Having a youthful, full and tear drop breast shape is a luxury that most women do not naturally experience. But, there is hope. A breast augmentation gives you that allusive ideal breast shape and size that you have long desired. It gives you that sense of freedom to embrace your body contour with confidence. It is truly empowering.
Breast augmentation is one of the most common procedures in plastic surgery and it is one of my specialties which I perform in the Denver, Vail, and Aspen areas. I utilize an extensive pre-operative evaluation that relies heavily on imaging (2D and 3D). I take a team approach with the patients, finding the perfect implant size to exceed their expectations while staying within a natural aesthetic. In general, it takes less than 1 hour to complete the procedure. Per our method, only Intravenous (IV) sedation is required avoiding the need for general anesthesia. I utilize every brand of FDA approved implants on the market including those manufactured by Allergan, Mentor and Sientra. As each patient is different, the implant type is selected on a case by case basis. In more complicated cases, I often use anatomic shaped implants (cohesive gel). For cases where the breast are different sizes and shapes, implant sizers are used to ensure the best outcome. I use all incision types including the armpit, around the areola and at the lower fold of the breast. With use of our intra-operative field block, discomfort is limited immediately following surgery. Recovery time is around 7 days and patients are back to normal activities within 2 weeks. Overall we have consistently amazing results by focusing on matching the right size and style of implant to your body type.
- Three surgical approaches are recommended: around the areola, in the axilla (arm pit) or in the inframmary fold (where the lowest part of the breast meets the chest wall). Even though the inframmary fold is the most often used approach, I regularly utilize all three approaches depending on where the patient wants the scar placed. The scar is very small (less than 1 inch in length) therefore it is rarely a problem. The approach through the belly button, the trans-umbilical approach, is not endorsed by the American Society of Plastic Surgeons and has a much higher incidence of complications.
- Placement of the implant underneath the chest muscle (pectoralis) is recommended. This approach has less of a chance of developing rippling or scar tissue around the implant (capsular contracture). Although there are specific cases where I place the implant above the muscle, this not the norm. Placing the implant above the muscle on a woman with small to moderate sized breast will lead to implant show and a fake appearance.
- Breast augmentation is not a permanent procedure and on average, the implants will be replaced or adjusted every ten years.
- The FDA currently recommends a screening MRI of the breast every 3 years after breast augmentation.
- Silicone implants do have less rippling and a more natural feel when compared to saline implants. I rarely use saline implants in my practice. Although silicone implants are slightly more expensive, it is worth the extra cost.
- Almost all silicone breast implants on the market are composed of cohesive gel and therefore they are much less likely to have migrating silicone if the implant ruptures.
- Recovery from breast augmentation is roughly 2 weeks. Although there is discomfort, in most cases, it is well tolerated and limited to the first 7 days after surgery.
- Per study data, patients with breast implants do not have an increased incidence of breast cancer when compared with patients who have no breast implants. Furthermore, the incidence of autoimmune disease in patients with silicone breast implant has not been found to be different than in patients without silicone breast implants.
- The most common complaint after breast augmentation is a desire to have larger implants. Therefore, in our clinic, we make our patients an integral part of the decision making process when selecting implants. We also rely heavily on imaging pre-operatively.
Although this section is extensive, I have included all information needed for anyone considering augmentation of the breast. It is important to first understand which category you fall into by considering your age, your breast type and if there is loose skin present. In my practice, patients fall into four categories:
Group 1: Younger patients (20 to 50 years old) who are concerned with the small size of their breast.
Group 2: Patients with a change in breast shape and size following pregnancy and breast feeding.
Group 3: A patient of any age with a previous breast augmentation that requires replacement.
Group 4: Middle aged patients (35+ years old) with sagging, deflated breast.
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Younger patients (20 to 50 years old) who are concerned with the small size of their breast.
A younger patient, with smaller breast and little pregnancy related changes, is an excellent candidate for a standard breast augmentation procedure. There are a few key points to understand about this procedure:
- Done correctly, the size of the implant used is dictated by a patient’s body type, or more specifically, the width of the chest. Patients who have a narrow chest (and usually narrow shoulders) will require an implant with a smaller diameter. Conversely, patients with a broader chest are good candidates for larger diameter implants. With almost all implants, the smaller the diameter the smaller the implant volume. For patients with a narrow chest who desire a larger volume augmentation, a high profile implant will be necessary. These implants have narrow diameters but increased volumes.
