Breast Enhancement Surgery
(Augmentation / Mastopexy)

IN GENERAL

Saline-filled implants generally have a less "natural feel" and consistency than silicone gel implants.  For those patients with thicker skin and preexisting breast tissue, the look and feel is very satisfying for most patients. Saline-filled implants may cause less capsular contracture than do silicone gel implants.  However, saline implants also appear to allow for more surface wrinkling/rippling.

In January, 2007, silicone gel implants became available for general use. Many women believe gel implants look and feel more natural. It is nearly impossible to detect a leaking gel implant. Because the gel is thicker than the older silicone implants, they leak very slowly. It is recommended that patients have a special type of MRI of their breasts 3 years after implantation and every 2 years to follow. Also, regular mammograms are recommended with either type of implant.

Remember that the smaller the original breast size and the larger the desired breast size after surgery, the larger is the implant and the greater is the proportion of implant with respect to the native breast tissue.  As a result, the larger this implant/native tissue ratio, the more the new breast mound will reflect the properties of the underlying implant. (i.e., a less natural feel, and greater wrinkling) Since there are limitations to breast implants, these limitations will be greater for larger implants and smaller breast size.

One may think of the breast as a pyramidal structure in which the nipple-areolar complex (NAC) forms the apex, the base lies over the ribcage and the skin forms the walls.  Within this pyramid, the glandular structures extend from the skin surface and are directed vertically toward the deeper tissues.  In the same fashion, the blood vessels and nerves are directed vertically from the ribcage toward the NAC.  Along the walls, blood vessels and nerves run more parallel to the skin surface of the overlying skin.  As such, the NAC can usually be moved upward during surface skin surgery without significantly affecting nipple sensation or blood flow.

CONCEPTS

Asymmetry

The body is not symmetrical in any of its parts.  The breasts cannot be made surgically to appear as exact mirror images of each other. A good concept to think about is that your breasts are "sisters not twins." 

The shoulder girdle and ribcage are not symmetrical since one side is better developed than the other side and, as a result, one shoulder is usually lower, fuller, and wider.  The ribcage on this side can be better developed and as a result the foundation under the breasts is not symmetrical.  As a result, even if symmetrical breasts could be placed on this foundation, since the breast foundation is asymmetrical then the breasts will necessarily appear to be slightly different.

The breasts usually appear to be similar to each other barring unforeseen or uncontrollable healing factors that come into play after the surgical procedure and initial healing has been completed.  Every attempt is made to make the breasts as equal after surgery as possible but mirror images cannot be created.

Remember that small differences in small breasts can become larger differences in larger breasts even if they are addressed at the time of surgery.  Therefore, small discrepancies of NAC size, placement, or position may be exaggerated with breast enlargement.

If your breasts had slightly different shapes before surgery, they may remain different after surgery but specific attempts will be made to maximize breast symmetry in shape, volume, and contour.

In order to maximize upon breast symmetry in shape, size, and contour the two factors that may require adjustment are surface area and volume.  These factors are discussed below.

If the NACs are asymmetrical before surgery, they are likely to appear more asymmetrical after surgery even if the asymmetry in size, position or shape is addressed with the procedure.  The periareolar approach can accommodate such differences in the NACs as well as provide access for skin envelope adjustment and implant insertion. Despite addressing these problems at surgery, asymmetry may persist. The transaxillary, inframammary, and transumbilical approaches cannot accommodate such differences in the NACs or allow for adjustment of the skin envelope.

Rarely, in spite of careful attention to detail, the dissected pockets may end up slightly different in shape or height.  If this is not noted while you are in surgery, but becomes a problem after healing, you may later need an adjustment surgical procedure.

Volume to surface area relationship

The two most important factors that determine breast shape and contour are the breast surface area (skin surface) and breast volume (breast size).  In order to obtain symmetry in breast shape, size and contour the two factors that may require adjustment are surface area and volume.  Measurements will be taken by Dr. McMenamin during one of your consultations and any significant differences in surface area and volume will be identified and discussed with you.

If a proper match exists between the skin surface and the breast size then the breasts will appear to be nicely shaped without ptosis (drooping) whether the breasts are small or large.  If a mismatch exists between the skin surface and the breast size then the breasts will usually appear to be ptotic (droopy), whether the breasts are small or large, since this mismatch usually reflects too much surface area (skin) as compared to the breast volume (size).

With weight gain followed by weight loss, pregnancy or increasing age, the effects of gravity take their toll and the skin surface usually becomes disproportionately large and the breasts have a tendency to droop or settle. We call this drooping “ptosis.”

Augmentation of the breast with an implant can improve upon a disproportion by increasing the volume to better match the surface area of the breast.  However, a volume increase alone may not be sufficient to correct the mismatch and a skin reduction procedure may need to be performed.  This can usually be achieved with a periareolar approach thus elevating the nipple-areolar complex (NAC) as well as reducing the overall skin envelope to better match the new breast volume. Unfortunately, this can leave unsightly scars.

The breast skin usually expands slightly after surgery as the force of gravity plays upon the implant and breast tissues during healing.  The extent to which a breast will relax and settle over time is beyond the control of the surgeon or the patient.  A support bra or sports bra can be worn for a few months after surgery, without displacing the implants into an abnormal position, in order to reduce the effects of gravity.

When an augmentation alone (volume increase) is performed in a breast with a proper match between skin surface and volume, there may be temporary mismatch in the skin/volume relationship. For instance if there is too much volume for the skin surface, the breast may appear to be too full.   Over the first few weeks after surgery, the skin will stretch to accommodate the new breast volume, the proper skin/volume relationship will be reestablished, and the breast will regain a pleasant and more natural shape.

