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Breast Augmentation

The majority of breast augmentations are performed using breast implants, silicone shells filled with saline or sterile salt water, or, more recently, silicone gel.

Silicone gel-filled implants are thought to provide a more natural appearance and are less likely to cause rippling than saline implants. One advantage to saline implants, however, is that the size of some implants can be adjusted after surgery by adding saline solution.

In 1992, concerned about reports of leaking silicone and possible health implications, the U.S. Food and Drug Administration (FDA) restricted the use of silicone breast implants to controlled clinical studies for women with breast cancer, those whose previous breast implants failed and those with congenital disorders. They were not permitted for women seeking breast augmentation.

In the past 15 years, however, more than 100 studies conducted on the safety of silicone gel-filled breast implants in the United States and around the world found no increased risk of connective tissue diseases (like scleroderma), autoimmune related disorders (like lupus and rheumatoid arthritis) or breast or other cancers or neurological disorders in women who have silicone gel-filled breast implants. In late 2006, the FDA approved the use of silicone gel-filled breast implants for cosmetic augmentation. Silicone gel-filled breast implants are currently approved for breast reconstructive surgery (surgery to rebuild a breast following a mastectomy) in women of all ages and for breast augmentation in women ages 22 and over. Silicone gel-filled breast implants are manufactured and marketed by Allergan, Inc., and Mentor Corp.

Today's silicone gel-filled breast implants benefit from 15 years of improved manufacturing technology and more stringent tolerance specifications. They have thick shells and a more cohesive gel. They were designed this way to greatly reduce the likelihood of rupture and to limit the possibility that gel will leak into the body if the breast implant does rupture.

Multiple recent clinical studies demonstrate that breast implant ruptures are relatively rare. To better understand the long-term safety of breast implants, the FDA has required that Allergan, Inc. and Mentor Corp. each conduct a 10-year study of 40,000 women with breast implants to assess potential safety issues to add to existing data. The FDA requires post-market surveillance for all medical devices and drugs as a standard condition of approval.

Surgical procedure for breast implants

During the surgery, breast implants are placed either behind the breast tissue (subglandular), or behind the chest muscles (submuscular). The former is primarily used in women with enough underlying fat to cover the implant; the latter in women with larger, heavier breasts. The surgery is performed under general or local anesthesia combined with a sedative in a hospital, office or outpatient surgical setting. In many instances, you can go home that same day.

Several surgical approaches are available:

• Inframammary. The surgeon makes the incision in the fold underneath the breast. This is the most common incision used in augmentation and is ideal for women whose breasts sag a bit since the natural droop of the breast hides the incision.

• Trans-axillary. The incision is made in the armpit, enabling the physician to place the implant behind the chest muscle. It is more commonly used in patients who have not had a pregnancy or whose areolas are small. However, the scar is visible under the arms and may even be seen when wearing sleeveless clothing.

• Trans-umbilical breast augmentation (TUBA). This is the newest form of breast augmentation incision. The actual incision is made through your belly button. Then the surgeon "tunnels" up through your chest area to a pocket under the breast or under your chest muscle with the deflated implant. Once the implant is placed, it is inflated with the saline solution. This procedure has a faster recovery time and less scarring, although there is a greater risk of damage to the implant itself. Because prefilled silicone implants are too large to fit through the navel, TUBA can only be used with saline implants.

• Peri-areolar. The surgeon inserts the implant through an incision around the nipple. Although this form can interfere with your ability to breastfeed, recent studies find that nipple sensation is typically not affected.

Breast Implant Complications

Breast implants carry a relatively high risk of complications. A New England Journal of Medicine study cited by the FDA found that 24 percent of women who had undergone breast implant surgery had complications requiring re-surgery within the first five years. Studies also show that about nine to 11 percent of women require additional surgery because of scar tissue that forms around the implant, causing it to thicken and contract. This process is known as capsular contracture and can sometimes lead to rupture or deflation of the implant. The risk of capsular contracture, however, is lower when the breast implant is placed in the submuscular position. It is important that you understand that similar to other medical devices, breast implants are not lifetime devices, and it is likely that at some point they may need to be removed or replaced.

Other possible complications include:

• Deflation. This risk is specific to saline breast implants and is greatest for breast implants placed under the muscle. A report by the Institute of Medicine found a deflation rate across studies of seven percent over seven years.

