Breast Augmentation

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Breast augmentation is simply intended to enlarge the breasts.  This will improve body image, self-confidence, and resolve clothing issues such as the need to wear padded bras and problems with swimwear.  However, it is neither intended nor successful as a remedy for psychological problems or to improve an unstable relationship.  

Both saline and silicone implants are now approved by the FDA for breast augmentation.  Silicone implants today are filled with cohesive gel that has a consistency more like jello than water.  This is expected to have a protective effect in preventing silicone migration once the outer plastic cover (shell) has worn out many years after implantation. 

Both saline and silicone gel implants have the same outer cover (shell) made of solid silicone plastic.  Silicone is one of the most biologically inert substances known. Although there have been claims in the past that there is a relationship between silicone gel and certain rare connective tissue disorders, this has never been scientifically proven.  The latest studies from prominent university centers continue to refute this notion.  In fact, the Institute of Medicine, a Washington agency, has concluded that silicone implants do not cause any disease.  Their findings have been published in a very informative brochure called Information for Women about the Safety of Silicone Breast Implants.  A copy can be obtained from the National Academy Press at 800-624-6242 or online at www.nap.edu.  Another website that addresses the safety of implants and has other useful information is www.breastimplantsafety.org. Additional information is available from the implant manufacturer and can be obtained at www.mentorcorp.com.

The only issue of any significance regarding silicone gel is that eventual rupture of the implant shell may go undetected.  There are usually no symptoms when this first occurs.  The gel remains contained within the scar capsule around the implant and therefore still maintains the size and shape of the breast.  If this condition is not eventually recognized the gel may migrate outside the scar capsule and into the surrounding tissues.  Fortunately, it is possible to remove all of the gel without ill effect even in these cases.  Routine screening of silicone gel implants beginning about eight years after surgery using ultrasound or MRI scanning can detect early silent ruptures. 

Saline filled implants do not pose this problem.  When a saline implant eventually ruptures the breast becomes smaller over a few days.  The saline fluid is harmlessly eliminated through the kidneys.  The deflated implant must be replaced surgically although this procedure is less involved than the original procedure.  Saline breast implants are expected to last at least ten years and often last much longer.  However, they can rarely deflate a few years after implantation.  All implants, both saline and silicone, eventually require replacement.  Young women should anticipate the need for replacement probably more than once during their lifetime regardless of which implant type is used.  Please review the separate document entitled Saline vs. Silicone Implants: Pros and Cons for more information regarding the differences between the two implant types.
Breast implants can be placed either through an incision in the armpit, under the breast, or at the edge of the areola.  The incision is about an inch long for saline implants and an inch and a half for silicone implants.  Women with very little breast tissue and small areolae are the best candidates for an axillary incision provided that they select saline implants.  Women with breasts that were previously larger but which have atrophied following childbirth and breast-feeding are often best served with an incision either under the breast or at the edge of the areola.  Factors that influence incision location include age, implant type, areolar diameter and breast anatomy.

Breast implants can be placed either in front of or behind the pectoral muscle.  The decision is influenced both by individual physical characteristics and safety concerns.  Thin women with small breasts look better when the implants are placed behind the muscle.  Ripples or a visible implant edge are prevented due to the extra padding that the muscle provides.  Heavier women with larger breasts that sag may look better with implants placed in front of the muscle.  Mammograms are easier to read if the implants are located behind the muscle although implants in either plane affect mammograms.  Self-examination is not impaired by breast implants however.  Studies have also suggested that capsular contracture is less frequent when implants are placed behind the muscle. 

The body normally forms a thin layer of pliable scar tissue around any foreign substance placed beneath the skin.  This occurs whether the device is a breast implant, a pacemaker, or an artificial joint.  This process is beneficial because it maintains implant position.  Sometimes this scar layer, or capsule, will contract around a breast implant and render the breast hard in consistency.  This is a biological and not a surgical cause of breast hardening and essentially represents an over-reaction by the immune system.  The shape of the breast may change if this process becomes more advanced.  In extreme cases the condition may be painful enough to require surgical correction by complete removal of the scar capsule and replacement of the implant.  This treatment is usually successful although recurrence of dense scar tissue around the implant can happen in some women, particularly those in whom the process affects both sides.  The cause of excessive capsule formation, or capsular contracture, is not known.  Fortunately, capsular contracture requiring additional surgery occurs in only about 5 percent of` women.

Implant sizes range from about 100 to 400 ccs.  Breast size increases approximately one cup size for each 200 cc.  Most breast implants placed for augmentation range between 200 to 350 cc.  Size selection is guided by a woman’s wishes but is also influenced by her height, chest size, and the amount of normal breast tissue present.  A natural appearance is an important goal of this procedure.  The greater the implant size, the more difficult it is to maintain a natural look. 
Implant size is determined prior to surgery.  During a separate appointment a larger bra is fitted and silicone implants of various sizes are placed inside to simulate larger breast sizes.  Most women are able to accurately determine what size breast implant they prefer by this method.  This process is repeated on the day of surgery to finalize the decision.

There are several implant shapes available today.  While a “tear-drop” shape might seem a logical choice for most women, a round implant of proper dimensions and fill volume actually looks more natural in the vast majority.  Tear-drop or “anatomical” implants can sometimes rotate inside the pocket at any time after surgery and adversely affect breast shape.  Additional surgery may be required if this occurs.  Tear-drop implants can also make the breasts look odd in the reclining position.

Breast implants can have a rough (textured) or smooth surface.  Studies are suggestive but not conclusive that textured surface may decrease the chance of capsular contracture.  However textured implants, particularly saline types, tend to wrinkle more than smooth ones.  Smooth implants are generally preferred for all applications.

The process of making a pocket for a breast implant can stretch sensory nerves and diminish nipple sensation.  This is usually transient when it occurs but it typically takes many months to resolve.  Rarely, diminished sensation can be permanent.  The larger the implant the more likely this is to occur.  Breast-feeding potential should not be affected by placement of breast implants.

Complications from breast augmentation are rare.  Infection or bleeding problems can occur and may require additional surgery.  Potential aesthetic problems include implant asymmetry and a palpable implant edge, the latter most often seen in very thin women with saline implants.  Most asymmetry problems are minor and do not require correction.  A palpable implant edge is not a health hazard and does not require treatment.   

Breast augmentation generally takes about two hours and is performed entirely by Dr. Hidalgo.  It requires general anesthesia in order to completely relax the chest muscles and thereby facilitate implant placement.  Surgery is performed in our office operating room facility and discharge home occurs several hours after the procedure.  Aftercare is minimal.  An elastic binder is usually placed at the time of surgery.  The amount of discomfort is variable but is generally more when the implants are placed behind the muscle.  Most discomfort subsides within 48 hours.  Skin stitches do not require removal.  It is often possible to return to sedentary work after one week.  Most normal activities can resume by two weeks.  Strenuous physical exercise involving the upper body must be avoided for at least six weeks.  Eventually there are no restrictions of any type.

There are separate surgical, anesthesia, operating room, and implant fees associated with breast augmentation.  There is a reduced surgical fee for replacing a deflated saline implant that is partially reimbursable by the implant company if deflation occurs within five years (this coverage period can be extended through an optional warranty program). 

It may be helpful to go back and highlight specific paragraphs in this letter that you wish to discuss further during your consultation.  We encourage scheduling a second appointment if there are important issues that require further clarification.  Our nurses are also available to answer questions of a more routine nature that may arise after your consultation. 

Copyright © 2007 David A Hidalgo, M.D.


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