Breast Augmentation; Consultation letter to Breast Augmentation Patients
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Breast implants were invented in the early 1960’s by Dr. Frank Gerow
and Dr. Thomas Cronin, two Plastic Surgeons from Houston, Texas. The
first implants were made from an outside shell of silicone rubber and
contained silicone gel. They had a remarkably natural feel that very
closely compared to normal youthful breast tissue. The major
complication of silicone breast implants was scar formation around the
implant which made them get very hard and even, in some cases, very
painful. This is not surprising since all foreign objects that are
placed into the body cause scar tissue to form. However in the case of
stainless steel plates for fractures or a pacemaker, no one cares if
they are hard because they started out that way. In the case of breast
implants, it occurred 80 percent of the time which was a very big deal.
After some research, Plastic Surgeons began placing the implants under
the Pectoralis muscle in an attempt to prevent this “Capsular
Contracture” from forming. This was somewhat successful and brought the
contracture rate to approximately 30 percent. Better but not perfect.
Then research was done changing the surface of the implant to what is
called textured or rough. The idea was that the irregular surface would
bond with the body’s tissue better and break up the scar tissue and,
thus, prevent contracture. This worked much better with contracture
rates approaching 5 percent. However, like everything in medicine,
nothing is zero percent and contracture rates still range around 5
percent. So in the late 1980’s there were silicone gel breast implants
with textured surfaces and the results were excellent. In fact the
results were so good that many times it was impossible to tell by
physical exam that patients had implants.
In the early 1990’s a group of women that had undergone Breast
Augmentation and Reconstruction began making claims that their Silicone
Breast implants were causing diseases in their bodies. These were
serious, progressive and non-curable auto-immune diseases such as
Rheumatoid Arthritis, Lupus, and Chronic Fatigue Syndrome. There was no
scientific evidence that this was occurring but the claims caused the
Food and Drug Administration (FDA) to ban their use. After several
years of litigation and scientific study, it has now been shown that
Silicone Breast Implants do not have any association with or cause
disease in patients. That does not mean that they are perfect by any
means. The problem with silicone gel is that it is not absorbable by
the body. So if it ruptures and the gel gets outside the scar tissue
that normally encases the implant (this is very uncommon), there can be
some very serious inflammatory tissues that can form and may require
surgery to correct. But this is not a disease. You must always keep in
mind that nothing in medicine or surgery is perfect. For example, if
you vaccinate your children, as many as one in two hundred thousand can
have a severe reaction and even die.
However, at the time of this writing, the only implants that
are approved for general use are Saline-filled. They are made of a
similar silicone rubber shell and are inflated at the time of surgery
to their appropriate size. The nice thing is that if they break, the
body just absorbs the water with little side effect other than the
volume is lost. However, as you will see during your consultation,
saline-filled implants do not feel anything like silicone gel or normal
breast tissue. This is why we now generally place these implants under
the Pectoralis Muscle. It is a sculpting technique to hide this implant
under normal soft tissue. In this way, the implant is less visible and
feels more natural. They are still not as natural feeling as silicone
gel but they are almost always acceptable in appearance and feel for
most patients. Another interesting thing about saline-filled implants
is that the rate of Capsular Contracture (becoming hard) is about the
same for textured and smooth implants. Since textured implants tend to
be more visible and palpable (easily felt), I think they are less
natural. Therefore, I have preferred smooth implants since 1996 and
have had little trouble with hardness.
There are three options for placement of the incision and there are pros and cons to each.
Placing the incision in the armpit is nice because there is no
incision on the chest. However, the most critical part of Breast
Augmentation is the placement of the implant in the fold below the
breast. Since this incision is the farthest from the fold, it is
technically more difficult to place the implant precisely. Also, you must consider this surgery a maintenance operation.
For many reasons it may be necessary for you to undergo additional
surgery to improve or maintain the result. Although I have not seen
these rates of re-operation in my practice, in recent data the
re-operation rate can approach 20 percent in ten years. The problem
with axillary incisions is that many of the surgeries that need to be
done in the future can not be done through that incision. Therefore,
many of the women that have used this incision will need a different
one in the future. For these reasons, I don’t prefer this incision.
