doctor would be able to tell you if you fit on this spectrum. The downside is that the implant could rotate and since it must “stick” in place, it must be textured and therefore carries the risk of rippling and firmness if there is little breast tissue to begin with.
SUBMUSCULAR VS SUBGLANDULAR?
SUBMUSCULAR: This involves lifting the pectoralis muscle and placing the implant beneath it. It allows more “coverage” over the implant protecting it from visibility, palpability while also decreasing the risks of rippling and capsular contracture. The operation is ideal for thin women with very little breast tissue as implants are more appreciable in those cases. The downside includes more pain after surgery and the possibility of “animation deformity.” This means that the implant will move when the patient flexes the pec muscle which can look strange and even be uncomfortable.
SUBGLANDULAR: This placed the implant over the pec muscle but under the breast tissue, without violating the pec muscle at all. It is ideal for patients who have enough tissue to “cover” the implant and for those with some degree of ptosis or sagginess to prevent a “double bubble.” This occurs when the implant is placed either above or below the breast mound, leaving the appearance of a breast on top of a breast. The risk of capsular contracture may be increased and your doctor may recommend textured implants in this case to lower that risk as well as prevent bottoming out of the implant or downward migration over time.
A COMPROMISE? “DUAL-PLANE” Augmentation involves placement of the implant such that the top half of the implant is covered by the muscle but the bottom half is covered by the breast tissue. It helps reduce visibility in thin patient that also have a little sagging and may be prone to “double bubble.” It reduced capsular contracture and possibly lessens the animation deformity.
- Inframammary fold incision – this is by far the most common incision and route used. The incision is fairly inconspicuous hidden under the breast and typically not visualized from a standing position. It allows the surgeon the greatest control and possibly decreased risk of infection.
- Peri-areolar – This incision may not be an option for those with very small diameter nipples especially with silicone implants. It may be ideal for those who are undergoing a simultaneous small periareolar lift. It does run the risk of exposure of the implant to the minimally sterile glands beneath the surface of the nipple and therefore could carry a slightly higher rate of infection and capsular contracture. If the scar is poorly formed, it may be obvious.
- Transaxillary – this is a good option for those with very little breast tissue and no true breast fold. The scar, although may be visible is away from the breast in the arm pit. Size of implant may be limited and it may be challenging for the surgeon to use this same incision for future breast implant surgeries or implant exchanges.
- Transumbilical or TUBA – This is reserved for saline implants only. It offers very little exposure for the surgeon and for this reason, leads to improper placement of the implants, therefore it is not widely used.
CHOOSING THE RIGHT SIZE
The most important measurement in choosing breast size is the width (or ideal width) of the patient’s native breast. This is done using a measuring device called a caliper as seen here.
Based on this width and the amount of stretch of the breast skin and tissues, your surgeon can give you a range of acceptable options depending on your goals. The range is all thanks to the certain projection that each style of implant has. Refer to the below photos and diagram of low, moderate and high profile implants, all with the same size base.
It is important to keep in mind that young patient should expect to need to change out their implants at least once and possibly more over their lifetime. As gravity and age set in, the skin envelope stretches. The larger the implant, the more prone to these changes and to avoid scars on the breast, your surgeon may advise increasing in size to fill out the stretched skin envelope. For these reasons, Dr Downey suggests that you “leave room to grow” rather than choosing the largest size possible
What Do I Need to do to Prepare?
Ideal candidate for breast surgery include those with good breast health. Women over the age of 40 or with significant family history of breast cancer/disease would require a screening mammogram prior to any breast surgery. Women with abnormal breast complaints, such as irregular nipple discharge, skin dimpling or recent changes to the breast or any lumps or bumps should seek a work up to ensure no underlying breast pathology.
Those who have recently given birth should wait a minimum of 6 months after birth or after breast feeding to allow the breast to settle to its final state. If planning a future pregnancy, surgery may not be advisable until after. If future pregnancy is undecided, the risk of inability to breast feed following a breast surgery as well as changes to the breast during and after a pregnancy should be discussed and weighed.
All patients undergoing augmentation procedures should be NON-SMOKING for a minimum of 4-6 weeks prior to surgery and must refrain from smoking during the 6-8 weeks following to ensure proper recovery, avoid wound healing and scarring issues as well as minimize risks of infection.
Patients should also strive to eat healthy including a diet with adequate lean protein and vegetables. If nutrition is of concern, consider a multivitamin and/or supplementation with protein shakes.
