THE BREAST ENLARGEMENT OPERATION

The breast enlargement operation is known as Breast Augmentation. Due to its very high satisfaction rate, this is one of the most common cosmetic procedures performed in the United States today. Enlargement is accomplished by surgically creating a pocket either under the breast tissue (sub-glandular) or under the pectoralis muscle (sub-muscular) which itself lies directly behind the breast tissue. Women with ample breast tissue are sometimes candidates for sub-glandular placement, while women with less breast tissue must have the implants placed sub-muscularly. Most commonly, the implants are placed under the muscle as the shape of the breast is maintained for a longer period of time with this placement. To learn more about implant placement, please refer to our FAQ page.

Some common reasons for seeking breast enlargement include minimal breast development, loss of breast tissue after breast feeding, or the desire for a more beautiful and fuller figure no matter the amount of breast tissue already present. In some instances an improvement in breast shape is sought.

This procedure involves using a "prosthetic implant" to accomplish the enlargement. Because of this, there are some particularities of this procedure which are an inherent part of the operation, and the result should be well understood by the woman who wishes to undergo this procedure.

THE OPERATION

The operation is performed under local anesthesia with light sleep sedation and may be performed using one of four different sites of entry to the breast. The four sites of entry are: (1) An incision is placed in the creases and folds of the nipple (areola). (2) An incision is placed in the inframammary fold (at the junction of the breast and the chest wall in the underside of the breast). (3) An incision is placed in the axilla (armpit). (4) An incision is placed in the belly button using the latest endoscopic techniques. The Cosmetic and Reconstructive Surgery Center is one of only a few in the Bay Area offering the belly button approach, making it our most commonly used approach for patients with saline filled implants. For more information, please see our additional literature on breast augmentation through the belly button.

THE FIRST THREE WEEKS AFTER SURGERY

At the end of the operation, two bras and an Ace bandage will be placed on the patient. Two days after surgery, one of the bras may be removed. The third day after surgery, the Ace bandage may be removed. Only dissolving sutures will be used, thus no sutures will be removed.

The bra should be worn for three weeks, both day and night. After three weeks, the patient may then wear the bra during the day only. After six weeks, the patient does not have to wear a bra if she so desires; however, we do not recommend this except on special occasions, as it tends to promote stretching. The patient will have been placed on antibiotics prior to the surgery, and these will be continued for two weeks after surgery.

Regarding activity, the patient should rest and relax for the first few days after surgery. There should be no bending, lifting, or straining for 21 days after surgery. Avoid overheating, excitement of any kind, and significant arm movements. Relaxed walking, up to a half-mile, may be started six days after surgery. Very light housework, such as dishwashing, may be started two weeks post-operatively. You may begin normal exercising three to four weeks after your surgery.

THERE IS MORE TO IT

Breast enlargement continues to be a procedure that confers a very high degree of satisfaction to both the patient and her surgeon. This satisfaction is in part due to a complete understanding of the different types of implants, different incisions available, and the risks and possible complications of the procedure. A thorough understanding of these factors is essential before deciding to proceed with this surgery.

TYPES OF IMPLANTS

Saline Implants:
Smooth Implants: Softer and much less frequently the cause of ripples compared to textured saline implants. We use these implants the majority of the time. Product life: 10-15 years.
Textured Implants: Created originally for silicone gel. When used with saline they have a higher rate of rippling, therefore they must be placed under the muscle. That said, even submuscular placement does not decrease rippling on the sides of the breast.

Silicone Implants:
Smooth Implants: Very soft; however, they can produce more scar tissue and hardening toward the end of their product life (10-15 years) or if there is an early rupture. These implants cannot be placed without an incision on the breast. They create less rippling than saline implants.

