Selected Chapters on Breast Enlargement from BeautyScience, by New York Plastic surgeon Dr. Bellin
Howard T. Bellin, M.D.
article courtesy Howard T. Bellin, M.D.
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from Dr. Bellin's Beauty Science
Introduction to Breast Enlargement
A woman's breasts are in many ways a symbol of her femininity. They are not only an important part of her outward appearance, but should contribute to an inner security that goes far beyond her aesthetic appeal. They should be a constant source of pride and enjoyment. Unfortunately, this is not always the case.
Small-breasted women, for example, often feel less feminine than their more generously endowed counterparts. Even women with "normal" breasts may see their once-beautiful bosoms sag or diminish in size from pregnancy or aging. Besides the obvious visual displeasure, they sometimes suffer emotional problems that persist throughout their lives.
There is a prevalent misconception that women want to enlarge their breasts to attract and please men. This is rarely the prime motivation. Most women do it for themselves. Numerous studies have shown that women want larger breasts for one reason - improving their self-esteem.
It is well known that there is a relatively simple surgical procedure called augmentation mammoplasty that almost always produces excellent results. So if you're among the growing number of women who want more beautiful breasts, this operation will be a safe and effective way to do it.
It is for this reason that breast augmentation is one of the most common operations performed by plastic surgeons today. There are an estimated 2 million American women who have had breast implants. An estimated 160,000 to 190,000 women had their breasts enlarged last year! In my 30 years in private practice I have personally performed over 2000 breast augmentations including 114 last year. Over this period of time I have used almost every type of implant approved by the FDA, placed the implants above and below the muscle and used all but one of the possible incisions. Among plastic surgeons there are varying beliefs about how the surgery should be done and I respect them; but because of my extensive experience, I believe my opinions on the subject of breast augmentation should be strongly considered.
CORRECTING AESTHETIC PROBLEMS
VERY SMALL OR NEARLY ABSENT BREASTS
This is a fairly unusual problem, because most women have at least some breast tissue. However, if you're among the few women who are extremely flat-chested, then this operation will really help.
The incision will have to be made around the nipple due to the scarcity of the breast fold, and the implant will usually product a nice cup. The surgeon will not attempt to make your breasts too large, because the edges of the implant might show through your skin. If you still want further enlargement after the operation, allow the implant to stretch the skin for about one year and then have it replaced with a larger implant.
SMALL TO MODERATE BREASTS
If you have some breast tissue but want to be larger, this operation will almost certainly produce satisfactory results. You can choose the type and size of the implant and also the location of your incision. While you're almost sure to be satisfied with the resulting enlargement, a further increase can be obtained as in the previous operation. However, one procedure usually provides a thoroughly pleasing improvement.
LOSS OF BREAST TISSUE FROM AGING OR PREGNANCY
The breast is an organ that constantly goes through natural changes. It enlarges and diminishes every month. When a woman is pregnant her breasts grow larger, but when hormonal changes cause them to shrink back, they may end up smaller than before. The same kind of shrinkage often results from aging. Unfortunately, the loss is usually the most noticeable in the upper part of the breasts. But you don't have to suffer from this, because implants will help tremendously. The partially empty sacs of skin at the top of your breasts can be effectively filled to their previous proportions (or even larger), and your bosom will be restored to its former beauty.
This particular problem may also result from aging or pregnancy, but it affects younger women, too. Mild to moderate sagging is usually improved through an implant that gently lifts the breast as it continues to fill out. But if you suffer from medium to severe sagging, you'll need a breast lift to correct it. Simply adding an implant to a badly drooping breast creates only larger badly drooping breasts. The surgeon will tell you which operation should produce the best results, and in some cases you'll need both implants and the uplift.
Stretch marks are a form of scar tissue resulting when the deep layers of skin are torn from pregnancy or excessive weight gain. If the stretch marks are accompanied by loose skin, you may be able to achieve a slight improvement. Otherwise no treatment will help.
When there is excess skin, the wrinkling is more pronounced. By adding a breast implant, the skin becomes tighter, pulling the stretch marks tighter too. While still present, the stretch marks should be taut and flatter and hopefully less visible than before. Of course, when the operation is over you'll also have larger breasts, which may be a factor in your decision.