When an augmentation alone (volume increase) is performed in a breast with a mismatch between skin surface and volume (too much skin,) there will be an improvement in the mismatch.  If the preexisting mismatch was small, the volume increase alone will correct the discrepancy.  If the mismatch was too large, reduction of the skin envelope will likely be required otherwise the breast shape will be reminiscent of a "rock-in-a-sock" deformity.  Skin reduction can be performed through a periareolar or inverted T approach.  The skin surface cannot be reduced through a transaxillary, inframammary or transumbilical approach.

Skin Reduction/Improvement of NAC Asymmetry/Periareolar Mastopexy

Improvement in breast mound and NAC asymmetry as well as in the relationship of volume to surface area ratio of each breast can be accomplished with a periareolar approach with skin reduction and NAC positioning. It is important to understand the limitations and consequences of this approach. Small differences in NAC position in small breasts appear to be magnified and become more obvious when the breasts are larger.  If one NAC is lower than the other and the positions are not improved, then this difference appears to be more obvious after the breasts are made larger and a compromise must be reached.  The choice of the compromise is as follows:

• If the implants are positioned similarly on either side in order to maximize upon breast mound symmetry, then one NAC will appear to be obviously lower on the enlarged breast mound.

• If the implants are positioned differentially on either side in order to maximize upon NAC-breast mound symmetry, then one implant will appear to be obviously lower after surgery.

In either case, the NAC or implant/breast mound asymmetry will often appear to be more obvious after surgery than the preexistent breast asymmetry.

In a case where the NACs are asymmetrical in position in which one NAC complex is lower than the other (which is in a desirable position), a periareolar approach is preferred in order to raise the low NAC to a position more equal with the other side.  This requires removing a superior crescent of skin on one side.  This does not usually result in any significant reduction in nipple sensibility.  If the wound is closed without the use of a purse-string stitch, then the elevated NAC may stretch and become enlarged in size, or even oblong in shape, and the upper portion of the periareolar scar will likely thicken in the early postoperative period.

The placement of a purse-string stitch, which is usually placed within the deep layer of skin of the around the outer, larger circle and then tightened, allows for a reduction in size of the outer circle. It is tightened down to the desired NAC diameter equal to that of the opposite side.  This removes tension from the wound closure and reduces (but does not eliminate) the possibility for periareolar scar thickening or widening. The trade-off of a permanent suture is that the stitch can be felt (but not seen) as a slight ridge in the edge of the lifted NAC.  It is also important to know that the stitch can break under stress or strain and the NAC may then stretch or become larger in size. This stitch failure can be corrected with a small procedure that can be performed in the office under local anesthesia in which the permanent stitch is replaced and the NAC tightened down to its previous diameter.

In a case where the NACs are nearly symmetric in position with both complexes lower than the desirable position, a periareolar approach is also preferred in order to raise the low NACs to a more desirable position.  This requires removing a superior crescent of skin on each side.  This does not usually result in any significant reduction in nipple sensibility.  If the wounds are closed without the use of a purse-string stitch, then the elevated NACs will likely stretch and become enlarged in size and the upper portion of each periareolar scar will likely thicken in the early postoperative period.

The placement of a purse-string stitch removes tension from the wound closures and reduces the possibility for periareolar scar thickening or widening.  If both sides are elevated, an absorbable or non-absorbable (permanent) stitch can be used.  The use of an absorbable stitch will lead to absorption of the stitch, which will eventually give way and allow for the NAC to become slightly larger in size and for the breast to settle somewhat but both sides will remain more symmetrical since this will occur on both sides.  This will then prevent the stitch from being felt as a small ridge in the margin of the NAC.

In the case where the NACs are nearly symmetrical in position with both complexes lower than the desirable position, a transaxillary or periareolar or inframmamary approach can be performed without raising the low NACs to a more desirable position.  This implies a compromise.  The choice of the compromise is as follows:

• If the implants are positioned as desired on either side in order to maximize upon breast mound positioning, then the NACs will appear to be obviously low on the enlarged breast mounds.

• If the implants are positioned on either side in order to maximize upon a proper NAC-breast mound relationship, then the implants will appear to be obviously low after surgery and may mimic a "rock-in-a-sock" deformity.

• The NACS are likely to become enlarged in size unless a permanent purse-string stitch is placed and tightened to the desired NAC diameter.

Breast Ptosis (breast settling/droopiness) and the Requirement for Mastopexy

Improvement in breast ptosis or "droopiness" as well as in the relationship of volume to surface area ratio of each breast can be accomplished with either a periareolar approach or inverted T approach with skin reduction and NAC positioning. It is important to understand the limitations and consequences of each approach.

As discussed above, the periareolar approach concentrates on proper NAC positioning and may elevate the breast to a limited degree.  If breasts have significant ptosis, then the choices become to either proceed with an inverted T augmentation-mastopexy procedure or to accept lowered implants and perform a more limited periareolar NAC lift.

If the periareolar approach is chosen then the inherent compromise is that one must accept a lower breast mound but without the greater extent of scarring than that achieved with an inverted T approach.

If the inverted T approach is chosen then the inherent compromise is that one must accept the greater extent of scarring for a more desirable breast mound position than that achieved with a periareolar approach.

Healing after Augmentation with/without Mastopexy

Improvement in breast size, volume, fullness, shape, asymmetry, ptosis (droopiness) as well as the relationship of the volume to surface area ratio of each breast can be accomplished with a well-chosen breast enhancement procedure.  However, it is important to understand that the extent of control of improvement of any breast procedure is limited to the nature and the duration of the operative procedure.

In other words, the fundamental concept of this, or any other cosmetic procedure, is that the procedure is performed in such a fashion as to maximize upon the expected result but that the control over this desired, expected result cannot extend beyond the procedure itself.  A surgeon has no control over the healing process or over the way in which the tissues will react to the surgical intervention.

