Breast Augmentation: Achieving Safe & Beautiful Results
Breast augmentation surgery is undeniably one of the most sought-after plastic surgeries worldwide. Year after year, it consistently ranks among our top three most commonly requested procedures. Patients seek breast augmentation when they desire to enhance the shape and size of their breasts, they tend to feel a little bit flat or they think their chest there is slightly deficient for the body they want - the needs of the patient are pretty clear.
Breast Augmentation Patients Tend to Know What They Are Looking For
Most of my breast augmentation patients have done tons of research even before coming through the door. That's the power of the internet, whether that’s researching a surgeon, seeing people’s before & after journeys, and more. This pre-consultation knowledge enables patients to have informed discussions with their chosen surgeons.
When it comes to really making a connection with the practice, a lot of my patients that come through the door have already made the decision I want my surgeon to be you so it's a really fun meeting, actually.
Initial Consultation
I start my consultations with, it's a really informative meeting for the patient because we know that the breast augmentation patient has done her research and we want to make sure that they hadn't got any erroneous, wrong information, any doubts or misconceptions, anything like that.
The consultation becomes an opportunity for patients to discuss specific concerns, gain further clarity, and establish a comfortable rapport with me. It is during this meeting that we evaluate the patient's goals, assess their unique anatomical considerations, and recommend the most suitable approach to achieve the desired results.
Understanding the Types of Implant Options
When it comes to breast augmentation, there are two primary types of implants saline and silicone. Each type has its own set of advantages and considerations that patients should be aware of before making their decision. Both implants are in the shape that’s lenticular. They're flat on the back, this is called the base, this part will be resting against the chest. Then the front is called the anterior surface and this will be pushing the breast tissue out.
Saline Implants
Saline implants are FDA-approved for patients aged 18 and older. These implants consist of a silicone shell filled with sterile saline solution with the consistency of water. This has a very natural feel and look to the breast and the liquid flows within the shell.
Silicone Implants
Silicone implants, on the other hand, are FDA-approved for patients aged 22 and older. These implants are pre-filled with a cohesive silicone gel and are renowned for their natural look and feel. The silicone gel closely resembles the texture of natural breast tissue, providing a soft and realistic result.
Cohesivity means how “gummy” - liquidy or firm - the implant is to begin with. If you look at it from the side, it does gravity does have a pull on it? The “gummy” Responsive silicone implant tends to drop to the bottom and flatten towards the top; the “gummiest” Cohesive implant has to retain its curvilinear shape. There's a price difference in the implants with the most Cohesive “gummiest” one tending to be more expensive than the Responsive “gummy” one. Then there's one in the middle, they call soft touch which is somewhere in between.
Silicone implants also tend to have a lower risk of rippling, making them a popular choice for patients with thin skin or minimal breast tissue.
Choosing the right implant for you
Typically the reason why patients choose the more cohesive one is if they want upper volume, meaning on the breast, somewhere above the nipple, the cohesive implant is going to give that lift a little bit more compared to the responsive implant. It's really important to have that discussion with the patient and we also play with the implants, let them see how they feel, and making sure they understand the difference.
The majority of patients opting for breast augmentation express a preference for silicone implants. Silicone implants are known for their natural look and feel, closely resembling natural breast tissue, and are chosen more frequently but saline ones are a little safer.
Implant Rupturing
If a saline breast implant ruptures, it's just salt water and your body's gonna absorb it. You will know within a day, wow, that side looks very flat and the implant has ruptured.
A fourth-generation silicone implant, if we cut one open, it's not gonna spill, it's actually going to retain its shape, sort of like a gummy bear, because the gel is cross-linked.
Occasionally I have revision cases of patients who had implants placed years ago and we never know what kind of implant that patient had. Sometimes they are ruptured and they have an oily, silicone substance that has spilled out. It's very difficult to get out.
Nowadays, because silicone implants are crosslinked pretty well, it's easy to remove because it tends to stick together, even in a ruptured case. The drawback is that it makes any kind of rupture detection difficult because the shape is retained. If there is a suspected rupture, we will have to get an MRI or some kind of imaging so we can actually find out if there is a rupture or not.
Implant Placement Options
One crucial decision in breast augmentation is determining the placement of the implant which can be placed in two different locations. You can put it:
Subglandular - meaning right underneath the gland, but over the muscle
Submuscular - meaning underneath the muscle
A lot of that decision making has to do with how thick is the woman's breast tissue to begin with. Do we have enough coverage? If we're looking with someone with very thin skin and not a lot of tissue, if we put it subglandularly, you're going to see the rippling. In such cases, surgeons typically recommend submuscular placement to provide additional coverage and a more natural-looking result.
