The best candidates for breast enhancement with implants are those that other women think “don’t need it.” Their breasts are of equal size, symmetrically shaped, and have ample tissue for concealing an implant. Most women, however, are not so lucky. They may have some limitations imposed by nature on the size and shape that can be achieved. The most common limitation is ptosis or droop (or as Oprah calls it “going south”). This can usually be helped by implantation surgery but often requires additional surgical maneuvers (mastopexy). Other conditions such as constricted breast or tuberous breast deformities impose other limitations and difficulties. We will discuss any limitations to your desired outcome during your consultation. Let’s assume you don’t have overriding physical limitations and get on with what you’re interested in.
You may be smaller in size that you’d like to be. To enlarge the appearance of your natural breast tissue an implant is placed behind it like a platform. The more natural tissue you have, the easier it is to conceal the platform. Saline implants will almost always be placed beneath the pectoral muscle to help them hide and look more natural. The doctor will take some measurements of your current breast dimensions to help determine what size implants can be used and what will be necessary to achieve the look you would like. You can also help to confirm your choice by asking women you know who have had implant surgery, assuming that they are similar to you in size and shape.
You will need to answer some medical questions and receive a screening physical exam prior to any surgery to insure that you are in good condition. ALTHOUGH MODERN ANESTHETIC TECHNIQUES AND SURGICAL PROCEDURES ARE AS SAFE AS CAN BE MADE, THIS IS SURGERY AND THERE IS ALWAYS SOME RISK WITH ANY PROCEDURE OR GENERAL ANESTHETIC.
On the day of surgery, you will talk with the doctor and he may make some markings to plan the surgery on your skin. Plan to be at the surgery center at least one hour prior to surgery so that you can meet with our nurses and anesthesia staff. They will start an IV and give you a mild sedative so you can relax. Wear something comfortable, loose fitting, and easy to get in and out of after surgery (a loose fitting top that buttons or zips in the front works best).
The surgery will take about 2 hours, however including preop and recovery time, you will end up spending about half a day at the surgery center. Almost everyone goes home. However, in the event of severe nausea from the anesthesia an overnight stay in the hospital (at hospital rates) is available.
Since saline implants are almost always placed behind the pectoral muscle, expect about 2-3 days of significant pain and discomfort. (THIS SURGERY HURTS.) You’ll want some help around the house at first. Plan to take your pain medication. After the first 2-3 days the chest
discomfort really lets up and you can probably switch to Tylenol. If you need additional pain medication, call our office and more can be prescribed.
To keep from getting an infection after surgery you will need to take an antibiotic pill. If the antibiotic makes you sick to your stomach, gives you diarrhea, gives you a yeast infection, rash, etc. quit taking it and call our office.
Your activities in your first couple of days will be limited, but once you start feeling better there are very few restrictions. You will be asked to wear an elastic strap over the implants for about 2-3 weeks to prevent the migration of the implants and to help with the “settling” of the saline in the implant. Some procedures or implant types require drainage tubes which should be emptied daily. We ask that you stay out of the shower until your drain tubes are removed. This is done at your follow-up visit 5-7 days after surgery when your stitches are removed. If no drain tubes are used, you may shower the first day after surgery. Limit overhead reaching for about 2 weeks as this changes the position of the pectoral muscles, which could lead to implant displacement or malposition. Refrain from contact sports and weight-lifting (especially the bench press or anything that requires your hands above the head) for about 6 weeks. Sex is a contact sport; be very gentle and use common sense for the first 6 weeks or so.
After your first follow-up visit, we will see you in the office as often as is needed. However, usually the next visit is at 6 weeks when the implant “settles” and loses the “top-heavy” appearance. Usually at this time you are released to do any activity you would like to participate in. Returning to work is up to each individual. Most people take a week off but otherwise may take 2 weeks of sick leave if it is available. Those with extremely physical work (construction or professional sports) may need as much as 6 weeks before returning to work.