Some patient's breasts may "settle" more than others.  Some may develop "stretch marks", although most do not.  Some may lose more sensation than others.  Some may develop capsular contracture, although many do not.  Some scars may become thicker than others, etc.

We strive to provide our patients with the best care available preoperatively, intraoperatively, and postoperatively in order to minimize the factors over which we, or our patients, have no control.  Our results speak for themselves but this cannot be translated into any guarantee or warranty with regard to the expected, final results.  There are important healing factors that are simply not under anyone's control and, at times, the patient must accept these limitations. The final result may not quite reach their level of expectation. For example, the result may have appeared better in the early postoperative period than it did after healing and gravity had more of an influence over the final result.

Capsular Contracture/Contraction

Capsular contracture/contraction is the most common "complication" or potential side effect of breast implant surgery.  It is important to remember that the body is genetically programmed to form a layer of scar tissue known as a capsule around any non-biodegradable implant (such as a pacemaker, shunt, joint replacement, breast implant, etc.) thus isolating the foreign object from the rest of the body's tissues.  This is not a rejection reaction but simply the body's reaction to foreign material.

During surgery, a pocket is created for the implant that is larger than the implant itself.  During healing, a fibrous/scar tissue membrane, called a capsule, forms around the device.  Under ideal circumstances, with a smooth surfaced implant, the pocket maintains its original dimensions (usually with implant displacement exercises) and the smooth implant "rests" inside, remaining soft and natural.

Scar tissue anywhere in the body is genetically programmed to shrink somewhat.  For reasons still largely unknown, however, the scar capsule may shrink, tighten, or contract substantially and may squeeze the implant tightly in some women, resulting in various degrees of roundness and firmness. Unlike other body implants such as with a pacemaker, shunt or joint replacement, where scar tissue tightens and stabilizes the implant, this tightening is undesirable.

Whenever tightening forces are exerted around a moldable object, due to the law of physics that dictates that the shape of the largest amount of material packed into the smallest space or surface area is a sphere, the object will become rounded.  In the case of a breast implant, the implant becomes rounded and if the tightening forces become too great, the implant will feel firm or hard to the touch.

This capsular contraction can occur soon after surgery or many years later and can appear in one or both breasts.

Current theories suggest that a low-grade infection may "trigger" some contraction.  The use of a textured surface on the implant, where the scar tissue is meant to form immediately on the implant surface, seems to alter the way in which the scar capsule develops and may prevent undue scar tightening.  Although use of textured implants has not eliminated capsular contractions, it appears to have reduced this risk to the 5-10% range.  The regular use of implant displacement exercises with smooth implants has reduced the risk of capsular contracture to a similar or even lower range.

Capsular contraction is not a "health" risk, but it can detract from the quality of the result and cause discomfort, pain, or distortion of the breast contour.  In cases of minor contraction, we usually will not suggest surgical correction.  Cases of very firm contraction may require surgical intervention, which usually involves opening and release of the scar tissue capsule from around the implant.  Rarely, if the contraction recurs and cannot be eliminated, the occasional patient may choose to have the implants permanently removed but this is unusual.

Questions you must answer for yourself

The following questions relate to the approach and nature of the procedure to be performed.

What type of implant surface?

All implants currently available for breast augmentation are filled with saline (the same salt water solution than is given in the intravenous line) but the surface of the implant is currently made with a solid silicone polymer shell that can be made smooth or textured. The body reacts differently to these implants and different concepts apply toward the prevention of capsular contracture. Capsular contracture, was reviewed above and simply refers to the development of a scar tissue membrane (the capsule) which tightens around the implant and which, in turn, slowly makes the breast rounder.  Eventually, further tightening could make the breast tight and firm once the capsule tightly binds the implant.

The smooth surfaced implant leads to the formation of smooth scar tissue (capsule) which is layered like an onion skin. Smooth surfaced implants have a slightly higher risk of capsular contracture from the development of a "ratchet-like" effect of the collagen fibers tightening end-to-end around the implant surface.  However, when patients perform the implant displacement exercises properly and regularly as taught to them after surgery, the capsular contracture rate is extremely low and appears to be lower than the reported rate for even textured surface implants. With a smooth implant, a large pocket is created during the procedure that is substantially larger than the implant itself. After surgery, daily implant displacement exercises effectively maintain the large pocket and thus prevent the scar tissue membrane from tightening on the implant. As long as the pocket is larger than the implant, capsular contracture cannot occur and a soft, supple breast is the result. These implant displacement exercises begin some 10-14 days after surgery. They are performed 3-4 times per day for at least 6-9 months after surgery and daily thereafter.

Smooth surfaced implants slide within the confines of the pocket created at the time of surgery.  Therefore, external influences after surgery that change the size and shape of the pocket will also result in a change in the size and shape of the breast. The large pocket around a smooth implant must not be reduced or "pinched off" with clothing worn the first 6 months after implantation. Constrictive clothing such as push-up bras, under-wire bras, or clothing that emphasizes breast cleavage may change the size and shape of the internal pocket if worn for an extended period of time.  Common sense would dictate that any clothing which displaces the implant and maintains that implant position will result in loss of the pocket area from which the implant was displaced.  In other words, if the implants are maintained in a "pushed-up" position for too long, they will remain there and it will lead to permanent breast distortion that can only be reversed with formal surgery, if it can be reversed at all. Smooth implants therefore require maintenance of a large pocket. These implants are less prone to surface irregularity since there is no adhesion between implant and surrounding tissue.  These implants are also less prone to develop implant leakage from fold flaw fracture. The implant valve may fail, as with any breast implant, and then slowly deflate over a few days as the saline slowly leaks out.  In summary, smooth surfaced implants prevent capsular contracture through the maintenance of a large pocket surface area by regular implant displacement exercises.  These implants do not require drain insertion at the time of surgery, and they do move or “bounce” within the pocket.  Restrictive clothing should only be worn for short periods of time (<2-3 hours, 2-3 times per week) followed by conscientious implant displacement exercises to keep the pocket widely open. Smooth surfaced implants seldom lead to breast surface irregularity or deflation from fold flaw fracture.  The chest wall muscle only covers about 2/3 of the upper portion of the implant but the smooth implant moves freely within the larger pocket, therefore one can usually feel the smooth implant in the lower pole of the breast.

