Breast Augmentation

Breast Augmentation (Mammoplasty Augmentation)

Breast Implants

Breast-AugmentationBreast implants (or Mammoplasty Augmentation) are one of the more popular cosmetic surgery procedures performed by Dr. Cory Goldberg. He has helped many women achieve their desired results through careful surgical planning using state-of-the art breast implants in conjunction with Vectra 3D image capturing system, providing photo simulations of your anticipated results.

Background

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.

Implants

toronto breast implants

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 breast 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 breast 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 breast 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 breast 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 breast 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 - before and after

Choosing the right doctor for your breast implant surgery can make a huge difference in the results. This sample of a patient who had her implant surgery done at our clinic by Dr. Goldberg shows how the end result should look.

The Procedure

Breast implant surgery 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.

Breast-augmentation-3d-thumb
Click here for a 3D Animation of this procedure

Incisions

There are several incisions to choose from, and each has its benefits and disadvantages.

Areola Incision

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.

Underarm Incision

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.

Belly-Button Incision

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.

Implant Location

breast implant location

 

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.

Recovery

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.

Risks

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 selected 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.

Alternatives

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.


Breast Lift (Mastopexy)

Women who have developed sagging of their breasts. In some this occurs early in life, but more often it is related to ageing and frequently to pregnancy. Atrophy and thinning of breast tissue after pregnancy, combined with extra skin from stretching during pregnancy results in a smaller and sagging breast. Breast Lift is a procedure that removes excess skin, thereby lifting the breast and the nipple to a normal position. This procedure can be combined with Breast Augmentation / Enlargement.

breast lift toronto

A breast lift can have a major impact on your appearance. This image of a patient who had her breast lift done by Dr. Goldberg at one of our clinics shows how good a breast lift can look.

The Procedure

The operation is done under general anesthetic and takes about 1.5 hours. It is day surgery, and you can go home about 2 hours after surgery is finished. During surgery Dr. Goldberg injects long acting local anesthetic in order to prevent sensitization of pain nerves, and to minimize discomfort after surgery. The usual incision is the “Lollipop” incision, which goes around the nipple, and then vertically down towards the fold under the breast. Through this incision the nipple is lifted to the new position, and the extra skin is removed. Absorbable stitches are used to close the incisions, and a compressive dressing is applied at the end of surgery.

Breast-lift-3d-thumb
Click here for a 3D Animation of this procedure

Benefits

The surgery will provide a lifted, more youthful breast which has a natural appearance. It requires minimal recovery, and causes minimal discomfort. Most patients require very little pain medication. The effects are long-lasting, and the effect on self-esteem is profound, both in and out of clothing. This procedure is often combined with others such as Breast Augmentation / Enlargement and Tummy Tuck (Abdominoplasty).

Recovery

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 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. Breast shape is not natural immediately after surgery. After 4 weeks it has largely settled, but ultimately the shape will continue to develop for about 6 months before the final shape is established.

Risks

There are general risks with Breast Lift such as bruising, bleeding, infection, and risks associated with general anesthetic. There are also some specific risks. The nipple is moved and left attached by a bridge of tissue to keep the blood supply, lactation ducts, and nerves for sensation. Sometimes this bridge isn’t adequate, and there can be a change in nipple sensation. Though most often temporary, this can be permanent. Approximately 50% of women are unable to breast feed for a variety of reasons. This risk does not change after Breast Reduction. Very rarely not enough blood is flowing to the nipple and part or even all of it may not survive, in which case it may need to be removed. This is exceedingly rare, and is more likely if you are a smoker. This surgery can correct asymmetry to a certain extent. However, some pre-existing asymmetry may persist. Also, it is possible that the surgery will result in minor asymmetry, though great care is taken to avoid this by doing precise planning and measurements before and during surgery. The scars usually heal well, and are minimally noticeable, but a small percentage of the population will develop thickened or keloid type scars. Because the skin is pulled together and “folded” at the base of the breast near the chest, there can be some minor puckering of the skin at this site. It may require as long as 6 months to diminish. In some people a small revision procedure under local anesthetic may be needed to remove some extra skin at this site. It is important for you to discuss these and other risks with Dr. Goldberg before proceeding with surgery.

Alternatives

The non-surgical alternative is to use a support bra. If the degree of sagging is mild to moderate and the patient is willing to consider breast implants, then Breast Augmentation / Enlargement is an excellent alternative, which has the benefit of both lifting the breasts and increasing size, while reducing the extent of the incisions and scar. Imagine a plastic bag partially filled with water; this is representative of a sagging breast. If the bag is filled with more water it then becomes tighter. The effect on a breast after an implant is inserted is similar. This is not effective for severely sagging breasts. In that case a Breast Lift or a combined Breast Lift and Breast Augmentation / Enlargement is required.