• Rupture. This risk is very rare, but breast implants can rupture in some cases. A large number of studies have concluded that a ruptured implant (saline and/or silicone gel-filled) has no long-term impact on a woman's health.

• Infection

• Changes in nipple/breast sensation

• Breast pain

• Hematoma, a collection of blood in the breast that must be drained

Many of these complications can be prevented with the method of insertion and by using antibiotics before, during and after the surgery, even infusing them into the breast cavity with the breast implant. If you suspect any of these complications you should consult your physician.

Despite the risk of complications and additional surgeries, most women who get breast augmentation are happy with the outcome. One study showed that after four years, 95 percent of women who underwent breast augmentation were satisfied with their breast implants.

After Breast Implant Surgery

After your breast augmentation, you will wear a special bra to prevent the breast implants from moving. You'll likely experience more pain with a subpectoral placement than a subglandular placement and may need a week or more off of work to recover. Expect to return to your full activities within a month to six weeks.

Mastopexy (Breast Lift)

A mastopexy, or breast lift, is a less intensive operation than a full breast augmentation. Most are performed in an outpatient setting, either in a hospital, your surgeon's in-office operating suite, or a freestanding outpatient surgery facility, usually under general anesthesia. The procedure itself takes between one and four hours.

There are several surgical procedures your surgeon may choose from for your mastopexy, but all involve the same major components: removing excess skin, repositioning the nipple and areola (the dark part of the breast surrounding the nipple) and ensuring a minimum of scarring.

Complications of Breast Lift Surgery

Complications include bleeding, infection and problems related to the anesthesia, although these are relatively rare. You will also have permanent scars, although they will be covered by your bra or bathing suit. You may also find that your nipples are unevenly placed, and you may lose some sensation in your nipples or breasts.

After Surgery

After mastopexy, you'll need to wear an elastic bandage or surgical bra over gauze dressings as your breasts heal. They'll be bruised, swollen and sore for a few days. The stitches are removed after a week or two. After that, you can wear a soft support bra over a layer of gauze for several weeks. You may experience some loss of sensation around your nipple area, but that usually fades over time.

Breast Reduction Surgery (Reduction Mammoplasty)

Several surgical procedures can be used for breast reduction surgery. The one that's best for you depends on several factors, including your medical history, size and shape of your breasts, desire to breastfeed and your surgeon's skill.

The most common procedure, according to the American Society for Aesthetic Plastic Surgery (ASAPS), is one in which the surgeon makes an anchor-shaped incision around the areola downward, following the natural curve of the crease beneath the breast. The doctor then removes excess fat and tissues, repositions the nipple and areola higher, and reshapes the breast. The major disadvantage of this procedure is scarring.

For women who need only moderate reduction, a vertical or short scar technique may be used. With this technique the horizontal or inframammary scar is avoided. The scars are located only around the areola and down the vertical midline.

For some women who require only a small reduction, liposuction may be considered. In this procedure, the surgeon uses a special tool to remove the fat and tissue from the breast without cutting and stitching, leaving minimal scars.

Most breast reduction surgery is performed under general anesthesia in a hospital or office-based surgical unit. You can usually go home the same day or, at the most, may require an overnight hospital stay.

Ask your doctor to examine the removed breast tissue for any abnormalities. A 2004 study published in the Journal of Clinical Pathology found that examining the removed tissue can help identify any cancerous or precancerous tissue.

Complications

While breast reduction surgery is a common and relatively safe procedure, there are some risks and possible complications. For instance, there may be changes in the sensitivity of your breasts and nipples. If the blood supply is reduced, the nipple area or other areas of skin may slough off. Other complications include fat necrosis or lumpiness in the breast. Breast reduction may also be associated with an inability to breastfeed because some of the ducts leading to the nipple may be cut during the operation. There may be delayed healing or minor differences between breasts following the operation. One way to reduce your risk of complications is to quit smoking. One study found the risk of complications after breast reduction surgery was three times higher in smokers than nonsmokers.

After Surgery

After the surgery, you usually wear a postsurgical bra over gauze dressings for four weeks and shouldn't lift anything heavy during that time. You may also have some drainage tubes in your breasts for several days or even weeks. While it may take up to six months for your breasts to return to normal, you can resume your normal activities within three to four weeks.