RISKS AND COMPLICATIONS

Infection : Infection is a risk with any surgical procedure. Because we are placing a foreign object into the body, infections require implant removal in all cases. The risk of infection is less than one percent using the umbilical approach, and one to two percent with the other approaches. You may be subject to an infection months or years after the operation, because foreign bodies in your body may become "seeded" by a serious infection or even minor dental work. This is quite uncommon but can occur. After placement of implants, you should always take antibiotics prior to any dental work, even cleaning, and prior to and after any surgical procedure.

Hematoma : The collection of blood in the pocket occurs in less than one percent with the umbilical approach and one to three percent with other approaches. This makes surgery necessary to remove the blood. Generally the implant may be placed back into the pocket at the time of hematoma removal. As noted, hematoma is much less common with the belly button approach in our experience.

Noticeable Scars : All four approaches to the placement of implants have their advantages and disadvantages. The scars generally heal extremely well, making it very difficult to see them; however, not everyone heals in the same fashion. An undesirable scar will occur in about five percent of patients. Scar revision may often improve the situation. In some instances, one must accept a less than perfect scar, along with an improved shape. The scar via the belly-button approach is inside the belly button and is therefore practically invisible.

Asymmetry : All people have asymmetries from one side of their bodies to the other. Breasts are no different, and one may be sized or shaped differently than the other. Although we attempt to correct asymmetries to some degree, there are limitations. One must accept the fact that though both breasts may be beautiful, they will probably not be exactly the same, and preexisting asymmetries will be the same post-operatively. An exception to this is size variation which can be improved by the surgery.

Numbness : The nipples may have reduced sensation temporarily, and in one to three percent of cases, can be permanent after surgery. This can vary from some loss to complete loss (rarely) post-operatively. Most of the time, sensation returns to the nipple within one year, and generally much sooner. The skin on the underside of the breast can become numb, but this generally disappears slowly over six to eight months. The umbilical approach has a one half percent (.5%) rate of permanent numbness.

Deflation or Leak of the Implant : Implant deflation with saline and silicone implants can and does occur. We see about a three to five percent rate of rupture over the first 10 years. In the event a rupture does occur, the replacement procedure is much less strenuous than the original procedure if performed within a couple of weeks of the rupture. Silicone implants last about the same amount of time; however, when a rupture occurs the silicone is not absorbed so the breast does not deflate. That said, the contact of gel with the body often causes scar tissue formation so that the breast begins to feel hard.

Excessive Firmness, Capsule Contracture and Wrinkles : The body's response to the placement of the implant is to form a membrane of scar tissue around the implant. This is known as a "capsule.” This is a normal occurrence and is present 100 percent of the time. In some instances, the capsule causes excessive firmness of the breast. This occurs in two to four percent of patients. Some patients do not mind the firmness, because the improved shape is what is important to them. In a smaller group of patients, the capsule will contract and cause the breast to change shape and, in fact, may be painful. When the firmness is unacceptable or with capsular contracture, another operation may be necessary to remove the capsule. Ripples and wrinkling occur in 10 percent of patients. This is where noticeable wrinkling in the skin happens because the weight of the implant pulls the implant and skin slightly, creating a visible ripple. Textured implants have a higher rate of rippling than smooth implants. Ripples, when present, are generally on the outside of the breast under the axilla (armpit). Silicone implants have the lowest rate of rippling and the highest rate of eventual hardening.

Breast Feeding : Most women can successfully breast feed after the placement of implants. The belly button approach does not affect breast feeding at all because no breast tissue or ducts to the nipple are injured in any way. Once the pocket is created, the implant is placed from below and then is slid up under the breast tissue and under the pectoralis muscle in submuscular placement.

Breast Cancer : There is no evidence that implants increase the rate of breast cancer. In some studies, patients with implants, in fact, had a lower rate of breast cancer. This may be due to the fact that patients having implants generally have less breast tissue to begin with. What is clear, however, is that the placement of the implant does make the breast more difficult to completely visualize with mammography. This may make detection of a cancer and early detection more difficult. Therefore, I recommend breast augmentation patients over the age of 30, who have a history of breast cancer in the family, to have a pre-operative mammogram as well as a mammogram one or two years post-operatively. As the vast majority of breast cancers are found through self-examination, the patient should examine herself monthly. The American Cancer Society has guidelines for mammography. We recommend that these be followed. They are not detailed here as they change from time to time, so please refer to their website, www.cancer.org.