What Can I Expect on the Day of Surgery?
Breast Augmentation is a minor to moderate procedure that does not require a hospital stay. You will be asked to arrive to the hospital 1-2 hours before the start of your surgery, when the hospital staff will prepare any necessary documentation such as have you sign a consent form. You will meet and talk with the anesthesiologist team as this procedure would require general anesthesia during which time you are completely asleep and supported by a breathing machine. The nurses or anesthesiologist will place an IV and start fluids. Your surgeon will greet you just before surgery and place marks on your breast with a marking pen. You will then be taken to the operating room and placed on the operating table, where you will gently be put to sleep. You will awake in the recovery room with only minimal discomfort and will have dressing and a bra in place. Your family will be instructed on your care prior to leaving the recovery room.
It is advisable to rest that day and avoid foods that easily upset the stomach such as dairy and heavy proteins until you feel the anesthesia is waring off, which may take up to 72 hours.
Risks to Breast Augmentation and Implants
- Bleeding or hematoma (may require return to the operating room to clear)
- Infection ( less than 2% in cosmetic augmentations)
- Capsular contracture – scar tissue formed around the breast implant. See chart below. The amount of scar can be very little to substantial. There is more risk of capsular contracture as time goes on but there is also a risk of “early” capsular contracture that occurs weeks to months after the procedure. There is no way to predict who is at risk.
- Poor scar formation – especially if prone to keloid or hypertrophic scars
- Malrotation – this can be an issue with shaped implants
- Asymmetry – if there are existing asymmetries, then the augmentation will only increase the appearance of asymmetry by magnifying everything. If the asymmetry is significant, Dr Downey may choose two different implants to attempt to lessen that asymmetry or she may suggest a small additional procedure to reposition the nipple if applicable.
- Increased or decreased nipple sensation
- Inability to breastfed
- Need for further exchanges and/or breast lifts overtime – implants are man-made devices that are not meant to last forever. You can expect to need to exchange them about every 10-15 years and possibly sooner.
I’ve been wanting to do botox and get my skin looking great for some time now. I was a little nervous, Dr. Downey had a great staff, and she was super patient and fed me enough information to calm m…
– Stephanie O.
I had such a great experience with Dr. Downey. I was referred by a friend. This was my third attempt at getting surgery on some trouble spots after significant weight loss. I didn’t go in with h…
– Paul V.
It was very easy for me to make a consultation appointment. There was no pressure to sign up for surgery that day. Dr. Downey was very professional and friendly. She answered all my questions an…
– Brittany G.
I had breast augmentation on 12/2/14 and Dr. Downey and staff made the whole experience amazing. Since the surgery I have minimal scarring and I look and feel great! This was one of the best decis…
– Ashly T.
Dr. Cara Downey, thank you so much for the care you gave to me and the exceptional work you have done to my body! You are amazing. Because of you, dreams come true! You are the best! Thank you for ble…
– Andrea C.
I didn’t think I would ever feel this great again. Now I can wear strapless dresses. My shirts no longer have the peep holes near the buttons. I’m just so pleased with the work Dr. Downey has done. Bu…
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After Surgery: Precautions and Recovery
Some pain and discomfort is expected in the first few days, which will be eased with pain medication. Bruising and swelling may also be expected though extreme swelling and pain on one side only may indicate a problem and warrants a call to the doctor immediately. You will also be given a short course of antibiotics to prevent infection. The bra and dressings should be left in place for 48 hours, after which you can remove and begin showering regularly. Avoid baths or submerging in water for at least 4 weeks.
Athletic women, be patient. Most can resume work and social outings within days of having an augmentation, but intense exercises should be put on hold until you get it cleared with Dr. Downey. For most this means avoiding anything in the first 2 weeks that can raise the heart rate and blood pressure. You will also not be allowed to lift more than 5-10 lbs for at least 4 weeks. At 6 weeks, you may be released to full normal unrestricted activity with a gradual ease into it. If your incision is in the fold of the breast, you will be told to avoid underwire for 6 weeks. Scars will be present, but those will greatly improve by about 6 months. Depending on the placement and type of implant, you may experience temporary “high riding” or higher placement of the implants in the initial period. This will settle out and “drop” over the first 3 months to the final position. Dr Downey may advise or may strictly prohibit breast massage so be sure to clarify this before performing it.
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