Breast augmentation is one of the most popular cosmetic procedures performed in the United States, with over 300,000 procedures performed every year.
As simple a concept as breast augmentation is (just place an implant to enhance the size of the breast), it amazes me how many issues one must consider.
First, the patient has to decide between saline (salt water) and silicone implant. Currently, the FDA has limited the use of silicone implants to patients 22 years of age or older. Secondly, the silicone implant is significantly more expensive than saline and, therefore, the cost will be higher. If age or cost is not an issue, silicone implant, overall, does feel more natural than saline implant. This advantage is more evident if the patient has thin skin, and less evident if the patient has adequate breast tissue and skin thickness. The disadvantage of the silicone implant is the additional cost, the inability to detect an implant leak in all cases (since the silicone gel is not absorbable, a leak may not be detected on physical exam), thus requiring additional imaging studies, and the inability to adjust the volume of the implant, which may be a factor if the patient has significant asymmetry before surgery.
Breast Implant Leaks
Since the subject of breast implant leak came about, let’s talk about it. ALL breast implants will eventually leak. When a leak occurs is unknown, I have had patients with a deflated breast implant 18 months after surgery, and I have seen patients who have had silicone implants for 22 years without any issues on physical exam. The good news is Mentor, Allergan, and Sientra, the only FDA approved manufacturers of breast implants in the United States, have a LIFETIME warranty on the implant, if it should fail. Currently, all companies also provide financial assistance towards the cost of surgery up to 10 years from the date of original surgery. To me, this indicates the rate of implant leak up to 10 years is low enough to allow both companies to exchange the implant AND cover some or all the cost of the surgery and still make a profit! This is good news for the patient.
Breast Implant Placement
The next question is should the breast implant be placed above the pectoralis muscle (the chest muscle which body builders flex to impress the judges) or below. I prefer to place the implant under the muscle for two reasons. First, the implant is partially covered by the muscle (there is no chest muscle at the bottom of the implant or to the side) thus minimizing the feel of the implant. Second, given that one in seven women in the United States will develop breast cancer, placing the implant under the muscle allows better visualization of the breast tissue.
Styles of Breast Implants
What about the style of the implant: low profile, moderate profile, high profile, tear shaped (also called anatomical), textured versus smooth or adjustable implant?
Low profile implants have a low projection and I mainly use them for a thin, skinny patient with little or no breast tissue. In this type of patient, this is the only way to achieve a natural result. The choice between moderate and high profile depends on maximizing the volume of the implant for the patient’s chest diameter and chest height. If the patient has a narrow chest and short chest height, but desires the largest implant volume possible, the high profile implant will allow us to place a larger volume (with more projection of course) and still keep the implant within the natural boundaries of the patient’s breast anatomy.
The tear shaped breast implant is flatter on the top and fuller on the bottom. Theoretically this will result in a more natural breast shape. In practice, however, the difference is NOT detectable. I personally have looked at before and after photos of round and anatomical implants and have been wrong on both accounts! There have been some studies which have showed the tear shape implant to look less natural. In my opinion, the theoretical advantage of tear shaped breast implant does not justify the extra cost of the implant and the potential for rotation of the implant. All breast implants may rotate when placed inside the body. With the anatomical breast implant, if the implant should rotate, surgery is required to reposition the implant.
To minimize this risk, the surface of the implant is textured (rough to touch), with the hope that the rough surface will adhere to the muscle or breast tissue. The potential problem with the textured implant adhering to the tissue is that when the patient moves it may pull on the tissue, causing rippling. Most plastic surgeons currently use smooth, round implants for breast augmentation.
What about adjustable breast implants? Adjustable breast implants have an outside shell filled with silicone gel, with a central “second” implant, which can be filled with saline. Seems like a great idea, right? Not so fast! The problem is most patients have swelling after surgery, which may take 3-6 months to fully resolve. Therefore, during the initial period, it is difficult to know how much to fill the implant. After 3 moths, if the patient desires additional volume, it may be difficult to do so, as the body forms a capsule around the implant to “ignore it” and “wall it off” from the rest of the body.
It may be difficult or impossible to expand the implant and still retain a natural look and feel, if the capsule does not yield. Theoretically a great idea, but in practice does not justify the additional implant cost.
What about nipple sensitivity, and breast feeding? Regarding nipple sensitivity after breast augmentation, the answer is no one can predict how nipple sensation will be.
In my experience, approximately 1/3 of patients have normal sensation, 1/3 has less, and 1/3 is more sensitive than pre-surgery. One important factor to keep in mind is the size of the implant. The nerve which gives sensation to the nipple comes from the underside of the chest muscle, at the outer edge of the muscle. It then travels towards the nipple to provide sensation. A larger (and therefore wider) implant will increase the risk of nerve injury. If the implant is too large, the patient may even lose nipple sensation completely. Therefore, it is critical to choose an implant which comfortably fits within the confines of the patient’s breast.