Autoimmune Disease: In the 1990’s there was much discussion in the news concerning these diseases, yet the scientific literature demonstrated no connection between implants and autoimmune disease. The population studies undertaken have shown the same percentage of women getting these diseases with implants as not having implants, meaning there is no correlation between the two.

COSMETIC SURGERY & RECONSTRUCTIVE SURGERY CENTER IN LAFAYETTE, CALIFORNIA

Our goal is to provide a safe, tasteful and comfortable environment for our patients and an efficient and enjoyable space in which to work. Within the surgery center are rooms for consultation and examination, modern operating suites, and a comfortable recovery area. Locating in Lafayette brings the comfort, safety and convenience of an office surgery center to a very beautiful setting. Residents in the Lamorinda region are now within five to ten minutes of the quality of care that they expect. A fifteen to thirty minute drive is all that is required to reach the Surgery Center from most areas of Contra Costa County and Berkeley. We are about an hour from San Francisco, Marin and the South Bay.

BREAST AUGMENTATION: THE BELLY BUTTON APPROACH

The belly button approach, also known as Transumbilical Breast Augmentation (TUBA), has been in use since 1991. Dr. Friedman is one of only a few surgeons in Northern California offering this approach and has been successfully utilizing this technique at The Cosmetic and Reconstructive Surgery Center since 1996. This is an endoscopic approach, meaning that only a very small incision inside the belly button is used for implant placement. This results in virtually no visible scarring (the scar is inside the belly button). Because there is no other cutting, there is only a tiny amount of bleeding (generally one to two tablespoons) and therefore less bruising and far less pain as compared to the other approaches used in breast augmentation.

Our experience is that there are lower rates of complications with this approach. For example, nipple sensation loss with the standard approach is two to three percent of patients. With the belly button approach, it is less than one percent. Bleeding or hematoma occur in one to three percent of patients with a standard approach, yet with the belly button approach, it’s less than one percent. Infections occur in one to three percent of standard approaches, while our rate with the belly button approach is less than one half of one percent. Patients also experience a lesser chance of hardening.

A big advantage for women considering pregnancy in the future is that the breast tissue is not harmed in any way with the belly button approach. The implant is simply slid under the breast tissue. No breast tissue or ducts to the nipple are cut or disturbed in any way.

Recovery is far easier and far more rapid with the belly button approach. With standard approaches, it is common for patients to have moderate to severe pain the first one to three weeks. With the belly button approach, the pain lasts, on average, three to five days. It is generally mild to moderate, and patients are ready to resume normal, non-strenuous activities within five to seven days.

Patients often ask how this procedure can be done. Briefly, a small incision is made inside the rim of the navel. A tunnel is made through the subcutaneous fat under the skin and above the abdominal muscles (no body cavities are entered). A long instrument is used to create a pocket for the implant, either under the pectoralis muscle (most common) or under the breast tissue. The empty implant, with fill-tube attached, is rolled up and pushed up the tunnel and into the pocket. The implant is then filled with sterile salt water (saline solution). The fill-tube is then removed which automatically seals the valve. The navel incision is closed with absorbable sutures, and a small drain is placed in the belly button.

THE FIRST THREE WEEKS AFTER SURGERY

DAY ONE TO DAY THREE:
You will experience mild to moderate bruising, mild to moderate swelling, and drainage via the belly button, decreasing on day two or day three. Change the abdominal pads as needed. Under the pad is gauze, and under the gauze is the drain. Do not touch the drain. Some patients will have the drain removed day two or day three. Patients who have their implants placed under the muscle will have more drainage and more discomfort. You should ice continuously for 48 to 72 hours. Take three Arnica tablets under the tongue every three hours. Day three after surgery, the second bra may be removed and the Ace wrap may be loosened. Activity: Sitting and minimal walking. You should not be doing any bending, lifting, straining, or exercising during this time.

