Breast implants were invented in the early 1960s by Dr. Frank Gerow and Dr. Thomas Cronin, two plastic surgeons from Houston, Texas. Interestingly, I went to medical school at Baylor in Houston and had the privilege to work with Dr. Gerow. He was a true visionary. The movie “Breast Men,” with David Schwimmer, was loosely based on the story of these two men, with considerable artistic license taken by the screenwriter. That’s a story for another day.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. In standard implant-based breast augmentation surgery, this implant is placed under the existing tissue to enlarge the apparent breast. This design remains the basis of all the implants that have been developed.
Breast augmentation surgery has been a safe procedure for over 40 years, with over 300,000 procedures being performed on women in the United States each year. It continues to have one of the highest satisfaction rates of any cosmetic surgical procedure, with over 95 percent of patients reporting that they are satisfied with their results in routine surveys.
- What Breast Augmentation Surgery Does
The goal of breast augmentation is to give a woman a more natural and pleasing breast, in appearance and feel. Although desired standards of beauty may vary depending on culture and societal expectations, larger, more proportional breasts have always been associated with youth and beauty. By placing a breast implant under the existing breast tissue, desired improvement can be achieved in most patients.
- Who Is a Suitable Candidate for Breast Implants?
Many women are unhappy with the size and contour of their chest. For these women, fitting into clothes can be difficult, and finding the right bathing suit is a challenge. By enhancing a woman’s breast, better proportions and an overall improved figure can be achieved. Most women who are dissatisfied with their figure are candidates for breast implantation. Exceptions include women with medical issues that prevent them from having elective surgery. After having children, some women may also require breast lift surgery to optimize any augmentation.
- The Difference Between Silicone and Saline Breast Implants
Women considering implant-based breast augmentation have the choice between saline (sterile saltwater) and silicone gel-filled implants. In brief, saline implants are a more economical and simple form of implantation. Because they come deflated, they can be put in through smaller incisions and, if they rupture, they contain a saltwater solution that is simply absorbed by the body. They are also much easier to maintain and replace, if needed. However, because they are filled with saltwater, they don’t feel as natural as silicone gel implants. Patients that have a fair amount of breast tissue do very well with saline implants. In thin patients, there may be visible wrinkling of the implants, and the implants can almost always be felt through the skin.Silicone gel-filled implants have been used since the inception of cosmetic breast augmentation surgery and feel very natural. However, because they come filled from the manufacturer, they require a slightly bigger incision for placement. In addition, if they rupture and / or become symptomatic of other negative conditions, it can be more involved to replace the implant. Also, the FDA recommends that patients with silicone gel implants undergo MRI scans every two years to detect possible rupture. This can be costly. Because silicone gel implants are so similar in feel to real breast tissue, the quality of the result is better. In my practice, approximately 70 percent of patients elect to have silicone gel implants in their breast augmentation.
- Gummy Bear Breast Implants
The original breast implants were comprised of medical-grade silicone gel that was more like a liquid than a gel. Thus, if the implant ruptured and the layer of scar tissue (capsule) that always forms around the implant was not intact, the gel could leak out of the implant pocket. Because of this potential problem, newer implants were developed in the late 1990s that contained gel that was “highly cohesive.” This means that it stuck to itself and was more solid than liquid. The idea was that the filling material would not migrate if the implant shell became broken and the scar capsule was not intact. This type of “highly cohesive” gel implant has been nicknamed the “gummy bear” implant on the Internet, due to its gummy-like consistency. There are different types of highly cohesive gel implants, and the implant manufacturers argue about whose is better.
- Over or Under the Muscle?
There are two types of pockets in which implants can be placed: one that is situated above the pectoralis muscle (chest muscle) and one that is located underneath the pectoralis muscle. The original breast augmentation method involved placing the implant behind the breast tissue and over the chest muscle, in what is called a subglandular implant pocket. Because the original implants were silicone gel and felt natural, the results were very good. However, when an implant is placed above the muscle, the visibility of the implant in the upper breast is more pronounced. Wrinkles in the implant may also be apparent from underneath the skin’s surface. Overall, the breasts may look like a half a coconut is situated on the chest. This looks artificial and is even more apparent with saline implants.To avoid visibility of the implant and to potentially decrease the risk of implant hardening (capsular contracture), techniques involving placing the implant under the chest muscle were developed. Placing the implant pocket beneath the pectoralis muscle is now the preferred technique, for nearly all patients. This results in a more natural-appearing upper breast and may have advantages in preventing hardening of the implants.
- How to Choose a Breast Implant Size
If you look on the Internet and even talk to patients that have undergone breast augmentation surgery, you may get the impression that the only thing to pay attention to when deciding what size of implants to get is the amount of “ccs” comprising the implant. “Ccs” refers to the volume, in cubic centimeters, of the implant.Some patients come in and say, “I want 400-cc implants because my friend has them.” When choosing the appropriate implant size for a specific patient, it’s best to take a variety of factors into account, not simply the amount of ccs of the implant.
