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Breast Augmentation by Kenneth Gilbert, M.D.

By Kenneth Gilbert, MD
Massachusetts Plastic Surgeon

Breast augmentation is also called augmentation mammoplasty. It involves the placement of a breast implant behind the breast to increase its size and improve its shape. It is performed after the breast is fully developed (usually in patients over 18 years of age).

It is one of the most popular cosmetic procedures for women. According to statistics provided by the American Society of Plastic Surgeons, 264,041 women underwent the procedure in 2004. Like other cosmetic surgical procedures, it should be performed to make you feel better about yourself, not to please someone else.

It is performed on an outpatient basis and is generally not covered by your medical insurance. It usually involves the use of a general anesthetic and can take from 1 to 4 hours, depending on what exactly is required. If there is any "drooping" to the breast, the breast may also have to be "lifted" at the time of surgery so that the breast will sit "on top"' of the implant placed behind it. An examination will be part of the consultation process to determine if a 'lift" is needed (an "augmentation mastopexy").

Post-operative recovery time will vary from patient to patient, but you can expect to be able to return to work in one to two weeks and exercise in approximately four to six weeks. It is not expected that there will be any long term limitations on your lifestyle as a result of this type of surgery. The presence of an implant does not affect pregnancy or nursing.

The first step is to arrange for a consultation with your plastic surgeon. During the consultation, you should have all your questions answered. You and your surgeon will be deciding what size and type of implant should be used, through what incision it will be placed, and where the "pocket" for the implant will be made.

Implants come in many different sizes, measured in cubic centimeters ("cc's"). The more "cc's", the larger the breast implant size. Implants can also be round in shape or "tear-drop" shaped. Round implants are used more commonly than the "tear-drop" shaped. The shell of the implant may be smooth or rough ("textured"). There is even an "adjustable" implant that can be made smaller or larger post-operatively. Your surgeon will help you decide on what size and type is best for you. If your breasts are different sizes, different size implants may be used to try and camouflage this asymmetry.

Implants are made of a silicone rubber shell that is filled with either saline ("sterile saltwater") or silicone gel. Saline implants were approved by the Food and Drug Administration in March, 2000. Silicone implants are currently undergoing the FDA-approval process. No scientific evidence has shown that breast augmentation increases the risk of breast cancer, autoimmune disease, or any systemic illness.

The incision used to place the implant can be made either in the axilla, around the periphery of the areola (the darker skin around the nipple), in the fold beneath the breast (the inframammary fold), or through a small incision near the bellybutton (the umbilicus). These are small incisions, usually less than 2 inches in length. The inframammary incision is used most often. If you need to have the breast "lifted" as part of the augmentation process, the incision used for this part of the operation would then be used for placement of the implant.

The implant must be placed in a surgically-created "pocket" behind the breast. This "pocket" can be made either on top of the pectoralis muscle behind the breast, or , more commonly, under the pectoralis muscle. The advantages and disadvantages of each site should be discussed with your surgeon.

Every surgical procedure carries with it some potential risk for complications. These should be discussed with your surgeon during the consultation process. In general, the potential complications of breast augmentation are similar to those of any other surgical procedure and are: bleeding, infection, poor scarring, and numbness or loss of sensation. You and your surgeon should discuss these potential risks and how they would be handled if they were to occur.

Bleeding can occur into the pocket made to accommodate the implant. This will usually occur within the first twenty-four hours after surgery and would be noticed by the breast getting larger, more painful and bruised. This is usually treated by returning to the operating room for removal of the implant, evacuation of the blood, stopping any bleeding that is found and replacement of the implant. Some minor bruising may be visible after surgery. This will resolve over 7 to 10 days and is of no consequence. There will be some swelling of the pectoralis muscle if the implants are placed beneath them. The implant will "settle" and this swelling will resolve over the two to four weeks after surgery.

Infection risks are reduced by the administration of antibiotics. You should notify your surgeon if you experience any warmth, redness, swelling or drainage from the incision.

Scarring is somewhat unpredictable and will vary from individual to individual. Your surgeon can suggest some post-operative scar care to minimize the risk of poor scarring.

After breast augmentation the nipple may have increased sensitivity or, uncommonly, have decreased sensation. It is rare for this to be permanent.

Unique to breast augmentation, are potential complications that involve the presence of a foreign body (i.e. the implant). The body will form a scar around the implant. This is the "capsule". In some women, this capsule can thicken and contract to a varying degree. This is called "capsular contracture". When it is severe, the breast can become firm, the shape can be distorted and the breast can become a source of discomfort. Additional surgery may be needed to try and correct this. It is generally felt that the incidence of capsular contracture is less with implants filled with saline and placed under the pectoralis muscle. Textured implants were created originally because if was felt that they may have a lesser incidence of capsular contracture, but this may not be significant and the potential downside of "rippling" that can be either felt or seen may make their use less desirable.

Breast implants cannot be expected to last forever. If a saline-filled implant leaks, you will experience a loss of volume and the saline will be harmlessly absorbed into your body. If a silicone gel implant leaks or breaks, the gel will, for the most part, be contained within the capsule formed around the implant. You would most likely experience a change in shape or an increase in the firmness of the breast as a sign that this has happened. Silicone breast implants may come to be routinely replaced in the future. Both manufacturers in the United States (Inamed and Mentor) have warranties for their breast implants that will cover replacement should a deflation occur.

Finally, the breast implant can potentially interfere with mammographic screening for early detection of breast cancer. It is important that you have your mammography performed at a center where they can make sure that all the breast tissue is imaged over the implant.

Be sure to find a caring and concerned plastic surgeon, with whom you have good communication, to guide you through your breast augmentation surgery.

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