DAY FOUR:
The discomfort is minimal but present (under the muscle placement may still have moderate discomfort). The swelling continues to go down but is still present (more swelling with under the muscle placement). Drainage is minimal. If the drain is still in, it will be pulled out today, tomorrow or on day six. If the drain was taken out yesterday, then you can shower, but do not bathe for one week after the drain has been removed. The gauze may be removed one day after removing the drain. Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising.

DAY FIVE:
The discomfort is still decreasing but present. The swelling continues to go down but is still present. Drainage is minimal if the drain is still in or if it was taken out yesterday. If the drain is still in, it will be pulled out today or tomorrow. If the drain was taken out yesterday, then you can shower, but do not bathe for one week after the drain has been removed. The breasts are slightly swollen, more so if implants are under the muscle. Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising.

DAY SIX TO DAY 21:
The discomfort in the breast is going away but there are still sore spots. The swelling goes down daily. As activity increases, the breasts may become more swollen and discomfort may increase. You are still restricted in activity, and if swelling and discomfort increase, you are doing too much. Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising. You may resume normal activities and exercise three to four weeks after surgery.

Frequently Asked Questions About Breast Enlargement

What is the belly button approach (Transumbilical Breast Augmentation or TUBA)?

The belly button approach has been in use since 1991. This is an endoscopic approach meaning that only a very small incision in the belly button is used with practically no visible scar (except inside the belly button). Because there is no other cutting and only small scopes are used to perform the procedure, patients experience much less discomfort and are back to non-strenuous activities much sooner. Our experience has shown a much lower rate of bleeding (hematoma), less hardening, much lower infection rate, and much less sensation loss.

Are there drawbacks to having larger breasts?

The benefits of breast enlargement are well known and easy to understand. Most of them relate to greater ease of finding clothing that fits well, without the need for internal padding or special lingerie. Women contemplating enlargement need to consider that there are some drawbacks to larger breasts and implants.

Larger breasted women:

need to wear a bra most of the day
need support during strenuous exercise
may not enjoy sleeping on the stomach
may get unwanted attention from men
may encounter envious treatment by other women
may get more sag over the years
may be able, in certain instances and positions, to see or feel the implants

What are the implants made of?

Breast implants are made of medical silicone, a soft, rubbery material, filled with salt water or silicone gel. Silicone gel implants require a modified umbilical approach if the patient wishes to have breast augmentation through the belly button, which results in a small scar on the underside of the breast, on the areola.

What is the difference between placing implants in front of vs. behind the pectoralis muscle?

The primary difference between placing implants in front of the muscle vs. behind the muscle is the type of "look" that the breasts have. In front of the muscle, the implant gives a distinct line, which extends up over the top of the breast. If patients are not at least a full “B” cup to begin with, then a “stuck-on” look may occur. Behind the muscle placement often yields a more natural look with softer transitions between the implant and the chest wall. The degree to which the placement affects the final result depends upon several factors, including:

The larger the change in size, the greater the impact of placement.
The heavier and larger breasted a woman is to begin with, the less the impact of the different placements.

When is it important to place the implants behind the muscle?

When the patient is a “B” cup or smaller, the muscle is needed to help cover the implant.
When a patient wants to go to a large size (a full “C,” “D” or larger), has little breast tissue, and thin skin and subcutaneous tissue, then behind the muscle is best.
When the patient desires a more natural look, submuscular placement is recommended.
In most instances, the submuscular placement yields a better look over many years. For this reason, well over 90% of our patients over the past 20 years have had implants placed in the submuscular position.

What are the disadvantages to placing the implant behind the muscle?

