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Consultation Letter to Breast Augmentation Patients

Oct 9, 2007
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 very closely 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 occurred 80 percent of the time which 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 was somewhat successful and brought the contracture rate to approximately 30 percent. Better but not perfect.

Then research was done changing the surface of the implant to what is called textured or rough. The idea was that the irregular surface would bond with the body's tissue better and break up the scar tissue and, thus, prevent contracture. This worked much better with contracture rates approaching 5 percent. However, like everything in medicine, nothing is zero percent and contracture rates still range around 5 percent.

So in the late 1980's there were silicone gel breast implants with textured surfaces and the results were excellent. In fact the results were so good that many times it was impossible to tell by physical exam that patients had implants.

In the early 1990's a group of women that 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. There was no scientific evidence that this was occurring but the claims caused the Food and Drug Administration (FDA) to ban their use.

After several years of litigation and scientific study, it has now been shown that Silicone Breast Implants do not have any association with or cause disease in patients. That does not mean that they are perfect by any means. The problem with silicone gel is that it is not absorbable by the body. So if it ruptures and the gel gets outside the scar tissue that normally encases the implant (this is very uncommon), there can be some very serious inflammatory tissues that can form and may require surgery to correct.

But this is not a disease. You must always keep in mind that nothing in medicine or surgery is perfect. For example, if you vaccinate your children, as many as one in two hundred thousand can have a severe reaction and even die.

However, at the time of this writing, the only implants that are approved for general use are Saline-filled. They are made of a similar silicone rubber shell and are inflated at the time of surgery to their appropriate size. The nice thing is that if they break, the body just absorbs the water with little side effect other than the volume is lost.

However, as you will see during your consultation, saline-filled implants do not feel anything like silicone gel or normal breast tissue. This is why we now generally place these implants under the Pectoralis Muscle. It 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 almost always acceptable in appearance and feel for most patients.

There are three options for placement of the incision and there are pros and cons to each.

Placing the incision in the armpit is nice 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. Also, you must consider this surgery a maintenance operation.

For many reasons it may be necessary for you to undergo additional surgery to improve or maintain the result. Although I have not seen these rates of re-operation in my practice, in recent data the re-operation rate can approach 20 percent in ten years. The problem with axillary incisions is that many of the surgeries that need to be done in the future can not be done through that incision. Therefore, many of the women that have used this incision will need a different one in the future. For these reasons, I don't prefer this incision.

Under the breast fold was the most common way when silicone gel implants were being done because you needed a large incision to place that kind of implant. The problem with that incision is that it frequently widens and rises up on the breast and is visible. Unless I am revising a patient from another practice who has this scar, I nearly never use this approach.

Most surgeons, me included, prefer an incision around the nipple. This is called the peri-areaolar approach. There are some misconceptions about this incision that deserve discussion. You might have heard that if you go through the nipple, you can not 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, all patients should have no difficulty breast feeding.

However, can you get nipple numbness from this operation? The answer is yes. But it has nothing 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. However, they might be permanently numb. But this has nothing to do with the incision. It is, again, due to the pocket.

There are three reasons that most surgeons perform this incision. For one, it is technically easier to create the pocket precisely. Two, if you ever need another operation you can usually perform it through the same incision. 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.

Breast augmentation is performed as an outpatient. In this practice it is performed under general anesthesia. Although some practices perform Breast Augmentation with sedation and local anesthesia, I believe that it is a much more pleasant experience and it can be done more precisely with you asleep. The risks of general anesthesia are commonly greatly over-stated.

In fact, most patients have a much larger risk of injury and death by getting into their car than from the sophisticated general anesthesia techniques now available. I do not use drains, or little tubes, to collect fluid that may occur around the implant. I know that some surgeons do, but I have found no advantage to using them. However, I would not fault a surgeon for using them and I have, on occasion used them as well. If they are used, they generally are removed 24 hours later.

We always see you the following day after surgery. We will give you a post-operative bra at that time. We will see you again in 7 to ten days to remove sutures and again at 6 weeks after surgery to make sure the implants are settling well into their pockets and everything is progressing normally. I like to see you yearly to check and see how you are doing.

Most patients take about 7 days off of work. I only have two major rules after Breast Augmentation. No push-up or under-wire bras until the implants have settled (about 6 weeks) and if it hurts, don't do it. 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 to see the final result with any type of surgery. However, areas of the body that have undergone surgery actually change and mature for an entire year. The changes from six weeks to a year are very subtle and occur slowly.

It may be wise to wait until after you have had your children before having breast augmentation. Because of risk of infection, you should not breast feed within 8 months of having your surgery. Also, becoming pregnant immediately after your surgery may compromise your result due the large hormonal stimulation to the breast with pregnancy. If you have questions about these factors, please bring them up at the time of your consultation.

There are two other concepts that are very important for you to understand. First is the concept of cup size. Cup size is the worst way to measure an individual's breast for many reasons. First, few people understand what is really meant by cup size. Few women wear the right size bra and all bra manufacturers make them differently. Also, each patient has a unique anatomy that will dictate what size implant is best for them and how they will look after surgery.

As the implants get larger, their base diameter becomes bigger and they can sit too close to each other. This looks ridiculous. The implants also only come in so many sizes. Because of these factors, there is no guarantee for post-operative cup size on any specific patient. However, I always ask what the patient wants to figure out what they are thinking.

Patients that come in desiring to be a C usually really want a D but are afraid to say that thinking that a D is too big. What that means to me is that they want to be proportional to their body size and look good in their clothes and bathing suits. They just don't want to be the object of jokes or have their significant others get in fights over them. Women who come in saying they want to be a D usually want to be much bigger.

Usually as big as I can possibly go. Sometimes patients come in with pictures from magazines and say "I want to look just like this." The reality is that we don't usually have that much flexibility with Breast Augmentation and that your individual anatomy will dictate your final result. I sometimes joke with my patients that this is not a Burger King operation. You can not "have it your way." If you started out looking like "Miss July", it is likely you will have her result. But otherwise, it is very unlikely that any patient would look exactly like "Miss July."

The other concept that you must be comfortable with is that Breast Augmentation by its nature is a maintenance operation. By having Breast Augmentation you are making the choice to enhance your appearance by enlarging your breasts. However, it is very likely that the results of this one operation will not last your lifetime. In most patients it lasts years, but there are multiple reasons that patients need additional operations.

Most of these will be covered below. The fact is that the majority of patients will undergo further surgery in the future to maintain or improve upon their result. Future surgery, whether for revisions or complications, will almost always result in additional anesthesia, facility, implant (if necessary) and possibly surgeon's fees. It is impossible to predict the kind of surgery or the costs that would be required in this case.
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