Your implants should continue to get more soft and natural in appearance, shape and feel for up to 6 months. At 6 months to 1 year we will re-examine your implants for any evidence of capsule contracture and then annually thereafter. This is also a good time to get a mammogram if you have been getting them prior to your implants. If you prefer, mammograms can usually be scheduled with your primary care doctor. As always, if you think you’re having an implant problem, contact our office and we’ll see you promptly. In the rare event of a rupture or deflation and you’re out of the area, contact a Board Certified plastic surgeon. We can send them any records they might need to treat you.
COMPLICATIONS
The procedure we are describing is generally viewed as safe, but there are many possible problems or adverse events, which should be clearly understood. Some of these are simply the limitations of implants, some of which relate to the specifics of placement in your body and some are common to surgery in general.
Saline implants are really a silicone Elastomer shell filled with sterile salt water. They have a shape that is largely determined by the manufacturer. There are limited shapes and sizes to choose from and to some extent choosing the right one for you will be important for your happiness. Once this is done very little can be done to modify the shape and size without replacing the implant. There is some leeway in the amount of saline filler used; placing a slightly greater amount in one or the other implant can compensate for small differences in breast size. When water is used to fill a non-rigid container (such as Baggie or implant), there will be wrinkles along the lines of stress of the container. The implant manufacturers have tried very hard to engineer the implants to minimize this by providing a suggested fill volume range. For women with very little breast tissue to hide these wrinkles, they may be visible through the skin. Even for women with more breast tissue, there is still the worry that these wrinkles lead to “fold flaw”, which is thought to be the most common cause of implant rupture. The rate of saline implant rupture is currently estimated at 1% to 5% per patient per year. (For example, if 100 women receive breast implants in a given year, by the next year one of them is likely to have a ruptured implant. By the end of 10 years, on average, 10 of them will have had a problem.)
The present manufacturers warranty the implants with free replacement devices for life. They occasionally provide some financial support for the cost of the replacement surgery. If your implant ruptures, the saline drains out and the implant goes flat. The saline itself is harmless and is passed out through your kidneys. Replacement of the implant is usually done in the surgery enter and is much less painful that the original insertion. There will be an additional cost for the surgery center and anesthesia.
Although rupture is the concern most people associate with implants, the more common and troublesome problem is capsule contracture. Any time any foreign body is placed in the body it generates a reaction. If an object is tiny and near the surface, like a splinter, your body may actually reject it by working it to the surface. Implants are placed deep inside, usually under the pectoral muscle, and your body reacts by building a scar around the implant in an effort to wall it off from your body. The term capsule has been applied to this scar build-up.
Every woman gets a capsule around her implant. Fortunately only a few get capsule contracture where the scar shrinks and tightens. Some get very minor unnoticeable tightening (Baker I) while others get a scar shrinkage that distorts the implant or can be painful (Baker IV). The best estimate of capsule contracture places Baker IV at about 1% or less. Most people are Baker I or Baker II. If the contracture is severe enough to require treatment this is best done under general anesthesia at a surgery center. (As above, extra cost…as you might have guessed.)
There are other concerns with implants. They interfere with mammograms, but usually this is easily solved by having the radiologist perform Eklund displacement views or other standard maneuvers to “shoot around” the implants. Despite possible interference with mammogram, the implants have no effect on cancer risk itself. (IMPLANTS DO NOT INCREASE NOR DECREASED THE RISK OF BREAST CANCER.) Breast implants may also interfere with breast-feeding. Subpectoral placement should minimize this, but if you would be greatly disappointed if you could not breast-feed, you should wait until you have had all the children you desire before augmentation. For similar reasons, breast implants may have some effect on the sensitivity of your nipples and in rare instances could result in numbness.
Another concern recently is on the effect of silicone in the human body. A great deal of litigation has been based on the lack of complete knowledge. The most recent studies show that most if not all of the concerns of the early 1990s were unfounded. The rheumatologic and autoimmune diseases studied have the same incidence in women with or without implants (both saline and silicone). Although it is impossible to state that the materials and implants have been proven to be absolutely harmless (you can drown in “harmless” water), there are no scientific studies to document any current known toxic effects from today’s saline implants.