The same sized implant will produce a different result in every patient. For instance, a few years ago, I just happened to do five breast augmentation procedures on the same day and used similar 375-cc saline implants on each patient. The results were completely different for each one.
The patient’s specific anatomy is, by far, the most influential factor when determining the eventual result. However, when choosing the “right” implant, many factors should be considered. These include the amount of skin and breast tissue a patient has, the actual dimensions of the chest and the desires of the patient. Truth be told, there is no such thing as the “perfect” implant. Usually, there is a range of implants that will give an excellent result.
Many offices will have patients try on bras with different sized implants or bags filled with rice and “choose” the one that they like best. The problem with this method of choosing an implant is that it can be very misleading to the patient and can result in them making an incorrect decision. From a sales perspective, it does allow the patient to feel in control and participate in the decision, and may alleviate some of the surgeon’s individual responsibility in the decision-making process. However, I have always felt that it can cause unnecessary confusion in deciding which size is appropriate.
- Incisions Used in Breast Augmentation
When doing research about which incision pattern to choose for breast augmentation surgery, you can find information on four options: the periareolar (around the nipple), inframammary (below the breast, in the breast fold), transaxillary (armpit) and transumbilical (belly button) incision patterns.Inserting an implant through the belly button was gimmicky a few years ago, but I don’t know of any plastic surgeon that believes that this is an acceptable option, for many reasons.
Using the armpit as the incision site is marketed as an approach to avoid having a scar on the chest. However, from a technical standpoint, it is the most difficult technique, and tends to have many problems related to implant malposition. Additionally, as I tell my patients, you have to approach breast augmentation surgery as a procedure that requires maintenance over the long run — most patients will have more than one breast operation over their lifetime. Revision surgery is very difficult or impossible to perform through the armpit.
Going under the breast, in the fold, is the easiest method for surgeons but often leaves a visible scar.
Most experienced plastic surgeons who perform many breast augmentation procedures prefer going around the nipple because it usually heals with a minimally visible incision, allows precise positioning of the implant and is easy to use for any maintenance procedures that may be necessary in the future.
- Recovery From Breast Augmentation
Breast augmentation surgery is a relatively routine procedure with very low risks, and is done on an outpatient basis, meaning the patient can go home after the procedure.Because a fair amount of long-acting local anesthesia is administered during surgery, most patients wake up with minimal discomfort. The next day, patients that have children tell me the discomfort reminds them of their milk coming in after they delivered their children. “Not too bad,” they say. Most patients will take pain medicine and muscle relaxants for 5-7 days.
It is common for patients with clerical or non-physical jobs to return to work in 5-7 days and to return to normal physical activity in 3-4 weeks.
A side note about recovery as it is portrayed on the Internet: I read an advertisement once in which a surgeon claimed his patients were returning to work within 24 to 48 hours after breast augmentation surgery, thanks to his special surgical technique, which he learned from a very famous surgeon. Interestingly, I was trained by the same surgeon and this doctor’s technique has been used by many plastic surgeons for more than 20 years — the technique is not as unique as this doctor claimed. Also, anybody can go back to work the same day as her surgery, but I doubt the person would want to. The patient probably would not be able to do her job properly, not to mention that she would greatly increase her risk of experiencing serious complications. Don’t believe everything you see online, especially if has been reported on national television.
- What Is the Best Way to Find a Great Plastic Surgeon?
When doing research about which plastic surgeon is the best, you should first start by confirming that the doctor is board certified by the American Board of Plastic Surgery. This is the minimum criterion to use when choosing your plastic surgeon. Membership in the American Society for Aesthetic Plastic Surgery is also an excellent indicator of the surgeon’s background and commitment to maintaining the highest standards of education and professional conduct.However, beyond that, what is the best way to “read between the lines” and find the most experienced surgeon who specializes in the procedure you are considering?
There are two parameters that are very helpful in evaluating a plastic surgeon: The first is the percentage of the surgeon’s patients that come from a referral from past patients, and the second is the quality of the results shown in their before-and-after pictures.
When a plastic surgeon has a good track record, they usually get the majority of patients from past patients who share their good experience with their friends. It is natural to conclude that the more experienced and successful a surgeon is, the more they will get patients from people who have been happy with their results. In our practice, we surveyed patients who came to us within a six-month span for a new consultation and found that over 75 percent of our patients had spoken to someone who had come to us in the past.
Again, always look at the before-and-after pictures on the plastic surgeon’s website. Confirm that these are pictures of their patients rather than some generic pictures provided by their website designer. Ask yourself if the results are artistically excellent and a good match for you. Each plastic surgeon has a unique “artistic eye” and sees beauty in a slightly different way. By looking at their pictures, you get a sense of their technical ability and vision for what they think is good result.