The textured surfaced implant leads to the formation of a rough layer of scar tissue (capsule) and may have a slightly decreased risk of capsular contracture due to the inability of the collagen fibers to tighten end-to-end in a "ratchet-like" effect around the implant surface.

An external drain may be used (rarely) for 3-5 days to prevent fluid accumulation around the implant. Fluid accumulation might lead to the body’s perception of a smooth rather than textured surfaced implant. This may result in a smooth layer of scar tissue rather than tissue adhesionthat may be more prone to encapsulation.  Textured implants do not become easily displaced once implanted.  They simply rock in position.  These implants therefore require no postoperative implant displacement exercises since the textured surface is the primary reason for the development of an overlying rough layer of scar tissue.  These implants may be slightly more prone to some surface irregularity, particularly in thin patients. These implants are also slightly more prone to develop implant leakage since surface folds may after implantation can rub together and result in a fold flaw fracture. The implant may then slowly deflate over a few days as the saline slowly leaks out. In summary, textured implants reduce capsular contracture through the development of a layer of scar tissue that is similar to a mirror image of the implant surface.  These implants may rarely require drain insertion at the time of surgery; do not require implant displacement exercises; and do not move (only rock) within the pocket. They can (seldom) lead to some surface irregularity that in turn can lead to implant deflation from fold flaw fracture. The chest wall muscle only covers about 2/3 of the upper portion of the implant, therefore, one can usually feel the textured implant more than a smooth one in the lower pole of the breast.

Where should the implants be placed?

                Choices:

1.       submammary                - above muscle and under breast tissue

2.       subpectoral                   - below muscle and breast tissue  

3.   subfascial                       -above muscle and under fascia & breast tissue

Since saline filled implants have a less "natural feel" and reduced consistency than silicone gel implants, the deeper their placement (preferably under the pectoralis muscle – subpectoral, or under the fascia - subfascial), the more "natural" their "feel" and appearance.  The placement of the implant under the pectoralis muscle or pectoralis fascia will provide for some overlying tension and improve the consistency of the implant. It will also provide for some upper pole and medial pole tapering to mimic a more natural appearance and reduce the potential for surface wrinkling. An unfavorable possible side effect of subpectoral placement is tethering of the pectoralis muscle to the breast implant capsule. If this happens, which is common with subpectoral placement, the breasts can look very distorted when the pectoralis muscles are flexed, for example when lifting. Also, subpectoral placement can make the space between your breasts over the sternum appear wider. These problems are minimized with subfascial placement. Other advantages of subfascial placement include a more natural appearance of the breast, less post operative discomfort, and usually, better cleavage. There may be slightly more rippling.

The implant is not covered completely by the pectoralis major muscle and/or fascia; rather, the muscle covers the upper 1/2 to 1/3 of the implant.  In these positions, the implant is always palpable in the lower pole of the breast just as the entire implant is usually palpable through the skin and breast when it is positioned above the muscle in the submammary position.

Visible and palpable wrinkling can occur in the lower breast, lateral breast, and medial breast. Every woman should plan on have some rippling no matter where the implant is placed or what type of implant is used.

What dimension or volume of implant is to be used?

Under most circumstances, patients desire to be enlarged to approximately a C cup.  There is a reasonable range of implant dimension or volume that can be tailored to suit individual desire.  However, it is important to realize that the implant sizes vary more in base dimension than in height/projection.  The volume of the implant is not of prime concern but rather the base dimension is a more appropriate parameter to be tailored to the individual.  Proper sizing of the implant base dimension will allow for a proper upper pole fullness, medial cleavage and lateral tapering of the breast.

It is also important to remember that the smaller the original breast and the larger the size of the ultimate breast mound, the more the new breast will consist of implant.  As a result, the properties of this new, much larger breast must reflect the properties of the underlying implant.  Simply put, the larger the implant, the more visible and palpable it will be especially in women with little natural breast tissue.

A great deal of time will be spent helping you determine the proper size and style of implant. We recommend a combined approach. First, we recommend that you purchase a bra that you want to fit into after surgery. Take some plastic sandwich “ baggies” and loosely fill them each with enough water so that when placed in each cup of your new bra, it is filled the way you want it filled. This will give you an “idea” of how you will look after surgery. It will also give you an idea of how the extra weight is going feel on your chest, back, and shoulders. This is particularly important if you have neck or back problems. Wear the baggies in your bra around the house for the better part of a day and while doing your normal activities. Second, study pre and post op pictures on the internet. One of many good websites is www.lookingyourbest.com. Third, actual breast implants will be tried in a bra at your pre op visit. They, along with pre op measurements, will enable you to pick the size you want.

Which approach should be taken for implant placement?

Choices:

·         Axillary – in the armpit

·         Periareolar – around the nipple

·         Inframammary – in the crease under the breast

·         Umbilical – through the umbilicus ( belly button)

The periareolar approach will allow for placement above or under the pectoralis muscle/fascia; does allow for repositioning of the nipple-areolar complexes (NACs) in case of NAC asymmetry; and the scar is hidden between the dark and light areas around the NAC.  The scars are usually very acceptable.