- In my practice, I complete all my cosmetic breast cases with IV sedation (twilight), rarely requiring general anesthesia. This is very beneficial to the patient as it allows for a quicker recovery with a much lower incidence of surgery related nausea, vomiting and headaches.
- Using the inframmary fold incision and placing the implant under the muscle is the most common approach. Furthermore, releasing the lower border of the muscle (dual plane) during the time of surgery leads to a more natural post-operative appearance.
- The incidence of rippling and implant show is much less common in patients who have at least average breast volume (a b cup size or greater).
- Limiting the use of the upper extremities during the first 4 weeks after surgery reduces the incidence of unwanted implant displacement.
- Massaging of the breast after surgery is important to improve the overall results and to ensure that the breasts remain soft.
- I commonly obtain preoperative mammograms on patients who are 35 years and older or who have a family history of breast cancer
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Patients with a change in breast shape and size following pregnancy and breast feeding.
A common complaint for woman after pregnancy and breastfeeding is the changes that occur in the breast, especially with the size and the shape. These changes are due to the expansion of the milk ducts associated with pregnancy and the disruption of the normal anatomy of the breast (increased fat and the stretching of skin) with weight gain. In most cases, these problem areas can be fixed with a simple breast augmentation procedure. When the breast are droopy, a lifting procedure may have to be added. A few key points are listed below:
- Due to the common stretching of the skin and breast tissue with pregnancy, larger implant sizes are usually required to fill out the breast. If a patient desires only a small increase in breast volume with placement of a conservatively sized implant then a lift may be also necessary. As non invasive skin tightening treatments offer little benefit for the breast, I commonly instruct patients who have valid concerns with breast lifting procedures to consider a larger implant size and to accept a more age appropriate post-operative appearance.
- For some patients, a lifting procedure cannot be avoided because breast augmentation alone has the potential to make droopy breast look worse. For example, a double bubble deformity occurs when an implant sits higher than the breast when placed under the muscle. This has a very disturbing appearance and is only fixed by adding on a lifting procedure.
- Although placing the breast implant underneath the muscle avoids damaging the milk ducts, the ability for a woman to breastfeed after breast augmentation can be affected. This is an important point to consider if future pregnancies are planned.
- Stretch marks on the breast a common after pregnancy. Placement of breast implants will improve the appearance of stretch marks but will not remove them. I commonly treat stretch marks that are discolored with lasers after breast augmentation surgery is completed.
- Newer anatomic shaped implants do have promise for these types of cases but the overriding drawback is that they are not soft to the touch. This in turn creates a rather unnatural feel to the breast. I commonly reserve these types of implants for my breast cancer patients who have undergone a mastectomy or in individuals with an optimal breast size.
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A patient of any age with a previous breast augmentation that requires replacement.
Breast augmentation is one of the most common procedures completed by plastic surgeons every year. As breast augmentation was introduced in the United States over 30 years ago, it is easy to understand why many of my cosmetic breast cases involve patients who have had a previous breast augmentation. The reasons for changing these implants can be varied but it is most commonly due to failure of the implant, scar tissue around the implant or a patients desire for a change in implant volume or plane (above or below the muscle). A few important points regarding these types of surgeries are listed below:
- In cases where scar tissue has formed around the implant and changed the appearance and feel of the breast, it is very important to remove all the scar tissue at the time of implant exchange. Although this may be tedious from a surgery perspective, it results in the best long-term results. This also presents a real issue for patients who had implants previously placed above the muscle and who have been thinned out after pregnancy. These clinical scenarios can be very complicated and require changing the implant plane to underneath the muscle and including a lift.
- Failure of a saline implant is rather easy to diagnose. The saline solution that was used to fill the implant leaks out and is absorbed by the surrounding breast tissue. The affected breast then deflates. As for silicone implants, this is much harder to diagnose. In these cases, an MRI of the breast is the study of choice due to its extreme accuracy.
- Exchanging for a larger implant is rather easy to facilitate if the plane is not changed. In those cases where a patient also desires a plane change (i.e. moving the implant underneath the muscle), the recovery will be longer and the patient will have more post-operative restrictions.
- I always encourage patients to upgrade to silicone breast implants if they were previously augmented with saline implants. As the literature has established the safety of silicone implants, the benefit from a shape and feel standpoint is immeasurable.
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Middle aged patients (35+ years old) with sagging, deflated breast.
