Breast Augmentation with Saline or Silicone Gel Filled Implants

Introduction:

As you contemplate having breast implants (boob job), it is important to realize that you are considering real, major surgery that requires mental and physical preparation, as well as education, planning, the surgery itself, recovery, and long term care and follow-up. Millions of women around the world have had breast augmentation surgery. In most circumstances, they are thrilled with the results and enjoy their enhancement for many years to come. However, there are limitations to the procedure along with risks, some of them serious. Therefore, it is important to weigh the risks and benefits of the procedure to decide if it’s the right thing for you.

Mental Preparation:

Breast augmentation can be very beneficial for a woman who wants to feel better about her outward appearance. A rounder, fuller breast that is size proportionate to the rest of her body is attractive and sensual and may promote self-esteem and confidence. Breast implants can help improve breast fullness lost during child bearing and nursing, or they may give you what nature forgot.

The final decision to undergo this procedure, after carefully weighing the risks versus the benefits, should be made by you alone and only with the understanding that there are limitations to what can be achieved. Breast implants will not improve depression, personal relationships, and other personal problems and should not be done for any of these reasons.

Breast implants are basically sophisticated balloons filled with saline or silicone gel placed behind your own breast tissue. The appearance and quality of your existing breast tissue and overlying skin has nearly everything to do with the post op appearance of your breasts. Loose, thin breast tissue over an implant will generally show more rippling, more sagging, and more visible, palpable implants. Pregnancy and nursing can have devastating effects on your breasts. These effects may be magnified after breast implants. You must be willing to take these risks. Fixing or improving problems, when possible, may require further and even more extensive and costly surgery. Some problems may not be fixable.

Some women should not undergo breast augmentation. Patients unwilling to give up smoking in the three weeks before and after surgery are not candidates for this surgery. Patients with severe mental or physical health problems are not good candidates. Patients with severely sagging breasts may not be good candidates. All of these problems will be discussed with you.

Physical Preparation:

Breast augmentation is an elective surgical procedure that must be performed under optimal conditions to minimize the risk of complications and to enhance your chances for the best results. Smoking, alcohol and/or drug abuse, and unwillingness to follow pre and post op instructions are indications against undergoing this procedure. For the two weeks before and after the procedure, you must abstain from alcoholic drinks, recreational drugs, some vitamins and herbal supplements, fish oils, and some over-the-counter and prescription drugs, and from tobacco products of any kind for three weeks. We ask this of you because these things can cause excessive bleeding (putting you at risk for a blood clot and excessive bruising) as well as infection, prolonged healing, and significant scar tissue formation.

Education:

The more you know about breast augmentation surgery the better you are able to make an informed decision. This handout and the other information we provide will help make you an educated consumer. However, we urge you to do research on your own. The Internet is a very good source. www.lookingyourbest.com and our office website www.renewyou.com are good locations as well as many others. Talking with friends who have had the procedure is advisable, too, although keep in mind that every patient goes through the procedure differently and every surgical office has their own routine. This information will allow you to ask appropriate questions, understand the pros and cons of the surgery, and give an informed consent if you decide to proceed. Be sure to bring a list of questions to your initial consultation with Dr. McMenamin. He will be spending approximately 45 minutes with you to provide information and to answer your questions.

Dr. McMenamin uses one of three different incision sites to place implants. The first and most traditional incision site is under the breast near the fold. This incision leaves a more visible scar on the breast that most patients do not prefer to have. The second incision site is at the border of the areola, the dark area around the nipple. This incision usually leaves a very acceptable scar, however, it is still a scar on the breast. This incision also requires going through breast tissue to get to the area where the implant will be placed. The third incision site, and the one most favored by our patients, is in the axilla (armpit.) This incision is hidden in a natural crease and, in our opinion, gives most patients the best and least noticeable scar. Going through the armpit also gives the surgeon easy access to the chest wall to place the implant with very little disturbance of the breast tissue. Incisions, no matter where they are placed, always leave a scar. Some skin types heal better and scar less than others. Dr. McMenamin will recommend the incision that he believes will give you the best, least noticeable scar. However, he will abide by your preference after you have heard the pros and cons of each approach.