Most women have breasts that are slightly dissimilar in size and shape, but some women have breasts that are markedly out of proportion with each other. This can always be improved if not completely corrected. An implant in one breast can produce instant equality, or both breasts can be augmented with different-sized implants to achieve the same result. But if one breast is small and "virginal" while the other is large and drooping, the correction may be more complicated. It may be necessary to augment one breast while reducing and/or reshaping the other. It' even possible to correct defects in the chest wall at the same time by using an additional custom-made implant.
At the initial consultation, the physician should thoroughly explain the operative procedure, the post-operative course, and the possible risks and complications. And of course there must be a discussion of the size of the implant desired. You should also be shown many pre and post-operative photographs of other patients he or she has treated.
There are several types of implants, including saline, silicone gel and hydrogel; there are different size and shape implants with different types of coverings; they can be placed over or under the muscle using local or general anesthesia and there are four different incisions that could be made. A discussion of all these options will follow.
THE PRINCIPLE OF THE SURGERY
A breast implant is essentially an inert object that is placed into a space created surgically behind the breast. It pushes the patient's own skin and breast tissue forward thereby increasing its size. It does not go into the breast tissue itself. When properly done, it does not interfere with the breast function in any way. It does not interfere with sensation or with nipple erection. Most people believe that it does not reduce the ability to nurse a child, although there is some evidence that lactation may be slightly diminished. An implant does not interfere with breast cancer, neither causing it nor preventing it, although some statistical studies have shown that women with breast implants have less of a risk of breast cancer than the general population -- no one knows why. Since the breast tissue remains in its normal position in front of the implant, any tumor growing in the breast could still be detected on self-examination or an exam done by a doctor. Most experts believe that mammograms, when done by a skilled person, can detect breast cancer in women with implants at the same stage as in women without them, but some minimal interference may occur. And if a tumor ultimately had to be biopsied, it could be done without ever disturbing the implant.
The operation can be done in an office or hospital operating room under general or local anesthesia with intravenous sedation, the latter being my preference as there is much less bleeding with local anesthesia and little if any nausea after the surgery. It is also safer. The procedure takes an hour to an hour-and-a-half. After a short recovery period the patient can go home with two small bandages and return one week later for suture removal. If the implants are placed above the breast there is only moderate pain after the surgery, much like muscle pain after too many pushups. Mild pain medication is usually taken for the first two or three days. Most patients can have the surgery done on Friday and go back to work on Monday, still a bit sore, but perfectly able to function. Under the muscle placement is much more painful and requires at least a week of immobility. But I advise no vigorous exercise such as jogging or workouts for three weeks. After that, virtually nothing one does can injure the implants.
CHOICE OF INCISION
The implants can be placed using one of four options: in the breast fold, around the nipple, in the armpit (axilla), or through the navel. A surgeon may give you a choice once you understand the implications of each.
1) In the breast fold: This is my preference as it hides the scar well should it thicken. It provides the easiest and safest approach for the surgeon and is the one most commonly used. I am able to do the surgery through an incision measuring exactly one inch.
2) Around the nipple: This is often a very thin scar; if not, it will be very visible. The biggest risk of employing this incision is loss of sensation in the nipple that can occur up to 50% of the time.
3) In the axilla: This is a popular means of access when the implant is put under the muscle, but it can also be used for over the muscle. My feeling is that everyone is now aware of the implications of a scar in this area, so if it thickens, raising your arm on the beach or in a low cut gown will be a dead giveaway that you have implants. This incision also makes proper placement of the implant very difficult. Unfortunately, I have seen many patients with implants that were placed too high on the chest because of this approach. I use it only rarely, when a patient insists on having it.
4) Through the navel: This is the only approach I feel is inadvisable. The surgery is performed through a long tube called an endoscope. While the scar may be imperceptible, it is nearly impossible to dissect a large enough pocket for placement of the implant in this manner. Therefore, the method used is creation of the space by blowing a dissecting balloon that tears open the area. This does not create a large enough pocket for the implant, so that its outline can be seen, producing a very unaesthetic appearance. If bleeding should occur, stopping it can be very difficult. Furthermore, because the implant can be abraded and weakened when pushed through the endoscope, the implant manufacturers will not guarantee their products in the event of leakage.