With age, the breast shape and size can drastically change. This is often seen in women with a fair complexion and who have breastfed. For these patients with droopy, deflated breast, a breast lift is often combined with a breast augmentation. The breast augmentation improves the size and shape of the breast and the lift repositions the breast back to a more youthful location. When considering these surgeries, a few key points must be considered:
- The newer types of lifting procedures are less invasive and have shorter scars. A vertical approach, with the lollipop incision is now standard and “anchor” incision is not necessary.
- Although it is rare, lifting procedures can increase or decrease nipple sensation.
- Procedure time for a breast lift with or without augmentation is 2 to 3 hours. General anesthesia is not required.
- Even though this is a combined procedure, the discomfort after surgery is similar to a breast augmentation without a lift.
- We also use our comprehensive post-operative scar treatment protocol to quicken scar maturation (silicone sheeting, silicone gel, laser treatments, dermapen and LED light therapies) after a breast lift.
- See the mastopexy (breast lift) section for a more in depth description of this procedure.
Frequently Asked Questions
[pane title=”Who is the best candidate for this procedure? “]
Any woman that desires an improvement in their breast shape and size is a good candidate for breast augmentation. This is especially true for woman with small breast since puberty or after pregnancy. In the case of droopy, deflated breast, a lifting procedure is often combined with the breast augmentation.
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Breast augmentation is not a permanent procedure. Per our current guidelines, the average duration of breast implant surgery is 10 years. Therefore, it is reasonable for a patient to assume that a replacement surgery will occur during that time frame. I do have many patients who have had breast implants for much longer than 10 years and who have not needed a replacement. Furthermore, the replacement surgery can be completed in less than 1 hour, without general anesthesia and with minimal recovery time.
[pane title=”Are silicone implants safe? “]
Although the 1990’s were littered with large tort cases revolving around silicone breast implants, their safety record is now well established. Large patient studies have proven that that there is no apparent correlation between autoimmune disease and silicone implants. I utilize silicone implants preferentially in 95% of my breast cases. Even my patients with autoimmune disease are candidates for augmentation with silicone implants. The rheumatology literature has shown no correlation with worsened disease. Silicone gel implants are superior to saline filled breast implants from an appearance, feel and durability standpoint. It should be the first choice.
[pane title=”What are ‘gummy bear’ implants? “]
Breast implant construction has improved drastically in the past 20 years. This is especially true for silicone implants which now utilize cohesive silicone gel. This novel silicone gel has a tighter connection between the silicone molecules present in the gel. Why is this important? The gel in the cohesive silicone implants is less likely to leak and migrate to other areas. Furthermore, they can be manufactured with a more anatomically correct shape. Although these implants are the new frontier in breast surgery, the FDA approval has been slow to come. Specifically, Sientra has been approved for distribution of these shaped implants while Mentor and Allergan are close to being approved. So what is the real benefit of anatomic shaped implants? For select patients, a better match to the natural breast shape is achieved. This avoids a balled up un-natural augmented appearance that can occur. Unfortunately, there is a lot of misinformation regarding cohesive silicone implants in general. All current silicone implants utilize some form of cohesive gel but it is the ‘gummy bear’ types that utilize the strongly cohesive gel. Contrary to some websites, ‘gummy bear’ implants are not for every patient. A majority of patients would be well served by a standard cohesive silicone implant. ‘Gummy bear’ implants are harder, have the potential to rotate and can cause deformities. From my perspective, they are very beneficial, but only for a subset of patients I see on a daily basis.
[pane title=”Is there any alternative to breast enhancement surgery that does not involve breast implants? “]
Autologous fat transfer to the breast has become an en vogue procedure. It has the benefit of taking fat from one area of your body where it is not wanted (the belly) and transferring it to an area where it is needed (the breast). This has a big upside. An implant is avoided while the patient has the potential benefit of transplanting stem cells along with the fat. The safety profile is well established. I regularly use fat transfer to improve the breast appearance after breast cancer surgery and to fix patients who have had undesirable breast augmentation results with other physicians. As it pertains to patients who desire fat transfer primarily over breast augmentation with an implant, the tide is turning. The concerns that fat transfer to the breast may disrupt breast cancer surveillance with mammograms have not been supported by the literature. Therefore, even though patients with a family history of breast cancer or a known genetic breast cancer condition (BRCA) should avoid this procedure, most women are good candidates. I believe that this is the future and is becoming an excellent alternative to implant surgery.