Breast Augmentation / Enlargement
Breast Enlargement can address issues of both size and shape of the breast. For some women their breasts did not develop as fully as they would like, and for others their breasts have decreased in size after pregnancy. In addition to increasing size of the breast an enlargement will also provide some lifting of the breast in cases where there is a degree of sagging.
In 1990’s there was a scare regarding silicone breast implants which caused them to be removed from the market in both Canada and the United States. From 1992 to 2000 Health Canada did not allow implantation of silicone breast implants. Of note, Europe and the rest of the world never stopped using them. Overwhelming unbiased scientific evidence proved that there is no link between silicone breast implants and breast cancer, autoimmune disease or inflammatory disorder.
Silicone filled implants are not the right choice for everyone. At this time silicone implants have a denser filling called “cohesive gel”. This gel is composed of silicone. The main advantage of the silicone gel filled implants is that they have smooth edges, and there is less likelihood of seeing or feeling the edge or ripples in the implants. The implants can rupture, though this may not be noticed by the patient or doctor. If a ruptured implant is identified then it needs to be replaced or removed. Some people think that gel implants feel more natural, but this is a personal decision.
Saline implants are available, and some patients feel strongly that this is what they would prefer given the controversy in the 1990’s. The disadvantages of the saline implant are that it can sometimes be felt or seen along the perimeter of the breast because of rippling along the seams, and if it ruptures the saline leaks out and a new implant must be placed.
Choice of size of the implants can be made by the patient at home. Take 2 small Ziploc sandwich bags and fill them equally with rice using a measuring cup. Put one into each bra cup and examine yourself in the mirror. Continue increasing the volume of rice in the bags until you are satisfied. The volume in milliliters (ml) is a good guide to the volume of implant you want. Implants come in a variety of shapes and sizes, and the selection of the correct volume and dimensions requires examination, measurement and a careful discussion with Dr. Goldberg.
Breast Augmentation is done as day surgery under general anesthetic and takes approximately 1.5 hours. During surgery Dr. Goldberg injects and applies long acting local anesthetic to prevent and minimize discomfort after surgery.
There are several incisions to choose from, and each has its benefits and disadvantages.
Incisions under the nipple where the colored area meets the normal skin are well concealed, but can limit the size of implant that is placed. It may not be an option for women with smaller nipples.
Under Breast Incision
Incisions placed under the breast at the crease where the breast meets the chest generally heal well, but nonetheless leave a scar in a place where it is visible when out of your clothes. It allows the placement of large implants.
Incisions placed in the armpit (axilla) allow placement of an implant with a scar that is well concealed at almost all times. The disadvantage is that it necessitates the placement of either a very small smooth surface silicone implant or a saline implant. For some this is a worthwhile trade-off, but requires careful consideration. Since this surgery is done through a small opening the surgeon cannot see the pocket where the implant is going, and there is the small risk that bleeding during surgery will necessitate another incision to be made under the breast.
Incisions in the belly button (umbilicus) are well concealed, but have disadvantages. Since the dissection is from below, there is some risk f the implants being placed or shifting too low. Also, only saline implants can be used. Dr. Goldberg does not perform this type of incision.
Implants can be placed in several different locations on the chest; under the muscle, under the fascia (fiber tissue), or under the breast tissue.
Under the muscle
The benefit of putting the implant under the muscle is that it is more covered by soft tissue to help camouflage it. However, the disadvantage is that because the implant lies under the muscle it will move or displace every time the chest (pectoral) muscle is activated. This is more often an issue with people who work-out or are performers.
Under the Breast
The benefit of putting the implants under the breast tissue only is that it avoids the problem of movement and activation with the chest muscles, but it may mean a more prominent margin of the implant if the overlying tissue is thin.
Under the fascia (fiber tissue)
The “fascia” is a fibrous layer of tissue that covers the chest muscles. Putting an implant under this layer avoids the movement due to muscle activation, and also helps to attach the outer surface of the muscle to the periphery of the implant thereby camouflaging it. This is often the best choice as it provides the benefit of both other methods, without the disadvantages.
Incisions under the nipple are well concealed at all times, but are limited in size and are not appropriate for women with small nipples or requesting large implants. Although there is no evidence to indicate such, there is a theoretical increase in risk of change to nipple sensation with this incision.
Dr. Goldberg prescribes several medications to ensure your comfort. These usually include Celecoxib and Percocet to control inflammation and pain, Ondansetron to prevent upset stomach, and Lorazepam (Ativan) to help with sleep if you need it. Swelling and bruising usually maximize around 3 days. You will also need to take antibiotics for 1 week. You are permitted to shower the day after surgery. You will need to wear something for support such as a sports bra continuously for 4 weeks, which can be removed for showers only. Most people are ready to return to work and light activities by 1 week after surgery. You will need to return for a check-up between 5 and 7 days after surgery. You need to avoid strenuous activity such as heavy lifting, work-outs, and sports for 4 weeks after surgery. Starting 2 weeks after surgery you will begin massage of the breasts to help break-down and prevent scar formation around the implants.
There are general risks with Breast Augmentation such as bruising, bleeding, infection, and risks associated with general anesthetic. There are also some specific risks. The current implants have many advantages. The durable shell that is used to create implants provides longevity that can last for decades. Also, the “cohesive” silicone gel that is contained in the implants shouldn’t leak even if the implant ruptures. As such, it is probable that some people will have implant ruptures that will never cause any problems or symptoms, will never be recognized, and don’t require any treatment. However, although there will most likely be little or no maintenance, one must accept the risk of needing further surgery to care for the implants. If infection occurs the implants may need to be removed. If a capsule or internal scar forms around the implant that is so thick that it becomes painful or deforms the implant then surgery may be required to remove the capsule or even the implant. Sometimes the implant can rotate or displace and further surgery may be needed to put the implant back into the correct position. If saline implants are slected there is also the risk of rupture and deflation. It is possible that nipple sensation will change after surgery, though this is almost always temporary. Approximately 50% of all women who have not had any breast surgery are unable to breast feed for a variety of reasons, and this risk does not change after Breast Augmentation. If the breasts are assymetric it is sometimes possible to correct the difference in size, but not shape or position of the breasts, and this assymetry will persist after the operation. It is important for you to discuss these and other risks with Dr. Goldberg before proceeding with surgery.
Non-surgical alternatives include support bras or padded bras. There is currently no injectable material nor a method of transplanting fat that exists which is safe and reliable for Breast Augmentation. If a breast is sagging but has reasonable size, then it may be possible to perform a Breast Lift (Mastopexy), which will both lift the breast and make it seem fuller. Sometimes it is necessary to perform both Breast Augmentation and Breast Lift (Mastopexy) at the same time. This is needed when there is sagging of the breast, and also a need for increased size.
Benefits: Breast augmentation is one operation that almost universally results in a happy patient. The surgery addresses the issue immediately with minimal recovery. There is not one approach that is applicable to all patients, and choice of incision, implant size and type, and placement of the implant should be tailored to your needs.
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