SAS Blog: Breast Augmentation; a Perspective
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 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 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 showed some improvement. Then research was done changing the surface of the implant to what is called textured or rough. The most successful of these was an implant that was covered with Polyurethane foam. However, because this foam degraded into possible carcinogens, it was discontinued. The use of modern textured surfaces has been somewhat controversial because they can be more easily felt through the skin and it is unclear of they truly make a difference in Capsular Contracture. Thankfully, with the latest generations of smooth implants, the likelihood of developing serious scar tissue has been remarkably reduced. In some patients utilizing Gel implants, successful augmentation can be done above the muscle.
In the early 1990’s a group of women who 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. Since the initial FDA’s ban on their use in the early 1990’s, silicone gel implants have been thoroughly investigated and there is no evidence that they cause any medical diseases. On November 17, 2006, the FDA reinstated their approval for the use of silicone gel for routine Breast Augmentation.
In recent years, implant manufacturers have been using a new type of silicone gel called cohesive gel or “Memory Gel.” You may have heard of this referred to as “Gummy Bear” implants. The issue that was addressed by this technological improvement was the fact that, with the old implants, if the implant ruptured and the scar tissue that was formed by the body did not seal it off, it could squirt out and cause serious inflammatory problems in the tissue. This new Gel actually sticks to itself and maintains its shape. So even if the implant wall breaks, the gel should not squirt out and cause problems.
Silicone Gel versus Saline-filled Implants. Issues and Answers:
Saline-filled Implants: Saline implants are made of a silicone rubber shell and are inflated at the time of surgery to their appropriate size with saline (0.9% salt water). If they leak (rupture), the body just absorbs the water with little side effect other than the volume is lost (Some patients just wake up with a “flat tire”). This is one big advantage of Saline-filled implants. A second advantage is that they come deflated and, therefore, require a much smaller incision for placement. However, saline-filled implants do not feel anything like silicone gel or normal breast tissue. This is why we recommend placement of these implants under the Pectoralis Muscle. This 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 acceptable in appearance and feel for patients with adequate soft tissue (breast and muscle tissue).
Silicone Gel Breast Implants: Now that the FDA has concluded that Silicone Gel is safe, I expect that most Plastic Surgeons use them in a significant number of patients. This is because Silicone Gel is far and away the most natural feeling and looking breast implant available. However, like everything in life, they are not perfect. The most noticeable disadvantage of Gel implants is that they require a larger incision (2 inches) for placement. This fact may prevent the patient from using the preferred peri-areolar incision. This could require an infra-mammary approach and a more visible scar. Also the maintenance of Gel is more involved. The FDA and Manufacturer recommends routine follow-up with MRI scans (very costly) at various intervals to detect rupture. Another concern that has recently come to light is that some Health Insurance Carriers may have issues with these implants and this may even cause you to lose or prevent your getting individual coverage. I have not actually heard of this happening, but you should check this out with your carrier to be safe.
There are three standard options for placing breast implants; Around the nipple (Peri-areolar), Armpit (Trans-axillary) and under the breast in the fold (Infram-mammary).
Trans-Axillary Incision: Placing the incision in the armpit may be considered advantageous 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. This may result in mal-position of the implant. Also if re-operation is necessary in the future, it may be impossible to re-use the incision and require a new second scar.
Infra-mammary Incision: Under the breast fold is the original method most Plastic Surgeons were trained to do because it is straight-forward and can be used with all implant types. The potential disadvantage with infra-mammary incisions is that they may widen and become visible. Unless I am revising a patient from another practice who has this scar or am required to use it because of the need of a larger incision, I do not prefer to use this approach. However, if I am placing a Silicone Gel implant and the patient’s areola is too small to accommodate a gel implant, I do not hesitate to use the infra-mammary incision and have found it to heal acceptably in most patients.
Peri-areolar Incision: There are three reasons that most surgeons prefer this incision when possible. For one, it is technically easier to create the implant pocket precisely. Two, it can easily be used for nearly all revisions, if necessary. 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. There are some misconceptions about this incision. You might have heard that if you go through the nipple, you cannot 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, patients should have no difficulty breast-feeding. Maybe you have heard 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 the same pocket is made regardless of the incision, the post-operative pain is the similar regardless of the incision. Lastly you might think 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 little 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.
Trans-umbilical (Belly Button): For a while it was trendy to put Saline implants in through the belly button. Because of the difficulty controlling where the implant would end up, the inability to safely place the implant under the muscle and the great difficulty of fixing anything, this option is not well thought of by the vast majority of Board Certified Plastic Surgeons.
Breast augmentation is performed as an outpatient. Although some practices perform Breast Augmentation with sedation and local anesthesia, I believe that general anesthesia (being completely asleep) is a much more pleasant experience which allows improved precision in implant placement. The risks of general anesthesia are greatly over-stated by some sources. After being in practice for 15 years, I would argue it is much safer than sedation. In fact, patients have a much larger risk of injury and death by getting into their car than from the sophisticated general anesthesia techniques now available.
Most patients take 4 to 7 days off of work. 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 before you can draw any conclusions about the result so don’t stress out. As the implant settle, they will look and feel more natural. They may actually change for up to a year, but changes after 8 weeks are usually subtle.
Breast Augmentation has been a relatively safe and effective way to enhance your appearance and proportions for over 40 years. By choosing a Plastic Surgeon certified by the American Board of Plastic Surgery, you can increase your chances of a successful and satisfactory result.