Under the breast fold was the most common way when silicone gel
implants were being done because you needed a large incision to place
that kind of implant. The problem with that incision is that it
frequently widens and rises up on the breast and is visible. Unless I
am revising a patient from another practice who has this scar, I nearly
never use this approach.
Most surgeons, me included, prefer an incision around the nipple. This
is called the peri-areaolar approach. There are some misconceptions
about this incision that deserve discussion. You might have heard that
if you go through the nipple, you can not breast feed in the future.
This is not true. We never cut through the ducts that connect the
nipple to the breast tissue and, therefore, all patients should have no
difficulty breast feeding. Another thing you might hear is that it is
more painful to go through the nipple. This is, again, not true. Most
of the pain associated with Breast Augmentation is related to muscle
spasm that results from making the pocket for the implant. Since you
are going to make a pocket below the muscle regardless of the incision,
the post-operative pain is the same for each incision. Lastly you might
hear that going through the nipple causes the nipple to become numb.
This is not true either. However, can you get nipple numbness from this
operation? The answer is yes. But it has nothing to do with the
incision. The nerves that go to the nipple are located near the pocket
for the implant and commonly get stretched and bruised. If they get
stretched or bruised enough, they can stop working. In the 15 to 20
percent of cases that have numbness after surgery, most will resolve
and be normal at 12 months. However, they might be permanently numb.
But this has nothing to do with the incision. It is, again, due to the
pocket. There are three reasons that most surgeons perform this
incision. For one, it is technically easier to create the pocket
precisely. Two, if you ever need another operation you can usually
perform it through the same incision. However, the biggest reason why
most surgeons use this incision is that for some reason, and no one
knows why, this area heals with nearly an invisible scar in the
majority of patients.
Breast augmentation is performed as an outpatient. In this
practice it is performed under general anesthesia. Although some
practices perform Breast Augmentation with sedation and local
anesthesia, I believe that it is a much more pleasant experience and it
can be done more precisely with you asleep. The risks of general
anesthesia are commonly greatly over-stated. In fact, most patients
have a much larger risk of injury and death by getting into their car
than from the sophisticated general anesthesia techniques now
available. I do not use drains, or little tubes, to collect fluid that
may occur around the implant. I know that some surgeons do, but I have
found no advantage to using them. However, I would not fault a surgeon
for using them and I have, on occasion used them as well. If they are
used, they generally are removed 24 hours later.
We always see you the following day after surgery. We will give you a
post-operative bra at that time. We will see you again in 7 to ten days
to remove sutures and again at 6 weeks after surgery to make sure the
implants are settling well into their pockets and everything is
progressing normally. I like to see you yearly to check and see how you
are doing.
Most patients take about 7 days off of work. I only have two major
rules after Breast Augmentation. No push-up or under-wire bras until
the implants have settled (about 6 weeks) and if it hurts, don’t do it.
Most patients can only lift 10 to 15 pounds for the first two weeks.
Mild exercise can usually be started in two weeks but upper body work
outs should be put off for four to six weeks.
It takes about 6 weeks to see the final result with any type of
surgery. However, areas of the body that have undergone surgery
actually change and mature for an entire year. The changes from six
weeks to a year are very subtle and occur slowly.
Other factors important when considering Breast Augmentation include
whether or not you have finished having children and how recently you
breast fed your children. Pregnancy and breast feeding have major
hormonal, physiologic and anatomic impacts on the breast that may be
very important to the outcome of your surgery. It may require more
surgery to improve or maintain the result after having children. It may
be wise to wait until after you have had your children before having
breast augmentation. Because of risk of infection, you should not
breast feed within 8 months of having your surgery. Also, becoming
pregnant immediately after your surgery may compromise your result due
the large hormonal stimulation to the breast with pregnancy. If you
have questions about these factors, please bring them up at the time of
your consultation.
There are two other concepts that are very important for you to understand. First is the concept of cup size.
Cup size is the worst way to measure an individual’s breast for many
reasons. First, few people understand what is really meant by cup size.
