Modern Advances in Surgical Techniques
Since the modern era of breast augmentation began in 1962 with the introduction of first-generation silicone implants, many women have chosen to surgically enhance their bust in order to increase their self-confidence and improve their physical proportions. Breast implant technology as well as the surgery itself is a continually evolving field with more advances each year. Dr. Perez is comfortable with all methods of breast augmentation, incision placement, implant position, and implant type. He does not dictate to patients which technique they must use; rather, he and his staff listen to each patient’s desires. After careful examination and consideration, they decide upon a treatment plan that his patients understand and are comfortable with.
Breast Augmentation Incisions
There are many inconspicuous areas of the body through which we can gain access to the breast. Each incision placement has advantages and disadvantages.
The inframammary fold is the crease beneath the breast where the breast tissue meets the chest wall. Placing the incision in this location allows the surgeon access to all areas of the breast during surgery. This type of incision is best for patients with a well-defined inframammary fold. It is also appropriate for those receiving larger silicone implants. The inframammary fold scar generally heals well and is usually visible only if the patient is lying down.
The areola is the dark, pigmented skin surrounding the nipple. A periareolar incision is placed at the junction of the breast and areola, usually at the bottom portion of the areola. This incision also allows good visualization and access to the breast tissue and is best for patients undergoing simultaneous mastopexy, or breast lift. This incision may not be appropriate for patients with small nipples, less than 3-cm in diameter, and may be more visible in patients with very light skin or an indistinct border between the breast skin and areola.
The axillary, or armpit, incision has the obvious advantage of not placing scars directly on the breast itself. With this incision, an endoscope, or a retracting device with a camera, is used as a visual aid during surgery. This incision placement is best for patients with small breasts, who have an indistinct inframammary fold. As placing a silicone implant can be difficult through an axillary incision, Dr. Perez uses a surgical “funnel” to aid in silicone implant placement when using this approach.
While it is possible to place saline (not silicone) implants through an umbilical, or belly button, incision, this is usually a long and potentially bloody procedure. Dr. Perez does not utilize this technique as he feels he obtains better results with less trauma by using other, more well-established incision types.
The implant can be placed into different layers of the chest.
Subpectoral or Submuscular
The term subpectoral and submuscular are often used interchangeably and describe placement of the breast implant beneath the pectoralis major muscle, which lies under the breast tissue. This position is the most commonly used and allows the superior and medial portion of the breast implant to be covered by breast tissue and muscle. Subpectoral placement is best for thin patients with little (less than 2cm) superior breast or subcutaneous tissue. This position helps decrease the chances that the implant will be visible through the skin postoperatively and may decrease longer-term complications like capsular contraction. However, some breast augmentation patients may notice implant movement with contraction of the muscle.
A subglandular implant is placed below the breast tissue but above the pectoralis major muscle. This position is best for patients with thicker upper chest skin, those with minimal ptosis (i.e. drooping of the breasts), or women with previously placed subpectoral implants requiring certain revision operations.
The term “dual plane” is used to describe a breast augmentation that places the implant beneath the pectoralis major muscle superiorly but lies directly under the breast tissue inferiorly. This technique requires dissection in both planes and is best for thin patients with moderate amounts of ptosis (i.e. drooping of the breasts) that would be difficult to correct with subpectoral or subglandular implant placement alone.
The fascia of the pectoralis major muscle is a strong, fibrous, connective tissue layer between the breast tissue and the muscle itself. Subfascial implants are placed beneath the breast tissue and fascia of the pectoralis major but above the actual muscle tissue. While this is a rather new technique, some surgeons feel that this position may allow extra coverage of the implant, decrease implant visibility, and decrease “bottoming out” (i.e. unwanted descent of the inframammary fold and implant over time) while decreasing movement of the breast implants seen with subpectoral implants.
