News & Features



Now, It's Adjustable Breast Implants


"Super Size Me!"

CosmeticSurgery.com Staff Report
Medically Reviewed by Boris M. Ackerman, M.D.

Super Size Me!

Saline is put into the white injection port which is still attached to the implant inside the breast via a small tube. Photo, courtesy of Hilton Becker, M.D., Boca Raton, Florida.

CONSUMER BRIEF: Last year, about 334,000 U.S. breast augmentations were performed, according to the American Society of Aesthetic Plastic Surgery. But, almost a third of patients were unhappy with the size, shape or comfort of their enhancements and returned to their surgeon for yet another operation to implant a larger size. Some surgeons have found a way around the dilemma by offering adjustable implants.


A professional woman (who asked to remain anonymous) in Georgia had looked forward to augmenting her small breasts for several years. She had kept the notion in the back of her mind since she was teenager, and had saved and worked a part-time job for the last two years to pay for the surgery, she told CosmeticSurgery.com.

But when the surgery was complete and the swelling had gone down, she was disappointed. She still was not as large as she wanted. But, if she had her heart set on a larger size, there was no other recourse - she would have to go back under the knife again, have the current implants removed and larger ones put in.

The woman in Georgia is not alone. Back in 2003, two plastic surgeons - both officers of the American Society for Aesthetic Plastic Surgery (A.S.A.P.S.) - surveyed 1,350 breast augmentation patients for an article that later appeared in the Aesthetic Surgery Journal. Results? 34 percent of subjects who underwent re-operation did so to change their implants for a larger size. And, currently, the North American Breast Implant Registry recorded 32 percent of breast augmentation reoperations were replacements for a more robust size.

Second Most Popular

Overall, breast augmentation remains a leading surgical rejuvenation. According to A.S.A.P.S., breast enhancement is the second most popular invasive cosmetic procedure, with some 334,000 done in 2004, the most current period for which statistics are available.

"It's often difficult for a patient to know exactly what she wants until she sees how a breast augmentation fits her proportions," says Ben Lee, M.D., an Englewood, Colorado, plastic surgeon.

So a handful of cosmetic, plastic and reconstructive surgeons around the nation offer adjustable breast implants to augmentation patients.

One surgeon, Barry J. Kaplan, D.O., with offices in Winter Park and Melbourne Florida, gives his patients a local anesthetic along with a mild oral sedation, creates a pocket under the chest muscle and then inserts the implants with the fill tube protruding from the incision.

"I then gently sit the patient up, let her look in a mirror and we decide together how large she should be," says Dr. Kaplan. "Patients really like seeing the size and shape of their new implants before closing."

Additional size is created when the surgeon injects more saline through the fill tube into the implant.

Lower Costs

Fifteen minutes after the half-hour operation, the patient walks out of the office and has somebody drive her home. Moreover, Dr. Kaplan maintains costs are lower because no general anesthesia fees are included. Additionally, he says bruising is reduced and the chance of a hardened capsule developing around the implant is far less because the insert is under, not over, the chest muscle. An article about the procedure was printed in the June, 2004, Journal of the American Academy of Cosmetic Surgery. So far, a total of about 400 patients have opted for Dr. Kaplan's adjustable implant operation.

"I really wanted to be awake during my procedure," says 31-year-old Elizabeth Kabler of Deland, Florida. "I was happy going from a 34 AA to a 34C and requested no additional size."

Lori Duerr, 41, of Pompano Beach, Florida, had been thinking about breast augmentation for quite a few years, thinking she was probably a "negative A cup."

"I saw a surgeon on a news program explaining how the size of the breasts could be changed with adjustable implants and immediately said, 'That's the surgeon who's going to do my augmentation!' I like having a say in size because I did not want the overly tight look of two grapefruit halves pasted onto my chest."

Dr. Lee typically puts his patients to sleep with a general anesthesia, creates the pocket, inserts the implant and leaves the filling tube between the stitches of the closed incision, covered with gauze. During the first follow-up visit, two to three days after surgery when swelling has subsided, the patient decides if she wants to be larger. If so, Dr. Lee can make her up to one cup size bigger by injecting saline solution. When the patient is satisfied, the small fill tube is taken out and the incision permanently closed.

