Breast Augmentation

This is a decision we try to make prior to surgery. It’s also very personal and depends largely on the patient’s own wishes and desires. However, a woman’s goals must be weighed against the reality of her own anatomy. Some of the critical anatomical issues which affect implant size are the size and shape of the woman’s rib cage, the position of the nipple and the ability of the breast tissue to stretch. Aesthetically, we also have to consider the rest of the body, including shoulder width, the abdomen and the hips, as a balanced silhouette should be the goal. We spend a considerable amount of time counseling patients about the available space they have internally in which to put an implant, and what we expect it will look like. Generally, the more of her own breast tissue the woman has, the more natural the result will be; conversely, a very small breasted woman with large implants will tend to look more unnatural.

At their office visit, we help women experiment with different size implants using a bra under tight clothing. We also show our patients before-and-after pictures of patients with anatomy like their own. In the end, a size range is chosen by the patient, but in the operating room, I am able to fine-tune things by experimenting with different size implants which are actually inserted into the patient. If careful preoperative counseling has been done, the size chosen in the operating room is almost always the same as size decided on preoperatively.

The surgery is performed at the Vancouver Plastic Surgery Center under a light general anesthetic administered by a certified anesthesiologist. Normally the procedure takes between 1 and 1 ½ hours. After the incision is made, a space (the “breast implant pocket”) will be created, either behind or in front of the pectoralis muscle, depending on the situation. After irrigation with a quadruple antibiotic solution, the breast implant is inserted through a specially designed funnel so that it enters the body without touching anything after leaving the sterile package. The final position of the implant depends on the location, size and shape of the breast pocket which is created by the surgeon. The incision is closed with hidden sutures, and the chest is lightly wrapped with a bandage.

Breast augmentation requires a lot of dissection deep in the chest wall. Therefore, it is usually performed under a light general anesthesia provided by the anesthesiologist who is certified by the Royal College of Physicians and Surgeons of Canada.

There are actually 5 possible incisions through which we can place breast implants:

• Transaxillary (armpit)
• Periareolar (around the nipple)
• Inframammary (fold under the breast)
• Umbilicus (belly button)
• Any existing scar which might be on the breast

Depending on the situation, I can use any one of these incisions, although, for technical reasons I have stopped using the umbilicus. There are many pros and cons for each of these approaches, but there are certain situations where one type of incision is preferred over another. For example, the medium sized breast after childbirth which has a distinct inframammary fold is a good candidate for an incision in the fold. Patients with very small breasts who need significant readjustment of their inframammary folds are good candidates for the periareolar incision (around the nipple). The axillary incision lends itself to the insertion of saline or smaller gel implants under the pectoralis muscle. In the end, it is usually the patient who decides on the incision, based on her own desires balanced against the type of surgery and size of implant I can introduce through the incision she has chosen. Since the introduction of modern silicone gel implants, in my practice, about 85% of patients choose inframammary, 10% choose periareolar, and 5% choose transaxillary. They all work.

There is a huge variety in the shape, size and construction of breast implants. Generally, they can be divided into 2 categories: saline and silicone.

Saline implants are empty plastic bags made of silicone, which can be rolled up like a cigar and inserted through a very small incision. Once inside the body, they are filled with sterile saline. The advantages of saline implants are the small incision, the ability to adjust the size by adding or subtracting saline and the fact that the implant’s filler substance (saline) is completely harmless. The 3 main disadvantages are that the bag tends to ripple which may create visible folds on the surface of thinner breasts, saline implants may spring a leak and deflate at any time in the woman’s life and they are a little heavier than real breasts.

Silicone implants are the same type of plastic bag as saline implants, but they are filled with silicone gel. With saline implants, surgeons fill the implants themselves, but silicone implants are factory-filled and sealed. Silicone gel can be manufactured with any type of consistency from liquid all the way up to solid rubber. Modern silicone gel is “cohesive,” which means that it sticks together. Typically, the gel in modern implants has the consistency of Jell-O. The firmest type of gel is the “highly cohesive” material used in tear drop shaped implants – the so-called gummy bear implants. These feel harder than regular cohesive gel implants and are designed to maintain their teardrop shape.