The axillary approach will allow for placement above or under the pectoralis muscle/fascia; does not allow for repositioning of the nipple-areolar complexes (NACs); and the scars are not on the breast.  The scars are usually very acceptable and hidden in a preexisting axillary crease.

The inframammary approach will allow for placement above or under the pectoralis muscle/fascia; does not allow for repositioning of the nipple-areolar complexes (NACs); and the scar is placed in or near the breast crease.  The scars are usually very acceptable but are most visible.

The umbilical approach will only allow for the placement of the implants above the muscle; does not allow for repositioning of the nipple-areolar complexes (NACs); and the scars are not on the breast.

RISKS SPECIFIC TO THE PROCEDURE(S)

Swelling - Some breast swelling is expected after surgery.  Most of the swelling subsides over the first 10-14 days although minor swelling may last slightly longer.

Transient, disproportionate NAC swelling can occur when a periareolar mastopexy (lift) is performed along with a breast augmentation.  This results in some greater swelling and projection of the NAC beyond the contour of the breast.  This swelling tends to settle over the first few months after surgery.  This disproportionate swelling occurs because of the fact that the periareolar lift causes a tightening of the circular wound margin against the breast and the augmentation pushes the breast tissue forward with swelling of the breast and NAC.  This translates into a mild, temporary herniation of the NAC, which usually flattens as swelling disappears.

Bruising - Some breast bruising is expected after the surgery.  Most of the bruising subsides over the first 10-14 days although minor bruising may last slightly longer.  Do not tan or use a tanning machine until all of the bruises have completely resolved as this may lead to permanent discoloration and skin darkening (hyperpigmentation) of the bruised area.

Hematoma - A hematoma is a collection of blood within the tissues.  Some postoperative bleeding into the pocket containing the breast implant occurs in 2-3% of women. If the bleeding is minimal, the body will absorb it with time. However, significant bleeding accompanied by marked swelling, particularly if accompanied by pain, would likely require a return to the operating room for the surgical removal of the blood.  A substantial amount of blood in the pocket around the implant might lead to eventual capsular contracture that might require surgical release.

Any significant increase in blood pressure (e.g., high blood pressure, constipation and forcing while going to the bathroom, bending over at the waist, lifting objects, exercise) or relaxation of the blood vessels (e.g., bath or shower too hot; use of hot tub) for 2 – 4 weeks after surgery can lead to excessive bleeding and the possible requirement for surgical drainage of accumulated blood.

Infection - Postoperative infection is very uncommon, but is a possible event. Intravenous antibiotics during surgery and oral antibiotics after surgery help prevent infection.  Most infections are mild and resolve without incident.  If a serious infection develops, the implant may require temporary removal and cannot be safely replaced for at least 2-3 months after resolution of the infection and subsequent healing.

Inflammation and Infection - A superficial infection may require something as simple as a topical antibiotic ointment. Deeper infections are treated with oral or parenteral (injection) antibiotics. Development of an abscess (a puss filled pocket) usually requires drainage. In unusual cases, infection may lead to wound disruption or skin loss requiring another surgical procedure.  This occurrence is rare and usually does not result in a significant compromise in the final result. However, it can lead to a delay in the overall recovery phase or promote thicker scars that may require revision to approve their appearance at a later date.

Loss of Sensation to Skin or Nipples - Nerves that supply skin or nipple sensation may be stretched, cut, or damaged while the pocket or space for the implant is being developed.  Although this does not happen routinely to the nerves that supply feeling to the nipple, it can happen in any part of the breast no matter how carefully the surgery is performed.  If sensory loss occurs, stretched nerves usually recover over a few weeks to 12-18 months.  Nerves that required division recover more slowly over a period of 1-2 years in about 85% of cases.

The nerves that supply the nipple (NAC) area are the third, fourth, and fifth lateral intercostal nerves that arise from the spinal column. From there, they travel under the corresponding rib, emerge between the pectoralis major muscle and serratus anterior muscle, travel over the pectoralis major muscle into the breast, and then travel vertically to the nipple.  Placement of the implant above the muscle may interfere more with these sensory nerves, however, whether the implant is placed above or under the pectoralis major muscle, there will be some nerve stretching which may lead to (often temporary) nipple numbness. A stretched nerve often recovers over time from decreased sensibility with a period of hypersensitivity (heightened sensibility) before it recovers toward normal sensibility.  The larger the implant inserted, the more these nerves are stretched.  The recovery period is variable and is often longer the more the nerve is stretched.

It is very common for nipple and breast sensibility to recover at different rates on either side.  One breast always appears to be lagging behind the other.  This is a normal and usual circumstance and usually resolves itself over time.

The skin and breast tissue is released more during surgery in the lower and lateral regions of the breast.  This means that the sensory nerves to the skin of the lower and lateral regions of the breast may become numb for a longer period of time as compared to the upper breast, the central breast and nipple regions.  On occasion, the feeling in the lower and lateral regions may not return to normal.

The breast tissue and/or pectoralis major fascia or muscle are partially released over the breastbone resulting in some nerve stretching and injury in the cleavage area.  Feeling in this cleavage area often drops after surgery and often returns to normal over the next few months.

Nerve Injury - Some degree of nerve injury is normal and expected after surgery.  Sensory nerves to the skin surface are often injured or bruised and this accounts for some of the numbness experienced in the surgical area after surgery.  Sensory nerve injury of this nature cannot be prevented and usually recovers completely over time albeit with occasional limited periods of numbness, discomfort, itching, burning or electrical sensation.  On rare occasions, the numbness is permanent. However, in the vast majority of cases, sensation returns over time. Motor nerve injury is very unusual.