THE BREAST IMPLANT
PLACEMENT OF THE IMPLANT
A breast implant can be placed behind the breast--above the muscle (sub-mammary placement) or behind the pectoralis major muscle of the chest (sub-pectoral placement). Since the pectoralis muscle does not completely cover the implant, a third method uses smaller chest muscles to cover it entirely. This variation is rarely done. An estimated 60% of the plastic surgeons in America place the implant above the muscle and 40% place it behind the muscle. I believe as the majority does in placing it above the muscle, (directly behind the breast) except in a very few circumstances. Of the 114 patients on whom I did a breast enlargement last year, I put only three of them behind the muscle. Here are the reasons for my preference for placing the implant over the muscle:
1) Aesthetically pleasing: Most importantly, done correctly, an implant looks perfectly natural over the muscle, as that is of course where nature put the breast. Placement behind the muscle often gives too much upper pole fullness that not only looks unnatural, but can sometimes cause the nipples to appear to point downward. This deformity is more likely to appear when the implants are placed from an incision under the arm.
2) Local anesthesia option: Over the muscle, the surgery can be done with intravenous sedation and local anesthesia which is safer and less expensive, but of course general anesthesia is available. Placement behind the muscle always requires general anesthesia or a complicated series of nerve blocks.
3) Preservation of the pectoralis major muscle: When implants are put behind the muscle, the inner attachment of the muscle must be cut to allow space for the implant. Not only does this increase the risk of bleeding, but also it severely weakens the pectoralis major, the main chest muscle. In the past year and a half I removed five sets of implants placed behind the muscle by other surgeons and put them in front of the muscle because they looked so abnormal. In all these instances, the pectoralis muscle was paper thin, having been destroyed either by the pressure of the implant beneath it, or by the detachment of the muscle. A muscle that is not attached at both ends cannot contract, cannot be exercised, and thus atrophies. Cutting the muscle also increases the risk of bleeding after the surgery.
4) Natural feel: The only reason for placement behind the pectoralis is that its proponents believe that it causes less capsular contracture (apparent hardness of the implant to be discussed later). This is very controversial as some studies have shown this to be true and others have shown no difference in the feel of the breasts no matter where they are placed. A colleague of mine says that he has done over 5000 augmentations, probably more than anyone in the country. He has placed implants in both positions and strongly believes that there is no difference in the feel of the breasts and now places them exclusively above the muscle.
In addition, because of the anatomy of the pectoralis muscle, it can only cover about half of the implant. Since the capsule surrounds the implant completely, it makes no sense that sub-muscular placement can prevent capsular contracture. The same is true about the complication of rippling.
5) Less pain: There is much less post-operative pain with the implant placed above the muscle. No strong narcotics are usually necessary; pain medication is usually taken for only the first two days, and patients can return to work in two or three days. Under the muscle placement is very painful requiring strong narcotics for a week and often two, and a week away from work is usually necessary.
To summarize the disadvantages of putting the implant under the muscle (sub-pectoral): it virtually destroys the muscle; it can appear very unnatural; there is increased risk of bleeding; it is very painful for a week or two; the implant is only about half covered by the muscle. And in my opinion, it does not make the breast feel softer or prevent rippling.
SIZE OF IMPLANT
The size of the implant is very important. You might want to be very large, or, as with most women, request just a cup to a cup-and-a-half size larger. Of course there is no standard cup size--every manufacturer has its own idea of what a C cup is, for example. There is no standard, so asking for a specific cup size will only give your surgeon an idea about how much larger you want to be. The implants are measured by the volume of fill material that they hold, but as a general rule, 200 cc. makes an enlargement of about one cup size in a smaller breast. Standard implants range from 125 cc. to 800 cc. when filled.