Few women wear the right size bra and all bra manufacturers make them
differently. Also, each patient has a unique anatomy that will dictate
what size implant is best for them and how they will look after
surgery. As the implants get larger, their base diameter
becomes bigger and they can sit too close to each other. This
looks ridiculous. The implants also only come in so many sizes. Because
of these factors, there is no guarantee for post-operative cup size on any specific patient.
However, I always ask what the patient wants to figure out what they
are thinking. Patients that come in desiring to be a C usually really
want a D but are afraid to say that thinking that a D is too big. What
that means to me is that they want to be proportional to their body
size and look good in their clothes and bathing suits. They just don’t
want to be the object of jokes or have their significant others get in
fights over them. Women who come in saying they want to be a D usually
want to be much bigger. Usually as big as I can possibly go. Sometimes
patients come in with pictures from magazines and say “I want to look
just like this.” The reality is that we don’t usually have that much
flexibility with Breast Augmentation and that your individual anatomy
will dictate your final result. I sometimes joke with my patients that
this is not a Burger King operation. You can not “have it your way.” If
you started out looking like “Miss July”, it is likely you will have
her result. But otherwise, it is very unlikely that any patient would
look exactly like “Miss July.”
The other concept that you must be comfortable with is that Breast Augmentation by its nature is a maintenance operation.
By having Breast Augmentation you are making the choice to enhance your
appearance by enlarging your breasts. However, it is very likely that
the results of this one operation will not last your lifetime. In most
patients it lasts years, but there are multiple reasons that patients
need additional operations. Most of these will be covered below. The
fact is that the majority of patients will undergo further surgery in
the future to maintain or improve upon their result. Future
surgery, whether for revisions or complications, will almost always
result in additional anesthesia, facility, implant (if necessary) and
possibly surgeon’s fees. It is impossible to predict the kind of
surgery or the costs that would be required in this case. An example of
additional surgery would be Mastopexy. Mastopexy, or a breast lift, may
be necessary at the time of the initial Breast Augmentation or may
become necessary as a woman ages or has children. As the skin of the
breast ages, it can stretch and cause the nipple to become too low on
the chest. Mastopexy is designed to reposition the nipple back where it
belongs. This is not commonly needed in patients that have had a
standard Breast Augmentation, but it is possible. Also some women
decide later in life to have the implants removed. Those who do may
develop cosmetically unacceptable dimpling and/or puckering of the
breast following removal of the implant.
Risks:
Although all routine cosmetic surgical procedures have very low
complication rates, it is always important that you understand the
standard potential risks and complications of any procedure. I joke
with my patients and tell them that I have to scare them before I
operate on them. The reality is, however, that even if the risk is one
in a 100,000, if it happens to you it is 100 percent for you.
RISKS OF BREAST AUGMENTATION
BLEEDING: Bleeding is a potential risk of any operation. The
chance of needing a blood transfusion from breast augmentation is
exceptionally small. If a collection of blood occurs around the
implant, it is called a hematoma. If you get a significant hematoma,
you need to go back to the Operating Room to have it removed. You
cannot heal properly if a hematoma is in place. At the time of this
writing, our practice has had only four hematomas over a period of over
six years and approximately 400 cases.
INFECTION: Infection is a potential complication of any
operation but can be especially serious in breast augmentation.
Although every effort is made to prevent any infectious complications
including use of intravenous antibiotics, placing the implant in
antibiotics, placing antibiotics inside the pocket and giving
postoperative antibiotics by mouth, infections can still occur. If the
implant gets infected, the implant must be removed and must stay out of
the body for at least 3 to 6 months. This is a potentially disastrous
complication. Since our practice began, we have had one major infection
that required implant removal.
DEFLATION: Breast implants are products and it is unlikely that
they will last more than 10 to 20 years. Although there are some
patients who have had saline implants for 20 to 30 years and have done
just fine, it is doubtful that any surgical implant will last forever.
If a saline implant ruptures, it contains saline which is easily
absorbed by the body. Most patients describe not feeling anything, but
rather waking up in the morning with a “flat tire." The warranties
regarding these implants have changed, but at the time of this writing,
the implant company (Mentor) is willing to give you a new implant and
pay $1200 toward replacement of the implant for the first five years.
