BREAST ENLARGEMENT | AUGMENTATION MAMMOPLASTY | BREAST AUGMENTATION
Breast implants have been in use since the 1960’s. Initially many different materials were experimented with until finally the original silicone gel implants were developed. In the early 1980’s these silicone implants were placed on a moratorium by the FDA pending further investigation and clarification of some issues that had raised concern with the public. Silicone implants were banned from use for cosmetic breast enlargement and in their place saline (salt water) implants were made available. By 2006 much research had been carried out and the safety of the newly developed COHESIVE SILICONE GEL BREAST IMPLANTS had been established. Therefore the FDA allowed these implants to be used for cosmetic breast enlargement.
SALINE VS SILICONE GEL IMPLANTS | IMPLANT DESIGN TYPES
SALINE IMPLANTS are devices similar to water balloons that are placed inside the pocket that is created at the time of surgery and filled with normal saline (physiological salt water). SILICONE GEL IMPLANTS are implants made of COHESIVE SILICONE. This is silicone that has been reformulated so that the molecules remain adherent to each other even if the shell tears or cracks. The current silicone gel implant can actually be cut in half and held upside down and the silicone will not pour out. Saline implants can often times feel like a water balloon under the breast, especially if the patient is thin and does not have much soft tissue covering the implant. While silicone implants feel much more natural and have the natural breast feel. Saline implants can deflate (lose their water) due to many reasons, the main one being a defective fill valve. This is a problem that happens in up to 30% of cases, automatically subjecting the individual to another operation and more expenses. The manufacturers have committed themselves to replacing the implant at no charge and in case this occurs before 5 years, they will also pay $1,200 towards the cost of replacing the implant. This still leaves the patient with almost $1,500 – $2,000 out of pocket expenses. Silicone implants obviously do not have this deflation problem. It is extremely unlikely but even if there is a tear in the shell, the silicone does not travel out of the shell and remains intact. So even though silicone implants are more expensive in the beginning, in the long run they are definitely more cost-effective. As for design types, the standard round implant comes in different sizes and profiles, and the appropriate design and size is selected at the time of consultation. Recently in addition to the standard round implant, there have been other designs such as tear-drop, shaped, etc. made available, giving ladies a wide range to choose from.
DR ABRAMS’ PREFERRED APPROACH
There are several different approaches to placement of breast implants. They can be placed through an incision along the inframammary fold, i.e. the fold under the breast, or through an incision along the lower half of the areola, or through an incision in the axilla (arm pit). Dr. Abrams prefers the areolar approach because the scar is almost always inconspicuous and hides in the interface between the skin and the areola. A lot of ladies are under the impression that an incision around the areola results in nipple sensory loss. This is absolute misinformation. Loss of nipple sensation has nothing to do with where the incision is placed. It has to do with how the pocket is dissected and the incidence is the same no matter what approach is used. If the pocket is dissected properly by an experienced plastic surgeon who has adequate knowledge of the anatomy, the chance of nipple sensory loss is less than 5%. The inframammary approach is also a satisfactory one, but if the scar turns out to be very visible and conspicuous it may stand in the way of comfortably wearing a bikini or tank top. The axillary approach has a high incidence of asymmetrical placement and is not very popular. In addition a conspicuous and visible scar in the axilla can be a problem when wearing sleeveless shirts, because it will immediately give away the presence of implants. Finally, there has been some experience with placement of saline implants, please note: only saline implants, through the umbilicus, the so called TUBA (Trans Umbilical Breast Augmentation). The claim has been that because there is no incision on the breast, the chance of nipple sensory loss is zero. Again, a totally deceptive claim. As mentioned above, nipple sensory loss has nothing to do with where the incision is placed. This approach is only mentioned for viewers to be aware of its existence. It has a very high complication rate and it is not a procedure that is condoned by the American Society for Aesthetic Plastic Surgery.