Other variations between breast implants include the type of implant surface (textured or smooth), and a wide variety of shapes: round low profile, round medium profile, round high profile and many different versions of the tear drop. All these different options have their own special advantages and disadvantages.

There is simply no “best” breast implant for everyone. The appropriate choice will depend on the woman’s own anatomy, including the volume and density of the existing breast, the shape of the underlying rib cage, and the thickness of the pectoralis muscle. Other considerations include the patient’s desire for size and shape, and the surgeon’s own experience with various breast implants. I have personally used all the implants listed here, and try to customize the approach for each individual patient. For example, a patient who wants a miniature hidden incision might be a good candidate for a saline implant, while a patient with moderate size breasts who has lost volume in the upper half of her breasts after childbirth might be a good candidate for a round gel filled breast implant.

The muscle we are talking about is the pectoralis major, a very large fan-shaped muscle that spreads across the chest from the armpit area to the collar bone (clavicle) and breast bone (sternum). Going under the muscle means that the implant is covered by the pectoralis in its upper half, but is not covered by muscle in its lower half. This is known as “partial muscle cover.” Going under the muscle requires the surgeon to cut the muscle where it attaches to the lower ribs. To some degree, this damages the muscle, which later can lead to distortion of the breast shape when the muscle contracts. Also, over time, the muscle can slowly push the implant down and out to the side, leaving a large gap in the middle. As patients age, implants under the muscle tend to stay put while the breast tissue slowly hangs away from it; at times this can look unusual making a breast lift necessary.

These various problems with an implant under the muscle beg the obvious question: Why do we ever do it that way? The main reason to go under the muscle is to hide the upper half of the implant. In a thin person, when the implant is put in front of the muscle, the upper edge of the implant can be visible, especially when the breast is pushed up with a bra. To decide if there is enough breast tissue in the upper part of the breast to allow an implant to go in front of the muscle – the “pinch test” is used. When the upper half of the breast is pinched and the breast tissue is more than 2 cm thick, there is usually enough breast to hide a breast implant even when it is front of the muscle. There are also some other reasons to go under the muscle. If any capsular contracture were to develop (scar around the implant causing hardening), an implant can look round, and this will be more hidden from view when the implant is under the muscle. Lastly, implants under the muscle make mammogram x-rays easier to perform.

There actually is another procedure called “retrofascial” – where the implant is placed in front of the muscle, but the surgeon uses a layer of white tissue called fascia (which normally coats the muscle) and uses it as an additional layer to cover the implant. When I am putting an implant in front of the muscle, this is the technique I usually use.

At my practice, the decision on where to put an implant (under the muscle, over the muscle, or retrofascial) depends on many things…the patient’s pinch test, the firmness of the tissue (firmer hides implants better), the patient’s degree of athleticism (I like to leave an athlete’s muscles untouched), the size of the implant desired, the type of implant to be used, the family history of breast cancer (behind the muscle is better for mammograms), and the patient’s own desires.

After all is said and done, about 1/3 of my patients end up choosing implants behind the muscle and 2/3 are retrofascial. Since the introduction of the new silicone gel implants, many more patients have been candidates for the retrofascial plane because silicone filled breast implants are more realistic than saline filled breast implants. In truth, most patients could have the surgery performed either way with equally good results.

You will wake up in the recovery room, wrapped up in a bandage with mild pain although some patients at this stage claim to be painless. The reason for the lack of pain is that a large amount of local anesthetic is placed around the implant, making the breasts more numb than painful. This freezing lasts between 12 and 24 hours. You will be in the recovery room for about 2 more hours after the surgery is completed before you are discharged home. You will be given specific instructions about when you may shower and when to start wearing a bra.

We always speak with you on the phone the following day, see you at 2 weeks later to instruct you on breast implant manipulation, 2 weeks for suture removal, and at 2 months to make sure everything has healed. You can return to minimal activity (like a desk job and driving a car) within a week, but will be restricted from athletics for 4 weeks. Post op photos are taken at your final visit, around 6 months after surgery.