If you elect for the extended warranty, the warranty will be extended
to 10 years and increased to $2200 to help you replace the implant.
After 10 years, there is a life-time warranty on the implant, but any
recurrent surgical fees would be your responsibility.
SENSORY CHANGES: It is inevitable with any operative site that sensation in that area will change.
Whether the surgery is an appendectomy, hernia or a breast
augmentation, the area of surgery will change in the way it feels. Any
patient may experience numbness, tingling, burning sensation, twingy or
shooting pains. Most of these sensation changes will be short-lived and
resolve on their own, but they can be permanent. Thankfully, these
sensations are rarely permanent.
SCARRING: Although every effort will be made to make the
incisions and resulting scars as minimal as possible, visible scars are
possible with any operation. Occasionally implants do not settle in the
pocket properly and there can be some asymmetry in their Position.
Occasionally reoperation is required to place an implant in a more
natural Position. It has been more than five years since I have had to
redo that for one of my own patients. Despite using saline implants
underneath the muscle, you can still have capsular contracture and
hardness of the implant, but this is reported to be less than 5%. In
seven years I have had one patient require repeat surgery for this
problem.
BREAST ASYMMETRY: It is common for women to have one breast that
is larger or in a different position from side to side. This is
actually the norm and not the exception. Every effort will be made to
minimize this asymmetry, but there will probably be asymmetries left
after the surgery.
BREAST INDENTATION AND DEFORMITY WITH ANIMATION: Because the
breast implant is located underneath the pectoralis major muscle, when
that muscle is flexed with upper body workouts or exercises, the
implant will be flattened and move laterally. This is inevitable
because of the location of the implant.
BREAST CANCER: In our country the instance of breast cancer is
one in eight women during their life-time. This is an unfortunate fact.
The problem with breast implants is that x-rays do not go through them
and therefore mammograms are not as good as without breast implants. If
a patient has a mammogram without a breast implant in place, only 90%
of the breast tissue is seen. In women who have had breast implantation
approximately 40% to 50% of the breast tissue is seen; however, what is
interesting is that women who have breast implants if they do get
breast cancer have a slightly higher cure rate than the general
population. Why is this? In general because women with breast implants
tend to check their breasts and pick things up earlier. The earlier the
cancer is detected the more likely it is curable. Also when a patient
has a breast implant on their chest wall and the breast tissue is
draped over the front of it, it is physically easier to do a physical
exam and detect a smaller lesion.
PALPABILITY OR VISIBILITY OF THE IMPLANT: All of the implants
wrinkle within the body, although in most cases these wrinkles are not
visible through the skin. However, occasionally these wrinkles are
visible and many times can be felt through the skin. This is one of the
limitations of saline breast augmentation and is actually one
indication for converting to Silicone gel. At the time of this writing,
there are certain studies in which Silicone gel can be utilized and
this would be one indication that would indicate that.
RARE COMPLICATIONS: Rarely there can be complications such as
collapsed lungs and blood clots with pulmonary embolism, but these are
exceptionally rare.
STANDARD ANESTHETIC RISKS: The administration of any medication
has some amount of risk. Although every effort is made to minimize
these risks, adverse reactions and side effects can not always be
prevented. Complications of anesthesia can be as mild as slight
dizziness or nausea to more profound abnormalities. Although rare,
hospitalization may be necessary to control and/or treat any potential
complication. Any patient undergoing general anesthetic has a 1 in
200,000 chance of catastrophe and death. However this risk is small
enough to say that it is safer to have general anesthetic than get into
an automobile. It is not risk free, but severe complications are rare.
CALCIUM DEPOSITS: The longer implants are in the body, the more
likely it is to have calcium deposits in the scar tissue surrounding
the implant. It is possible these calcium deposits can make the breast
firm, but they can also further impair mammograms. This does not occur
in all patients.
About the Author
Located
in Sacramento CA, Board Certified Plastic Surgeon Dr. Donald Hause
provides the highest level of compassionate service in his practice of
Breast Augmentation, Breast Implants, and Breast Enhancement surgery. Check out his Breast Surgery page.
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