Breast Reduction ( Reduction Mammoplasty)

Background

Breast Reduction is a procedure that aims to reduce the size of breasts that cause symptoms such as neck, back and shoulder pain, or bra-strap-grooves. Women with excessively large breasts also often suffer from social effects due to embarrassment or unwanted attention. Physical activity can also be limited since activities like jogging and sports like tennis can cause pain and social discomfort. Breast Reduction surgery is similar to Breast Lift (Mastopexy) in many ways, and it also has the benefit of lifting the breast. Large breasts often develop significant sagging, and so this cosmetic benefit is a pleasant effect of this surgery in addition to the improvement of physical symptoms.

Breast Reduction involves both excision (direct removal) of excess breast tissue as well as Liposuction of the breast and the side of the chest. For patients who have coverage by the Ontario Ministry of Health (OHIP) part of the cost of surgery may be covered, though this requires approval from the Ministry of Health. OHIP will pay for the excision, but not the liposuction. The reason is that the excision is the part of the surgery that will reduce the physical symptoms of large breasts, while the liposuction component provides cosmetic benefit only. Although the surgery can be performed with excision alone and no liposuction, this usually results in a smaller breast that may not have an appealing shape, and may have disproportionate fullness in the outer portion. The decision about whether to do liposuction should be made after discussion with Dr. Goldberg.

Benefits

Women who undergo Breast Reduction are extremely happy patients, and the relief from years of neck and back pain is immediate. The reduction allows women to attain an active lifestyle that they otherwise could not, and provides a proportionate body contour that can profoundly affect self-esteem. Most women recover quickly, and report that discomfort after surgery is much less than they expected.

The Procedure

The surgery is done under general anesthetic and requires from 1.5 to 2 hours. Most patients are allowed to go home within 2 hours after their breast implant surgery. After the patient is asleep, Dr. Goldberg injects a large volume of long acting local anaesthetic in order to prevent sensitization of pain nerves during surgery, and to minimize discomfort after surgery. The incisions are made and the excess breast and fat tissue are removed. The nipple is carefully protected on a bridge of tissue in order to maintain the nerves, lactation ducts and blood supply. At this point liposuction is performed on the breast and chest to contour the shape and eliminate fat pockets. The nipple is then lifted to its new position and the skin is closed using dissolvable stitches. A dressing is applied often using one of the patient’s old bras to hold it in place.

Breast-reduction-3d-thumb
Click here for a 3D Animation of this procedure

Recovery

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 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. Breast shape is not natural immediately after surgery. After 4 weeks it has largely settled, but ultimately the shape will continue to develop for about 6 months before the final shape is established.

Risks

There are general risks with Breast Reduction such as bruising, bleeding, infection, and risks associated with general anesthetic. There are also some specific risks. The nipple is moved and left attached by a bridge of tissue to keep the blood supply, lactation ducts, and nerves for sensation. Sometimes this bridge isn’t adequate, and there can be a change in nipple sensation. Though most often temporary, this can be permanent. Approximately 50% of women are unable to breast feed for a variety of reasons. This risk does not change after Breast Reduction. Very rarely not enough blood is flowing to the nipple and part or even all of it may not survive, in which case it may need to be removed. This is exceedingly rare, and is more likely if you are a smoker. This surgery can correct asymmetry to a certain extent. However, some pre-existing asymmetry may persist. Also, it is possible that the surgery will result in minor asymmetry, though great care is taken to avoid this by doing precise planning and measurements before and during surgery. The scars usually heal well, and are minimally noticeable, but a small percentage of the population will develop thickened or keloid type scars. Because the skin is folded at the base of the breast near the fold, there can be some minor puckering of the skin at this site. It may require as long as 6 months to diminish. In some people a small revision procedure under local anesthetic may be needed to remove some extra skin at this site. Although breast tissue cannot regrow, if you gain weight after surgery the size of your breasts will also increase. Similarly, if you lose weight your breasts will decerease in size as they normally would. It is important for you to discuss these and other risks with Dr. Goldberg before proceeding with surgery.

Alternatives

Most women who consider Breast Reduction have exhausted non-surgical alternatives such as support bras and custom-made bras to help with their comfort. Some women who have extremely large breasts require a reduction that uses both a vertical incision and also another longer one than runs across the fold under the breast (shaped like an inverted “T”). The decision of what technique is best for you is made during a careful discussion with Dr. Goldberg.