Wrinkling - With the use of textured implants (where the body makes a scar tissue lining that adheres to the surface of the implant), visible wrinkling under the skin is more noticeable in the upper and medial breast area, particularly when the implants are placed above the muscle.  Occasionally, the edge of the implant can also be seen and/or felt.  These problems are usually mild and require no treatment but if they persist, treatment requires that the implants be placed beneath the pectoralis major muscle/fascia.  Experience has shown that the wrinkles may improve over time.  (See Subpectoral Placement below.)

Subpectoral Placement of the Implant - If you and Dr. McMenamin have decided to place the implants under the pectoralis major muscle, a unique set of risks applies.

During contraction of the muscle, the implants may temporarily be flattened and/or pulled up and outward disfiguring the breast. Implants are usually placed under the muscle in very thin, small-breasted women or in women who have thin coverage in the upper and medial breast regions in order to provide more "cover" and some dynamic tension over the implant.  Placing the implants under the muscle may reduce visible wrinkling particularly in these upper and medial breast regions.

Placing the implants under the muscle may also reduce visible implant dropping or inferior migration and the development of a "rock-in-a-sock" deformity since Cooper's ligaments are left undisturbed between the pectoralis major muscle and the breast skin thus supporting the skin.  The skin may have less of a tendency to stretch under the effect of gravity on the implant if Cooper's ligaments remain intact.

Subfascial Placement of the Implant - If you and Dr. McMenamin have decided to place the implants under the fascia (tough, fibrous covering) of the pectoralis muscle, you will have many of the benefits of subpectoral placement without some of the negative side effects. Subfascial placement generally gives a gentle, more natural slope to the breast and better cleavage. There is a slightly higher risk of rippling in thin skinned individuals. Most of our patients choose subfascial placement.

Submammary Placement of the Implant - If you and Dr. McMenamin have decided to place the implants above the pectoralis muscle, a unique set of risks apply.  During contraction of the muscle, the implants may  temporarily be pulled upward.  Occasionally, the implants may "fall" lower than their original position because of the stretching of the skin under the influence of gravity.  With the use of textured implants, the frequency of capsular contraction appears to be the same as when the implants are placed below the muscle but the risk of wrinkling is higher particularly in the upper and medial breast regions.

Placing the implants above the muscle may also allow for more visible implant dropping or inferior migration and the development of a "rock-in-a-sock" deformity since Cooper's ligaments are divided between the pectoralis major muscle and the breast skin in order to develop the implant pocket thus reducing skin support.  The skin may have more of a tendency to stretch under the effect of gravity on the implant if Cooper's ligaments are destroyed.

Stretch Marks (Striae) - Stretch marks are also known as striae and represent a break or crack in the dermis (deep layer) of the skin of the breast.  They usually arise from sudden enlargement of the breast, with rapid stretching of the breast skin, such as with pregnancy or rapid weight gain.  These striae cannot be removed without removing the skin bearing them.  Striae may appear to be worse initially after surgery due to skin swelling that makes them appear more prominent but this is usually temporary and resolves itself once the swelling subsides.  Striae can be made permanently worse with surgery.

If someone has already been pregnant and delivered her child without developing stretch marks, then she is unlikely to develop stretch marks after breast augmentation.

Striae can occasionally occur with breast augmentation.  This can occur when a young patient in her teens or early twenties, who has never been pregnant or has always been thin and who has relatively small, tight breasts and desires a large augmentation.  In such a case, the skin has never been previously stretched and the striae may occur as a result of a sudden, rapid increase in the volume of a breast with a tight skin envelope.  These striae are usually reddened early after surgery and fade in color over the next few months.

Striae can also occur in a patient with constricted or tuberous breast deformity, in which case the breast is tight in the lower breast pole.  The requirement for lower pole expansion in 3 dimensions (vertically - horizontally - in projection) demands wide and aggressive surgical release of the breast tissue and skin in this area thus thinning the tissues dramatically.  The surgical release may be required through the entire breast soft tissue of the lower pole with release just under the dermis.  This then places the implant immediately beneath the skin surface.  This results in the implant being quite palpable in the lower breast region, and the sensibility of the skin being dramatically reduced. It can also lead to the development of stretch marks.

Deflation - Breast implant deflation is not common after surgery.  If, for any reason, the valve or implant covering fails in a saline filled implant, the saline will leak and be absorbed and excreted by your body.  This results in a painless, visible, rapid and dramatic change in the shape of the involved breast.  This causes no medical harm, but the implant will need to be replaced in a secondary procedure.  You will incur some additional expense, but the manufacturer will usually replace the implant and pay part of the surgical fee under their warrantee if the occurance is the fault of the implant and your warrantee is still in effect.  The rate of saline-implant leakage is quoted at about 3-4% over many years.

A silicone gel implant leak is nearly impossible to detect. While extensive studies have not determined a link between gel implants and systemic disease, it is know that silicone gel can promote cysts, granulomas, and capsular contracture in the breasts. Special MRI's are recommended at 3 years post op and every 2 years following to rule out a leak. These tests are expensive and may not be covered by your health insurance.

Loss of Skin, Breast Tissue, or Nipple - This is an extremely rare complication of breast enlargement.  It usually develops from an infection that has gotten out of control and results in the death of the involved tissues.  This very rare complication will usually involve only small areas that will eventually heal with good wound care.  Secondary surgery is a possibility.  The combination of augmentation with breast lift (mastopexy) and cigarette smoking may lead to this complication due to interference with blood flow to the nipple or breast tissue secondary to nicotine in the blood stream.