COVERING OF IMPLANT
The outside surface of the implant can either be smooth or "textured", meaning rough. The textured surface is meant to break up the direction of the fibers that form the capsule so that they cannot contract in unison and cause hardening. I found that with textured implantsI had a much higher incidence of hardening than I did with the smooth-walled ones. But some studies have shown results to the contrary. There are also different types of texturing.
There are other serious problems I have found with textured implants. Because the manufacturing of a textured implant requires that its wall be thicker, if the implant ripples, it does so with a vengeance. Even more distressing, there was a high incidence of leakage with the textured implants. Finally, if textured silicone is used, the rough surface requires a large incision because the implant will not slide through a small one.
SHAPE OF IMPLANT
Implants come in various shapes. They are commonly round. They may have a high, medium or low amount of projection. They can also be shaped like an oval or tear drop. These so-called anatomical shapes have more projection in the lower pole than in the upper. This is meant to mimic the natural shape of the breast. However, years ago, an experiment was done where one breast was enlarged with a round implant and the other with an anatomical one (with the patients' permission, of course). Six months later, independent observers could not tell the difference. The real problem with oval-shaped implants is that if they are smooth-walled, they can rotate. When that happens, the breast can appear terribly misshapen. To prevent this, it is necessary to use a textured implant, which has the disadvantages just mentioned.
There are several risks associated with breast enlargement. Remember that a risk is something that the surgeon cannot control, so misplacement of the implant, for example, is not a risk. It is a mistake. If your prospective surgeon does not describe all the risks of the surgery, do not let him operate on you. Find someone else.
1) Infection: I give antibiotics right after the surgery to attempt to prevent an infection from occurring. Infection in my personal experience is very rare -- about one in one thousand operations; however, should an infection occur, the implants might have to be removed. They would be replaced later on at no extra charge.
2) Bleeding: Bleeding after the surgery is also very unusual, about one in one hundred patients. It is not life threatening. This can happen because a small blood vessel can open up a few hours after the surgery and begin to ooze. The breast would swell a great deal and become quite painful. It would necessitate returning to the operating room to stop the bleeding. I emphasize that it is not a dangerous condition, only something that needs to be taken care of.
3) Hardness of the breast: The most common problem with breast augmentation is that the breasts might not feel natural. This can happen because your body makes a covering around the implant, sort of like a scar, that is referred to as a capsule. This is the way the body walls off an object that is foreign to it. (Silicone has the property that it cannot be rejected, so in a sense, it is just isolated). If you form a thin capsule around the implant, your breasts will feel soft. Unfortunately, if your body makes a thick capsule, it can squeeze the implant and then it will feel hard. This is called capsular contracture. (Think of it as a balloon not quite filled with water that you then squeeze--it feels hard.) The problem does not cause illness, it is simply unaesthetic. It can be remedied in most cases with a procedure called a closed capsulotomy. To accomplish this, the doctor will squeeze your breast very hard to break the capsule. (It is almost impossible to break the implant.) Breaking the capsule alleviates the contracting effect and allows the space around the implant to expand making the breast feel soft again. This could recur again. The overall risk in my practice is about 10% to 15%. Years ago a surgical procedure call open capsulotomy was performed. This entailed opening the old incision and removing the capsule. It was soon learned that this was fruitless, as the capsule almost always formed again the same way.
It is, however, strongly recommended that closed capsulotomy no longer be done on those with silicone gel because these older implants are more prone to rupture.
4) Rippling of the implant: Sometimes, when the capsule forms, it can pull the implant in such a way that it causes it to ripple. This is sometimes felt and less frequently seen. There is nothing that can be done once this occurs. Recently I have begun over-inflating the implant slightly. This slight bit of added tension seems to prevent rippling in most cases. This problem is much more pronounced with saline implants than with silicone gel-filled implants because the gel adheres to the inside of the shell and prevents rippling. On occasion the gel implants can fold slightly so that an edge of the fold can be felt.
Rippling is much more frequent in women who have stretch marks or very thin breast tissue after pregnancy (not small breasts, but breast tissue that has thinned after having a child).
5) Deflation - Leakage: If a saline implant has a manufacturers defect, the saline would slowly leak out and be absorbed and eliminated. It is totally harmless - just like drinking salt water. The manufacturers guarantee the implants, providing a new one for no charge and reimbursing the surgeon a modest amount for replacing the implant.