Since the introduction of first-generation silicone implants nearly fifty years ago, they have been the subject of much controversy and have undergone many changes. While no medical or scientific correlation was ever made between silicone implants and rheumatologic diseases, silicone implants were pulled from the market in 1992 mainly because of media pressure. Newer, fourth-generation implants were made available for aesthetic breast augmentation in 2008. Today’s implants have a double-walled shell to help prevent leakage and are filled with thick, “gummy-like” filler (i.e. “gummy bear implants”). Silicone implants tend to have a more natural feel and show less visible rippling when placed in the subglandular plane. Because silicone implants have “silent leaks” and do not deflate like saline implants when ruptured, it is recommended that patients undergo MRI monitoring three years after placement then every two years thereafter.
Saline implants have the benefit of showing obvious deflation if ruptured and do not require routine monitoring. They are less expensive than silicone implants but tend to have a slightly less natural feel and may show more rippling if placed in a subglandular plane in patients with thin skin and little natural breast tissue.
The size of implant chosen for breast augmentation is a very personal decision. While there is no exact formula to determine the ideal breast size for every patient, there are guidelines with the goal being to create harmony and balance between the lower and upper body while providing the patient with long-term satisfaction. During the initial consultation or preoperative evaluation, Dr. Perez can review the patient’s goals for breast augmentation, conduct a thorough physical exam, and take measurements. Most importantly, Dr. Perez can determine the width of the breast, amount of skin laxity, amount of existing breast tissue, and nipple and inframammary fold location.
In general, patients with a larger breast width, looser skin, and little existing breast tissue require a larger implant to obtain an attractive result. Conversely, younger patients with a small chest, tight skin, and adequate amounts of breast tissue may not be able to safely accommodate a very large implant. Placement of implants that are larger than recommended may lead to long-term complications such as permanent loss of the existing breast tissue, stretching of the skin and early ptosis (i.e. sagging breasts), deformation of the chest wall, and possible implant extrusion (i.e. thinning of the breast tissues to such a degree that the implant becomes exposed). Dr. Perez’s skill lies in being able to deliver a beautiful result consistent with the patient’s desires while ensuring long-term satisfaction and patient safety.
Considerations About the Procedure
Satisfaction rates among breast augmentation patients are among the highest of all plastic surgery procedures performed in the United States. Over 90 percent of patients report high satisfaction with their results and over 95 percent of patients feel their appearance was significantly improved. Despite such positive results, like all surgeries, there are risks associated with breast augmentation.
The most frequently encountered postoperative complications of breast augmentation are hematoma (i.e. bleeding into the implant pocket requiring surgical removal), which occur in one to three percent of patients nationwide, and infection of the implant occurring in less than 1 percent of patients nationwide. Most all patients will experience some temporary change in breast and/or nipple sensation immediately after surgery. 15 percent of patients may experience permanent increases or decreases in breast sensitivity and nipple sensation. Dr. Perez examines all of his patients on the day after surgery so that in the unlikely event there is a complication, it can be diagnosed and treated efficiently.
Over 90 percent of patients report high satisfaction with their results and over 95 percent of patients feel their appearance was significantly improved.
While not considered a complication of surgery, it is important to note that like a natural breast, augmented breasts will change over time, especially after weight loss and pregnancy. Additionally, the implants placed, whether saline or silicone, may also need to be replaced after a number of years. In general, the reoperation rate ten years after breast augmentation is approximately 25 to 40 percent for implant-related causes such as implant rupture or capsular contracture (i.e. excessive amounts of normal scar tissue formation around the implant that leads to distortion of the breast tissue).
Proper Postoperative Care
Breast augmentation surgery typically takes one to two hours and is performed on an outpatient basis under general anesthesia. Recovery times vary but patients are generally able to return to work in a couple days, light exercise in two to three weeks, and full exercise in five to six weeks. Antibiotics and pain medicines are usually prescribed following the surgery.
Contact Us With Additional Questions
If you are ready to experience the high quality care we provide at Plastic Surgery Center of Tampa, contact us online or call (813) 877-3739. To discover answers to frequently asked questions, visit our breast augmentation FAQ page or schedule your consultation today.