Scarring - The scars resulting from surgery are not completely predictable although your overall genetic predisposition to scarring can be estimated from other scars that you may have incurred.  The inframammary scar is often difficult to hide completely and may be more obvious than other scars.  The umbilical scar is often acceptable.  The axillary scar is hidden under the arm but may be apparent in sleeveless dresses.

The periareolar scar is the easiest to hide in clothing, can be covered with makeup or can be tattooed with permanent coloring to match the NAC once the scar is white.  At first all scars are reddened and must be protected from the sun with sun block and clothing to prevent them from darkening.

Abnormal scars may occur even though we have used the most modern cosmetic surgery techniques.  Injection of steroids into the scars, placement of silicone sheeting onto the scars, application of pressure tape (Microfoam tape), or further surgery to improve the scars is occasionally necessary.  Some areas on the body scar more than others do, and some people scar more than others do.  Your own history of scarring should give you some indication of what you can expect.

Skin Loss - Skin loss can also be called skin slough, ischemia or necrosis.  It usually leads to the development of an open wound which may require further minor surgery often without significant effect to the ultimate outcome, or may need to heal on its own with scar tissue and requiring later surgery for improvement.

Wound dehiscence refers to the incision line breaking open and can be due to mechanical stretching apart, to skin loss and then a breaking open, or to infection.  It usually requires some surgery later to refine the result and in most cases translates into a delay in healing without a serious compromise in the ultimate surgical outcome.

Implant Palpability - Implants feel like implants. Saline implants DO NOT FEEL LIKE NORMAL BREAST TISSUE. Silicone implants DO NOT FEEL LIKE NORMAL BREAST TISSUE although possibly to a lesser extent. The doctor will allow you to hold a saline and a silicone implant in your hand during a consultation, thus giving you an idea what to expect.

Interference with Breast Feeding - Many women with breast implants have nursed their babies successfully.  Nevertheless, any breast surgery can theoretically interfere with your ability to breast-feed.  If you have never breast fed before surgery, you cannot know for sure if you can actually breast-feed.  Breast-feeding involves a complex neuro-hormonal mechanism that may or may not function properly in every pregnant woman. If you breast fed before surgery, you are more likely to be able to breast feed after enhancement surgery.

Also remember that breast-feeding results in greater breast swelling and skin envelope expansion than pregnancy alone.  The breasts are then more likely to settle, drape over and fall beyond the underlying implant after breast-feeding has been completed than with pregnancy alone.  Should you not wish to breast feed after breast surgery, you may discuss the opportunity for an injection of a hormone that stops the flow of milk after pregnancy with your obstetrician. Pregnant and post-partum patients are more likely to develop a breast infection that can effect your implants.

Calcium Deposits in the Tissue around the Implant - In some patients, a thin layer of calcium will develop within the scar capsule surrounding the implant.  This usually occurs several or more years after the implant has been inserted. In these patients, the added density of the scar may reduce the detect ability of lesions close to the scar on mammograms.  Breast cancers are often still visible and detectable when specialized techniques are used.

Breast Cancer - There is no evidence linking implants and breast cancer.  The only clinical studies available show that the prevalence of breast cancer in women with implants is the same or even slightly lower than in women without breast implants! Furthermore, two studies have shown that the stage of breast cancer detection in woman with implants appears to be identical to that found in the overall population.  In other words, it does not appear that breast implants, although they may interfere somewhat with mammography, lead to a delay in detecting breast cancer.  Breast self-examination does appear to be as valuable and easy to perform when the implants are placed under the pectoralis muscle since the implant is buried beneath the muscle and the overlying breast tissue is spread over the base of the breast pyramid.

Interference with Mammography - You should alert the technician to the fact that you have breast implants.  Special techniques will be used and extra views may be needed in order to see as much of the breast tissue as possible.  As a result, the mammography may be more expensive.

Even under the most ideal circumstances, some breast tissue may remain unseen and a suspicious lesion missed. However, the stage of breast cancer detection in women with implants appears to be identical to that found in the overall population.

However, you should recognize that IN YOUR CASE, if a breast implant delays detection of a breast cancer, it may prevent timely treatment, and you may die from a cancer which would otherwise have been curable.

Because the breast is compressed during mammography, it is possible for an implant to rupture.

Symmastia (Loss of Cleavage) - This is an unusual problem that can develop after typical breast augmentation regardless of where it's placed.  The skin over the lower sternum (breastbone) pulls away from the bone, and normal cleavage is reduced or eliminated. This is also called a “unibreast” deformity.

In the more minor form, the pockets remain separate, but the skin tents upward. In the more advanced form, the pockets on either side merge to form a single pocket. Reduced fibrous or elastic "strength" in the subcutaneous tissues may be contributory but is difficult to predict.  If the problem develops, correction will require secondary surgery.

This problem appears to be less likely to occur when the implants are placed in the subpectoral plane since the muscle attachments will reduce the tension placed upon the overlying skin. The down side again, is a decrease in cleavage.

Presence of Silicone Polymer Shell - The shell of saline and silicone gel  implants are made of silicone polymer (inert, hard, vulcanized, silicone material).  Although the silicone polymer has not been implicated in any diseases and has been used in many types of implants, its use remains under investigation.

GENERAL SURGICAL RISKS

We want you to understand fully the risks involved in surgery so that you can make an informed decision.  We will use our expertise and knowledge to avoid complications in so far as we are able.  If a complication does occur, we will use those same skills to solve the problem as quickly as possible.  The importance of having a highly qualified medical team and the use of an appropriate facility cannot be overestimated. It is in your best interest to maintain a positive, professional relationship with your surgeon and his medical team. The majority of surgical complications simply delay your overall recovery and do not often lead to any serious impairment or permanent consequences. Your doctor and his medical team are the most motivated to assist you in solving any problems as quickly as possible with as few side effects as possible.