Measuring and Sizing of Breast Implants
The most important part of the consultation is the measuring part. If you can compare implant sizes, you can see a difference in base width or the diameter of the implant. Sometimes my patients will come in ready with a set idea that they would like to have 450 CC implants, they already have a number in mind. What I do is say, “well, that depends on your anatomy, whether that's feasible or not.”
To determine the appropriate implant size, we take accurate measurements of the patient's chest and breast width. It is crucial to ensure that the implant's base width is slightly smaller than the natural breast width, typically around one centimeter on each side. This consideration maintains proportionality and avoids potential complications.
Implants do come already in premade sizes so we have to see if that shape and volume is something that's available but the pre-op measuring appointment will determine the success of the procedure by selecting the most suitable implant size and projection.
Patient’s last-minute decisions on Breast Size
When it’s time for surgery and we’re in the operating room, the patient may have a last-minute decision change and say “I wish I could go a little bigger.” For this reason, I order a few implants, one size up, the correct size we chose, and one size down. My operating room staff has also asked me why do I bring three implants of each size and my answer is “we’re not doing three implants but if we drop one on the floor, we're in big trouble, aren't we?” There's no “five-second rule” when it comes to a sterile implant. If we drop it, it’s contaminated and it’s done so that's why we bring three. It’s all about preparation, preparation, preparation.
Breast Augmentation and Infections
Implants are “foreign bodies” that remain underneath the patient's tissue and infection is a serious risk. To minimize the risk, several precautionary measures are taken as we don't want any infections. All patients receive intravenous antibiotics while under anesthesia. This helps prevent bacterial infections from developing during and after the procedure.
Additionally, the chest area is thoroughly sterilized with an antibacterial solution to create a clean surgical field. These measures aim to ensure the highest level of patient safety and reduce the likelihood of post-operative complications.
The selection of the incision site for implant placement also plays a role in infection prevention and we also use a specific “hands-off” method of placing the implant which we’ll describe below.
Incision and Tissue Removal Process
Personally, I prefer making an incision at the inframammary fold, which is the crease beneath the breast. This location offers several advantages . Firstly, the incision is discreet and hidden within the natural fold of the body making it less noticeable to patients and very socially unnoticeable. Secondly, the inframammary fold provides a clean and sterile area, reducing the risk of contamination during surgery. It also serves as a reliable anatomical landmark for precise implant positioning.
Once the incision is made at the chosen site, the surgical process continues with meticulous dissection through the breast tissue. As we approach the chest wall, it is crucial to ensure the implant placement is correct. By slightly pressing on the chest, specifically locating the rib, I can confidently identify a safe area for incision until we reach the pectoralis major muscle, or the chest muscle. This muscle serves as an important landmark in determining the appropriate placement for the implants.
In most cases, the implants are positioned beneath the pectoralis major muscle, however, there are instances where an over-the-muscle placement may be more suitable based on the patient's anatomy and desired outcome. Regardless of the placement technique, we carefully create a pocket where the implant will be housed.
During this process, maintaining a clean dissection and minimizing bleeding are of utmost importance. The pocket for the implant is meticulously created to match the predetermined size of the implant which pre-marked on the patient's chest and adhering to the surgical plan. This ensures an accurate and proportionate result.
It is essential not to over-dissect the pocket, as having excessive space can lead to implant migration and an unfavorable position. Respecting the tissue at the bottom part of the breast is crucial, as gravity tends to cause folding and downward displacement. Similarly, over-dissecting the sides of the chest should be avoided to prevent the implant from falling towards the sides.
Implant Placement Technique - Keller Funnel “no touch” method
During implant placement, a careful and controlled approach is followed. To assist with this process, I utilize a tool called a Keller funnel, which is a glorified pastry bag. It is a clear plastic bag that we place the implant using what we call “no touch” method.
When the implants are opened up, they come in a plastic bowl that we fill it with antibiotics solution. Once we open the implants, everybody has a change gloves. We make sure the patient's chest area is cleaned of any blood, any debris, all dirty instruments are put to the side, and we start fresh with everything.
Now at that point, I open the keller funnel and the assistant will pour the bowl with the implant into the bag so that nobody touches the implant. Once that's done, we squeeze the bag pushing out the implant into the cavity so that it doesn't touch the skin and it doesn't bring any kind of bacteria in once we place it.
The benefit to this method is both it’s more sanitary and damage or injury to implants that cause a rupture is often caused at the time of placement. It slides in and you're not pushing in with your fingers. There are no sharp nails underneath the glove that may ruin the integrity capsule or shell either.
It's an extra step and extra expense to get the keller funnel but to me it's well worth it. That's why I like the keller funnel method.