UNDERSTANDING POSSIBLE COMPLICATIONS
There are several complications that can occur after breast augmentation, and the prospective patient needs to know what they are. Do not let anyone operate on you who does not discuss these complications.
The first and most rare is infection. In my experience it occurs in about one in one thousand operations. Antibiotics are often given after the operation in an attempt to prevent an infection. However, if an infection were to occur, the implants might have to be removed. After a suitable waiting period, the implants would be replaced, usually for no extra charge.
Next is bleeding after the surgery. It is not life threatening. It happens because a small blood vessel under the breast can open up a few hours after the surgery and begin to ooze. This will make the breast swell even more and require a return to the operating to stop the bleeding. Again, it is not dangerous, it must simply be taken care of. This happens in about one in every one hundred operations.
The commonest complication is firmness of the breast months after surgery. This happens because the body "walls off" the implant by surrounding it with a scar-like shell which we call a capsule. If the capsule contracts down around the implant and squeezes it, it makes the implant feel hard. This can often be helped by having the doctor squeeze the breast very hard to break the capsule which the body makes. When the capsule breaks, it lets the space the implant is in expand and the implant will again feel soft under the breast. It could occur again. The overall risk is stated to be anywhere from 5% to 15%. This procedure, called a closed capsulotomy, has its own risks: the rare chance that the implant could break or that bleeding could occur.
The risk of rippling has already been mentioned. It is mainly a problem caused by saline implants and tends to occur more frequently in patients who have severe stretch marks on their breasts or have very thin breast tissue.
Finally, there is the risk of rupture of the implant. It could occur because of an injury to the implant during surgery, because of a manufacturer's defect or because of a "fold fault." This is caused by the shell of the implant becoming folded by the capsule, and the motion of the body keeps bending it until it wears out and breaks. (Think of bending a paper clip back and forth until it breaks.) Most manufacturers guarantee the implants for at least ten years and most surgeons will do a replacement free of charge. If a saline or hydrogel implant ruptures, the material is completely eliminated from the body. If silicone gel ruptures, it is harmless, but might cause lumps that can be felt and will need removal. Silicone implants that were put in 15 or 20 years ago have a significant incidence of rupture, but the newer models present much less of that risk.
All operations have essentially the same recovery period and possible complications. Although there is rarely any real pain after the surgery has been completed, patients often experience some soreness for about one day following the operation. Try to avoid strenuous activity for a week or two while healing progresses. But after three weeks you can do anything you want, including hard exercise. Also, you should be aware of the possible complications and what can be done about them. Whenever a complication necessitates further attention from the surgeon, it is almost always done for free. For example, postoperative infection is fairly rare, but if it does occur, the implant may have to be removed to treat the infection and then replaced later on. A few patients bleed after the surgery, but this condition is never life-threatening. They will probably need another operation to quell the bleeding and eliminate excess blood. Other complications include thickening of the scar and deflation of a saline implant. These problems have already been discussed. While they are infrequent occurrences, they do happen and should be considered. Also, some women lose softness in one or both of the corrected breasts. This results from the body's reaction to silicone bags. After the implant is in place, the body surrounds it with a fibrous capsule. If the capsule becomes too thick, it contracts around the implant, causing the breasts to feel harder than normal. While this is troublesome, it is easily rectified. The surgeon simply squeezes the breast very hard until the capsule breaks open and softness returns. Even though the risk of breaking the implant is minimal (since it is rubber), you should never attempt to do this on your own. See your surgeon! If the problem later recurs, the capsule can always be ruptured again.
Finally, in rare I instances a woman may be displeased with her implants, and then they can be easily removed. The breast skin almost always shrinks back to its original state.
As you can see, the subject of breast implants is highly complex and allows for many options. It is for that reason that I recommend that if you intend to have a breast augmentation, reread the information presented here. Then, consult a board certified plastic surgeon, preferably one with a lot of experience doing the procedure. Make sure he or she fully discusses all your options as to all the subjects I have discussed, and of course tells you all the risks. If you would like a personal consultation with me, just click here to contact me.