More discomfort post-operatively for the first week
Breast movement associated with contraction of the pectoralis muscle (50% of patients)
Longer recovery with more initial discomfort

Can salt-water implants harden?

The hardening that can occur is due to excess scar tissue formation and contraction of that tissue around the implant. If this occurs, another operation may be required to remove the scar tissue. Our rate of hardening over the past 20 years with saline implants is about three to four percent.

What is the expected product life of the implant?

An estimate for the product life is 10-15 years. This is true of both saline and silicone implants. Implants do not need to be changed unless there is a deflation. There is a three to four percent rate of deflation in the first 10 years. The implants are guaranteed by the manufacturer for life and against defect for up to 10 years. While at anytime in your life you may obtain a replacement, the manufacturer will pay for the operating room fee within the first 10 years should a deflation occur and the extended warranty is in effect.

Is it true the replacement of implants is fairly minor?

For removal and replacement of implants, the answer is “yes.” The major part of the original operation is the creation of the pocket. When replacement is needed, the pocket is still there, so all that is needed is to open the pocket, take the present implant out, and put the new one in. With saline implants, this can be accomplished in most patients through the belly button. Silicone implants require a nipple or inframammary incision.

Can a woman breast-feed after breast augmentation?

Particularly with the belly button approach, the breast tissue and ducts are not disturbed, cut, or affected. The procedure literally takes place under all of the breast tissue, without needing to go through it. There is no evidence that silicone from the implant shell enters the milk. When silicone implants are placed using the modified belly button approach combined with a small inframammary incision, the disturbance to the breast tissue is minimal, and in the majority of instances, will preserve the ability to breast-feed without difficulty.

Can implants achieve some lifting of sagging breasts?

Although implants do not lift up a sagging breast, they do help mildly sagging breasts to appear less saggy. They do this in two ways:

Implants take up some of the slack in loosened skin thereby increasing the volume and decreasing the saggy look.
Implants, to a mild extent, rotate the lower portion of the breast upward making the breasts appear less saggy.

For moderate or severe sagging, a lifting procedure or a lifting procedure with implants is performed.

Do breasts with implants experience sagging over time?

All breasts relax as time passes, because the weight stretches the skin, elasticity is lost with age, and the amount of breast tissue often decreases as the person gets older. These three factors mean that breasts can be expected to relax and sag whether or not there are implants. The implants add some weight to the breast, which may increase the rate of relaxation, and yet implants and surrounding scar tissue can provide some internal support for the breasts. The overall result is that usually the breasts sag less than they would have if they had grown to that same size on their own, and yet somewhat faster than if they were left their original smaller size.

What are the advantages and disadvantages of silicone implants?

Advantages: Silicone implants are softer than saline implants. How much difference in softness depends upon the amount and density of breast tissue present, skin thickness, and amount of subcutaneous tissue. There is less rippling visible on the skin with silicone implants.

Disadvantages: With silicone implants, a scar is required on the skin of the breast or on the areola. The scars heal well but are generally still slightly perceptible. When a silicone-filled implant fails or breaks, it is not readily apparent, with the first sign often being hardening of the breast. This is due to the body’s natural response to silicone gel, which forms scar tissue to “wall off” the silicone from the body. It can be a tedious operation to remove the gel from the breast pocket, and one cannot generally remove the microscopic amounts of silicone. This can, in some instances, lead to hardening again, even with a new implant.

Saline or Silicone: Which is better for me?

Most of the breast augmentation procedures we perform are using saline implants with the belly button approach. Overall, there are slightly fewer complications with the belly button approach than with all other approaches. Healing time, discomfort, and lack of a visible scar are the advantages. Saline implants are also soft but not as soft as silicone. If your are very concerned with the softness and do not mind a slightly higher rate of complications (.5 – 2%), a higher rate of each of the possible complications, as well as a greater possibility of hardening many years down the road, then silicone is for you. If you want a quicker, less painful recovery with no visible scar and you don’t mind a slightly firmer implant, then saline is the better choice.