"Adjustables are a good option for patients who are wavering on size, women who are also having a breast lift at the time of augmentation and women with narrow breasts who want a fuller look," says Dr. Lee.

Balloon-like Devices

The idea of adjustable breast implants started in the early '80s when a Florida plastic surgeon, Hilton Becker, M.D., was required to do two or three operations for reconstructive patients who had cancerous breasts removed. The first operation inserted breast expanders -- balloon-like devices that slowly inflate to stretch skin and muscle to create the pockets that make space for saline implants.

"But after the expander created a new bosom, many patients did not want the device taken out," Dr. Becker says. "And then, I noticed many women - after receiving a regular implant -- were not happy with the size and wanted yet another operation to put in larger implants."

Eventually, Dr. Becker hit on the idea of reducing the number of operations by inserting an expandable breast implant of his own design, the Becker Expander/Mammary Prosthesis Smooth Becker 50/50 Implant which was F.D.A. approved in 1985. Surgeons favor reducing the number of operations on a patient because the risks of complications rise with each procedure. For patients, it's far easier, less time consuming and more economical to recover from a single procedure instead of three.

"I currently use the adjustable implant in cases where the patient has sagging, narrow or differently sized breasts," says Dr. Becker. "I also see many patients who have capsular contracture, or scarring, in their standard implants. I remove the old implant and put in an adjustable version."

Injection Dome

Another common method surgeons use to increase or decrease implant size is through an injection dome attached to the implant. The dome can be left in place for several months after the operation, so the surgeon can use a syringe to add or remove saline during follow up visits. The dome is then removed later through a small opening in the original incision. Some surgeons, like Dr. Becker, leave the injection dome outside the patient's body.

"An excellent way to achieve a natural, tear-drop shape in augmented breasts is to overfill and then slightly empty the implants," says Dr. Becker.

Yet another use for adjustables is when a woman has breast augmentation and a mastopexy, a procedure to lift sagging breasts. However, mastopexy lifts by removing some breast skin while augmentation enlarges. So some surgeons do the procedure in two stages. However, if adjustables are implanted and left underfilled, the mastopexy has time to heal. After that, the adjustables can be filled.

Adjustable implants are also frequently used in reconstruction surgery.

For instance, Ann a 43-year-old, New Jersey stock broker (who also asked not be fully identified) had prophylactic breast removal because her mother, grandmother and two cousins were stricken with breast cancer. Moreover, the stock broker's mammograms became so blocked by fibroids, radiologists could not see much else, causing a constant round of biopsies to be ordered and endured. Just after the breasts were removed, while still in the operating room, her surgeon put in adjustable implants.

"I opted for that because I don't do well under anesthesia and wanted to take care of everything in one operation," she said. "I also wanted my reconstructed breasts to be the same size as before."

Her surgeon left the injection dome under her arm and, over three more appointments expanded her chest tissues and implants to the desired size.

"There was no pain when the doctor injected more saline," says the married stock broker. "And now, a year later, I could not be happier with the results. If I had to do it all over again, I would do nothing differently."

One of Dr. Becker's patients underwent a double mastectomy to remove cancerous breasts and later had her bosom rebuilt. She was extremely distraught about how she would look in a bathing suit or during intimate moments. Eventually, she became romantically involved, went on a two-week cruise with her new boyfriend and asked afterwards what, if anything, he had noticed about her body. The man only had compliments and was clueless about the mastectomy and reconstructed breasts.

However, not every surgeon is a fan. Says Steve R. Fallek, M.D., a cosmetic and reconstructive plastic surgeon with offices in New York City and Englewood, New Jersey: "I've used adjustable implants for reconstructive patients but I generally don't offer them to patients wanting breast augmentation. It just adds another layer of complexity to an already bewildering situation with so many types, sizes, styles and shapes of implants."

But the handwriting seems to be on the wall - more patients want more say in their procedures. And, while it's always been a woman's prerogative to change her mind, the concept until now had somehow escaped the cosmetic and plastic surgery operating rooms.



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