In general, the least serious problems occur more often and the more serious problems occur rarely.  If a complication does arise, you, your surgeon, and the nursing staff will need to cooperate together fully in order to resolve the problem.  Most complications involve an extension of the recovery period rather than any permanent effect on your final result.

In general, most complications do not arise directly from the surgical procedure, as one might suspect, but rather from the lack of knowledge of or lack of patient compliance with proper postoperative care.

NORMAL SYMPTOMS

Asymmetry - No one is symmetrical on either side.  As a result, the appearance of various areas during the healing phase (and after recovery) will be different.  Furthermore, the various normal symptoms usually felt during this phase will also be different on either side such as, swelling, discomfort, bruising, numbness, itching, etc.  The speed of recovery will also be different on either side. Remember "sisters not twins."

Swelling and Bruising - Mild to moderate swelling is normal after any surgery and usually lasts for approximately 10-14 days.  Following the postoperative instructions carefully can minimize swelling.  Some bruising is expected after surgery and may also last for approximately 10-14 days and can also be minimized by following the postoperative instructions carefully.  Severe swelling and bruising may indicate bleeding or possible infection.  Call your doctor in this event.

Discomfort and Pain - Mild to moderate discomfort or pain is normal after any surgery.  This discomfort or pain is usually well controlled with the prescribed medication.  If the pain becomes severe and is not relieved by pain medication, please call us at (916) 564-8888.

Crusting Along the Incision Lines - We usually treat this with antibiotic ointment.  Keep any crusted areas moist with antibiotic ointment (preferably Bacitracin ointment) until the skin has healed beneath the crust.  Rub the ointment into any crusted area 4-5 times per day and then protect your clothing with a light dressing.  Once healed, the crust will fall off.

Numbness - Small sensory nerves to the skin surface are occasionally cut or bruised when the incision is made or interrupted by undermining of the skin flap during surgery.  The sensation in those areas gradually returns, usually within 2 or 3 months, as the nerve endings heal spontaneously.  On occasion, strange sensations such as electrical shocks, "pins-and-needles" sensation, itching, burning, extra-sensibility, etc. may be felt as the nerves recover.  These unusual sensations will usually subside as sensation returns to normal as the nerves heal.

Itching - Itching and occasional small shooting electrical sensations within the skin frequently occur as the nerve endings heal.  Cold compresses, skin moisturizers, anti-inflammatory medication and massages are frequently helpful.  These symptoms are common during the recovery period and subside over time as the nerve endings heal.

Redness and Scars - All new scars are red, dark pink, or purple.  Scars on the face usually fade within 3 to 6 months.  Scars on the breasts or body may take a year or longer to fade completely.  Scars can be improved in the recovery period with the regular application of pressure such as with digital massage or with the application of Microfoam tape over the scar.

It is important to protect the scar with sun block as long as the scar is pink in color since sun exposure (or exposure in a tanning booth) can lead to permanent scar darkening (hyperpigmentation).  Eventually, scars fade and often turn light in color.

On occasion, often under tension, scars may become thickened, ropy, raised, reddened, and tender.  Scar revision can be an option, often with improvement in the scar, but is usually deferred until the scar has matured sufficiently, usually at 9-12 months or more.

COMMON RISKS

Change in Skin Color - Scan can change color in reaction to surgery and may turn darker or appear darkly stained.  Prevention is related to abstinence of sun exposure until all bruising has completely resolved. Most darkened skin can be lightened with bleaching creams. It is unusual for skin to be lighter than before surgery except in an area of a healed scar.

Behavior Changes - It is not unusual for patients to become depressed for a period of time after surgery.  The best prevention is a good night's sleep.

Allergy - Allergies to topical medication or to tape reaction can develop during the recovery phase. These reactions are usually self-limited and are quickly resolved when treated properly.

Unusual Reactions - Severe unexpected reactions to medication during surgery are extremely uncommon and can be quickly treated as soon as recognized.These reactions, although severe, seldom lead to a serious outcome but may require termination of the procedure to be rescheduled at a later date.

Additional Restricted Activity - In addition to other restrictions mentioned above, driving a car is not permitted for the first 5-7 days after surgery. We require this more for legal than medical reasons since driving with a dressing or driving under the influence of any medication that can influence your reflexes (whether prescribed by your doctor or not) is considered to be a driving under the influence (DUI) and is a felony.

Activity level can be increased in stages after the initial 7 - 10 day period. Those who work a sedentary type job should be able to return to work at that time. You may drive a car if you are not taking narcotic pain medication and have power steering. Limited aerobic exercise like walking can begin after 3 weeks. Finally at one month, any desired activity can be undertaken, including lifting weights. You should get clearance from Dr. McMenamin before restarting any activity requiring physical exertion.

RARER COMPLICATIONS

If they are severe, any of the problems mentioned under Common Risks may significantly delay the healing or necessitate further surgical procedures.

Medical complications such as shock (very low blood pressure), deep vein thrombosis (blood clot in the leg veins), pulmonary embolism (blood clot that migrates to lung blood vessels), severe allergic reactions to medications, cardiac arrhythmias (abnormal heart beat), heart attack, severe hyperthermia (increase in body temperature), hypothermia (decrease in body temperature), or adverse drug reactions are very rare life-threatening problems that can occur.

Having a qualified surgical team present at your surgery reduces these risks as much as possible.  Failure to disclose all pertinent medical data, including recreational drug and/or alcohol use, before surgery may cause serious problems for you and for the medical team during surgery and may place you at unusually great risk for serious complications.

Please follow your common sense. If you think you shouldn't do something, don't do it until you ask us first.  Remember, how you take care of yourself after surgery can make the difference between an ideal result and a mediocre result or cause a complication that may require further surgery.

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