The surgical procedure itself places a small scar either in the breast crease (inframammary fold) or around the nipple to provide access. While it is unlikely that any significant scar hypertrophy or keloid will result, everyone heals differently and it is impossible to guarantee that this will not happen. It is quite possible that the incisions on the two breasts may be somewhat different but every attempt is made to have them as symmetric as possible. The breasts themselves may not be perfectly symmetric to begin with and may not be symmetric when augmented. If different enough, additional surgery or incisions may be required to correct this in addition to the implants. Such differences and expected results should be understood and discussed before any surgery to avoid disappointment or misunderstanding. Even with “normal” breasts there will be some slight differences after augmentation.
Every attempt will be made to ensure that the implants themselves are placed in the position that best achieves your desired result, but there is a risk that the implants may move in the postoperative period. To minimize this, an elastic strap is recommended to keep the implants from “riding up”. Once the implant is securely healing in position (after that magic 6 weeks or so), it is extremely unlikely to be displaced. There have been reports of this happening with automobile airbag impacts and similar significant traumatic events, but you need not worry about the average slips, falls, or daily activities.
Another concern is the accumulation of body fluid (seroma) or blood (hematoma) in the implant pocket that can also add to the risk of early implant displacement or perhaps late capsule contracture. For this reason the surgeon will occasionally (very seldom) use a suction catheter. Suction catheters are not completely harmless (remember the water example) and some people believe they may contribute to infection risk rather than prevent it. These and other considerations will determine whether a drain is warranted for your surgery. Whether or not a drain is used, the risk of infection is very small (less than 1%). However if an implant does get infected, it is usually necessary to remove it for weeks or longer before replacement can be attempted.
Breast augmentation surgery is generally a safe outpatient procedure, but surgery in itself entails some risk. One of the risks is clotting of blood in the leg veins and rarely a deep vein thrombosis (DVT). The incidence of this in a short elective procedure in a healthy young adult is very rare, but it can happen. The affected leg would get swollen, may be hot and tender, and usually hurts, especially with attempts to use the calf muscles. The best prevention for this in the postop period is early walking. If you notice any of these symptoms, call the office immediately and we will arrange to see you in the office or occasionally in the hospital emergency room. Although a DVT is terrible in itself, the biggest reason to evaluate and treat promptly is a possible life-threatening condition known as pulmonary embolus where the clot breaks loose and can lodge in the bloodstream of the lungs, in many ways simulating a heart attack. The risk is extremely rare, but it can happen. There are other unlikely risks to any surgery with some of them even leading to death, so this surgery (like other operations) should be taken seriously and consideration given to who will be with you during the postop period, should anything happen. As is always the case, ANY CONCERNS, QUESTIONS OR PROBLEMS SHOULD BE IMMEDIATELY REPORTED TO OUR OFFICE so that he can make sure that safety comes first, that your health is protected and you get the best results possible.
For almost any surgical procedure, smoking cigarettes poses an additional risk to your health. Fortunately, the breast and muscle tissue where your implant will be placed has a very rich blood supply and is very resilient. However, nicotine from cigarettes constricts the very small blood vessels such as skin capillaries and interferes with all wound healing. Cigarette smoking has also been shown to increase the risk of DVT or pulmonary embolus discussed previously. It is always important to quit smoking and all other sources of nicotine including “patches” at least two weeks in advance of surgery to minimize the risks of breast, fat, nipple or skin necrosis (death of tissue). This is of even greater importance if corrections such as mastopexy (lift) or other skin revisions are needed during your surgery. Please talk to the doctor about this…quitting smoking may be the best side effect you could possibly have from your surgery.
This is not an all-inclusive list of problems, but is an attempt to highlight some of the most common concerns. Your individual consultation with Cosmetic Surgery Associates may include other important issues that pertain to you. As always, if you have any questions or anything discussed here doesn’t make sense, please ask so you can be well prepared for surgery.