Regarding breast feeding, if a patient has never had a child, there is no way to know if that patient can breast feed at all. If a patient was able to breast feed with previous children, ANY type of breast surgery may affect breast feeding, and there is no way of predicting who will be affected.
“My friend got the same type of implant as I did, but my breasts don’t look anything like hers.”
Occasionally I hear this comment, usually from my younger patients. Young patients, for the most part, are very impatient! The culture of “every thing happening right now” can not be applied to surgery. Any surgical procedure will result in swelling. In case of breast augmentation, it may take 3-6 months for the implants to settle in their pockets.
Initially, when the implant is pushed up by the swelling, the breast may look smaller than it will be once the implant has settled in. Also, every one’s breast shape, amount and thickness of the breast tissue and skin is different. Therefore, having the same volume or style of implant is not going to achieve the same result in patients unless their breast shape is EXACTLY the same (even identical twins do not have perfectly symmetrical bodies). Therefore, competing or comparing your breasts after surgery is a self defeating exercise.
At our office, the patient tries the implant with a bra in front of the mirror. This is as close an approximation as we can provide the patient and the patient must be honest with herself.
Are Breast Implants Dangerous?
Does breast augmentation increase risk of breast cancer? Not according to studies. The risk of breast cancer does not appear to increase with breast augmentation surgery. Of course, the patient must follow the guidelines for breast examination and mammography. As mentioned previously, I prefer to place the implant under the chest muscle to increase the chance of tumor detection by mammography.
Are breast implants, especially silicone ones, dangerous if the implant leaks? No. Multiple studies, studying tens of thousand of women have found no correlation between auto-immune disease and breast augmentation (saline or silicone).
“My friend didn’t need a breast lift, why do I need one?”
Your friend’s nipple was in a good position relative to the breast tissue and she had no loose skin. If your nipple is low relative to the rest of the breast and you have loose skin, the nipple must be repositioned and the loose skin removed, otherwise the breast will have fullness on top with the nipple and loose skin hanging over the implant. Believe me, this is not an attractive breast! That is also why the same patient above is surprised about why her total cost is more than her friend. Depending on the type of breast lift, considerable amount of additional time is required, thus resulting in additional cost.
“I had breast augmentation and now my breasts feel hard and the shape is strange.”
What the patient is describing is capsular contracture, which is hardening and tightening of the capsule which normally forms around all breast implants. The most common classification used for describing capsular contracture is Baker’s.
- Grade 1: the breast and implant feel and look normal.
- Grade 2: the implant feels slightly firm, but otherwise the breast looks normal.
- Grade 3: the implant feels firm to touch and the breast shape is distorted.
- Grade 4: the implant feels hard to touch and the breast is painful to touch and is distorted.
Unfortunately, we do not know what causes capsular contracture and therefore cannot prevent it or predict who is at higher risk. What is known is the risk for contracture increases with the age of the implant.
In my experience, patient’s who had bleeding right after surgery, even if the amount was small enough not to warrant surgery, are at much higher risk of capsular contracture. Patient’s who do not massage their implants after surgery are also at higher risk.
Currently, the only solution for treating Baker grade 3 and 4 capsular contracture is surgery. The options are capsulotomy (making vertical cuts in the capsule to open up the pocket) or capsulectomy (removing a portion or the entire capsule).
In general, if the capsule is not too hard and this is the initial episode of contracture, I perform a capsulotomy. If the surgery is for recurrent contracture, I perform a capsulectomy. It is important to note both procedures increase the risk of thinning of the breast tissue, thus increasing the possibility of implant visibility and palpability.
“I had surgery six months ago and I want to go larger.”
Increasing the volume of the implant or exchanging to a larger size is not as care free as it seems. First, in my experience, in order to notice a significant change in the breast size, an increase of at least 60cc (2 ounces) is required. This usually requires exchanging the implant, since adding 60cc to an already fully filled implant may make the implant feel harder than desired. Second, since the capsule has already formed, a capsulotomy is required to increase the pocket size for the new implant. The patient must seriously consider whether the cost and potential risk of complications is worth the additional volume or not. My advise is “if it isn’t broke, don’t fix it!”
“I had breast augmentation and now the skin at the bottom of my breast is slightly red and the skin is shiny.”
This can imply an infection and you must contact your surgeon immediately! Although in rare cases the implant can be “saved” by admitting the patient and giving IV antibiotics, the usual scenario is removal of the implant followed by antibiotics. The patient must then wait at least six months before contemplating insertion of a new implant (the same implant should NEVER be used). This is a horrible experience for both the patient and the surgeon. Although the risk of infection is very low, infection is always a possibility with any surgery or procedure.
Please take a moment to view the below actual patient video to acquire a better perspective regarding breast augmentation.
Michael A. Jazayeri, M.D. is a board certified plastic surgeon with over ten years of experience. His office is located in central Orange County. To schedule a complimentary consultation, please call 714-834-0101.