Once the capsule has been implanted, we're very careful to close it in layers, make sure the breast tissue is closed over, the skin is closed in layers, we dress the wound and that's really about it.
Addressing Breast Ptosis (Sagging)
In cases where patients have significant sagging of the breast tissue, known as breast ptosis, additional considerations and procedures may be required. It is important to assess the severity of ptosis by measuring the degree of sagging, ranging from mild to moderate to severe.
In mild cases, the breast tissue may expand and lift to some extent with the insertion of the implant, correcting the ptosis and making a breast lift unnecessary. However, in moderate to severe cases, a phenomenon called a waterfall deformity may occur, where the breast tissue hangs over the edge of the implant, the nipple is pointing downward, and the result is an aesthetically displeasing appearance.
Combining Breast Lift with Augmentation
When a breast lift is necessary after breast augmentation, I typically perform the augmentation first. This allows for the expansion of the breast tissue and provides a foundation for the subsequent lift. Once the patient is in an upright position on the surgical table, we carefully assess the degree of ptosis. We use temporary staples, known as tailor tacking, are used to mark the desired nipple position and make precise markings on the breast. This preliminary step helps plan the subsequent breast lift procedure.
The breast lift is then performed on top of the augmented breast to achieve optimal aesthetic results. This surgery can be complex and meticulous, as it involves addressing two conflicting goals - tightening while expanding the skin simultaneously. It does take a little finess, an eye for symmetry is important, and it is a time-consuming procedure but the patient is very happy afterwards.
Complications and Risks
Breast augmentation, like any surgical procedure, carries certain risks and potential complications.
Capsular Contracture
One common complication is capsular contracture. When a foreign body, such as a breast implant, is placed in the body, scar tissue forms around it to create a capsule. In some cases, this capsule can become too thick and contract, resulting in a firm and sometimes painful breast.
Capsular contracture can occur due to various factors, including infection, bleeding, or low-grade inflammation. This does typically occur within the first few months and not years later, unless the implant ruptures and the inside silicon is causing issues.
There are different grades of contractures depending on:
How severe it is?
How hard is the breast
Is it bad enough that it causes a deformity visually
Is it cold to the touch?
Is it painful?
In severe cases we have to do a capsulectomy and the capsule may need to be surgically removed, get down to normal tissue, and allow for the placement of a new implant if desired by the patient. If this does happen, we do want to put the implant in a new pocket. There are some other potential solutions but we’d have to examine the patient before recommending them.
Infection of the Implant
Another possible complication is an infection of the implant, although this is rare. If an infection occurs, the implant must be removed, and a period of about six months for healing and resolution is necessary before a new implant can be placed. You CANNOT put a new implant in an infected area - it will just get infected again so that’s one of many reasons we have to wait. These complications are important to discuss with patients before proceeding with the surgery, ensuring they are aware of potential risks and outcomes.
Hematoma
Hematoma, which refers to the collection of blood around the implant, is another complication that may require a return to the operating room. If bleeding occurs in the surgical cavity, it can lead to swelling, expanding and discomfort. Prompt evaluation and intervention are crucial in such cases to evacuate the blood clot and replace the implant. This will typically happen very quickly so that’s one reason I see my patients on day one right after surgery, to look for excessive brusing or excessive fullness on one side.
Seroma
Seroma is a straw-colored fluid collection, is relatively rare, but can happen immediately after breast augmentation (more common during a tummy tuck).
In even rarer cases years AFTER the breast augmentation surgery, this condition can be detected by an accumulation of fluid or swelling in the breast, where the breast begins to feel larger than normal. A specific cancer called Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) may present with seroma.
If BIA-ALCL is suspected, further investigation, such as an ultrasound-guided aspiration of the fluid, may be necessary to analyze the cells in that Seroma. If it’s determined that BIA-ALCL is present, additional treatment involves removing the entire capsule and referral to an oncologist for further management.
Revision Breast Augmentation
It is important to note that breast implants are not permanent and may require revision or replacement in the future. Implant rupture or deflation can occur, necessitating implant removal and replacement. Regular monitoring and follow-up appointments are recommended to ensure the long-term success and satisfaction of the breast augmentation procedure in Columbus Ohio.
Conclusion
Regardless of the implant type chosen, it is crucial for patients to undergo regular monitoring and follow-up appointments. Monitoring allows for the timely detection of any issues, including implant rupture or changes in breast health. Regular check-ups and open communication with our Stratus Plastic Surgery in Dublin ensures that any potential problems are identified and addressed promptly, leading to optimal outcomes, patient satisfaction, and life-changing results that boost confidence and empowering individuals to embrace their unique beauty.