IMPLANT POCKET | OVER THE MUSCLE VS UNDER THE MUSCLE | DUAL-PLANE POCKET
The muscles referred to in breast implant placement are the pectoralis major and the serratus anterior muscles. As can be seen there are different types of pockets that are created for placement of implants. Dr. Abrams prefers sub-muscular implant placement (under the muscles). It is slightly more painful in the beginning due to stretching of the muscles, but in the long run the results are much more satisfactory as compared to placement above the muscle. With submuscular placement of implants the breasts appear and feel more natural, and to be more specific, the incidence of problems such as capsular contracture, rippling, bottoming out, are definitely lower when implants are placed under the muscle. During the past few years there has been much talk about dual-plane pockets, in which the top of the implant is placed under the muscle and the bottom part above the muscle, supposedly giving a more natural appearance. Dr. Abrams has had the occasion to revise many breasts that had undergone dual-plane placement of implants. In every case the pectoralis major muscle had shriveled superiorly and the implant was basically floating under the skin. So, the safest and most reliable pocket is the complete submuscular pocket.
RECOVERY AFTER BREAST ENLARGEMENT | POST-OPERATIVE RECOVERY
Pain tolerance and threshold varies tremendously from one individual to another. There are ladies who are pain-free only 3-4 days after breast augmentation, and there are those who continue to have pain and require pain medication up to 6 weeks after surgery. On the average most patients are able to return to their day-to-day activities in 24-48 hours, return to light work in 10-14 days, and return to full activity and exercise in 6 weeks. However, it takes on the average about 3 months for the implants to settle, for the spost-operative swelling to subside completely, and for the implants to attain their final shape and feel. Again, there are many individual variations to this sequence of events.
PROBLEMS | COMPLICATIONS AFTER BREAST ENLARGEMENT | UNFAVORABLE OUTCOME
The most common complication with breast enlargement is capsular contracture. Whenever a foreign material is placed inside the body, the body forms scar tissue around it which is referred to as a “capsule”. The capsule (scar tissue) that forms around breast implants can be very soft, hard, or extremely hard. The hardness of this capsule has been clinically classified as Grade I to Grade IV. Usually grade I and II is negligible and most patients do not mind its presence. However, grade III and IV need to be corrected and the correction involves surgical removal of the capsule, commonly known as capsulectomy. Another complication is asymmetry. This is usually a result of the lower part of the pocket not being dissected to the same level on both sides. In general all women are slightly asymmetrical, so slight asymmetry is usually acceptable. However, there are times when the asymmetry is more than what can be considered acceptable, anred again it would have to be corrected surgically. One cause of asymmetry can be bottoming out. This is when the lower part of the implant descends inferiorly due to for example weakness of the muscle or weight of the implant. In most cases this is also a problem that needs to be corrected surgically. There are other complications, namely bleeding, hematoma, infection, nipple sensory loss, which are extremely rare and collectively comprise not more than 5% of cases. Finally, as mentioned above, with saline implants, deflation (leaking of the saline) can occur, which automatically requires removal and replacement of the saline implant. Again, as mentioned, the problem of leakage does not exist with the current silicone implant, as the silicone has been reformulated and will not separate even if the shell cracks which is quite unlikely anyway.
Another common misconception is that “breast implants have to be replaced every ten years”. There is absolutely no set rule for this. Implants only have to be replaced if there is a problem.
FOLLOW-UP CARE | LONG-TERM CARE AFTER BREAST AUGMENTATION
Many women are concerned that with the presence of breast implants there will be interference in their annual mammography. All mammography centers are now aware that a high percentage of women have breast implants. Therefore, there is a special technique developed for mammography of breasts with implants, known as the displacement technique. So, the patient only needs to notify the technician that she has implants. In addition to the routine annual mammography, it is recommended that women with silicone breast implants have an annual MRI of the breasts, to detect any crack or rupture. Of course, as mentioned, any crack or rupture of the silicone implant shell will be asymptomatic and theoretically does not require removal and replacement of the implant because the silicone will not leak out. However, mot patients will probably feel more comfortable if the implant is replaced. It has to be noted that both saline and silicone implants have a lifetime warranty and the manufacturer will replace them at no charge.
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