Although it rarely happens, it is possible that based on your expectations, health history, or other factors, you or Dr. McMenamin may decide against going ahead with the procedure. It is a serious, long-term decision to have real surgery. We strive to help you make a sound, informed decision.

Planning:

If you decide to schedule surgery we will require you to get a baseline mammogram if you haven’t had one in the previous year. We request this study to help rule out or identify breast disease. Those x-rays may be used by your radiologist to compare future mammograms. The cost of your pre op mammogram is included in your surgery fee if you use Diagnostic Radiological Imaging. Of course, you are welcome to go to the imaging center of your choice at your own expense. If there is an abnormality on your mammogram that requires further study, you will be responsible for those fees that may or may not be covered by your health insurance. Routine pre op lab work, if needed, is also covered by your surgery fee.

You will be given or sent a "Surgery Packet" which will include your schedule of visits to the office, schedule of surgery fees and when they are due, referrals for blood tests and screening mammogram (if none in the previous year), and paperwork to be read and completed BEFORE your "Pre Op" appointment. Your "Surgery Packet" is a good place to keep all of your paperwork related to your surgery for future reference.

Your “Pre Op” visit will occur approximately two weeks before surgery. At this visit, measurements and photographs of your breasts will be taken. Dr. McMenamin will go over a detailed surgery consent form and answer all of your questions. The Physician Assistant (P.A.), Cathi Lown, or Dr. McMenamin will do a history and physical exam, including a breast exam. You will be counseled on pre op and post op care and what to expect the day of surgery as well as how to take care of yourself afterward. Medications will be given to you to take along with a vial of disinfectant soap to shower with prior to surgery. Lastly, you will choose your implant size with the help of the P.A. or Dr. McMenamin. You will “try on” implants in a bra to help determine what size you would like. You will be asked to bring at least three nude, frontal pictures of women's breasts. You can get these from Internet websites or a magazine such as Playboy. We will want one picture that you consider too large, one picture that you consider too small, and one picture that is close to the size you prefer. (It is important to note that the pictures are for size reference only, not appearance.) The incision site (through the armpit, through the nipple, or under the breast), placement site (under the muscle, under the fascia of the muscle, or under the breast tissue), and implant type (saline vs. silicone gel, round, anatomical, smooth, or textured) will be decided by you after discussion of the pros and cons by the surgeon. This appointment will be approximately 2 hours long. You are welcome to bring your significant other or a friend to this appointment, but keep in mind that the final decision is yours. It is essential that you complete all of your “homework,” including reviewing the consent form and handouts, and initialing or signing in the appropriate places before your pre op visit. Dr. McMenamin and his physician assistant will review all of the material with you, but you must have completed your part to maximize the quality of our scheduled time.

Day of Surgery

You will be given a list of instructions to follow on the day of surgery at your pre op. Those instructions will include what to do, what to wear, what time to be here, etc. Dr. McMenamin will be marking out the “pocket” for the implants on your chest and taking final photographs. You will be taken to the operating room where you will meet the anesthesiologist. He will ask you some general health questions. An intravenous line (IV) will be inserted and monitors for blood pressure, pulse, oxygen saturation, and carbon dioxide levels will be hooked up to you the same as for major surgery in a hospital. The anesthesiologist will administer IV medication for deep sedation. (This is not general anesthesia requiring assisted breathing or intubation.) You will pleasantly drift off to sleep and stay asleep until the procedure is over. Most patients have very little discomfort on waking, but do often describe a tight, heavy feeling on the chest much like the feeling women have after childbirth when their milk "comes in.” Steri-strips will be applied to the incision sites and a comfortable bra that we supply will be put on you. An absorptive dressing will be applied over the incision sites and a roll of gauze may be placed under the bra over the sternum (breast bone). Written post op instructions and medications will be given to you along with Dr. McMenamin’s home phone number. He or an office staff member will be calling you daily in the early post op period to check on your status and answer your questions. You are urged to call him in the event of an emergency.

Recovery

You are required to have a driver to take you home from surgery and to drive you to and from your post op visit the next day. You must also have a caregiver to help you in the first 24 hours and longer if you have small children. Most patients are able to drive themselves one week after surgery if they have a car with power steering. All post op patients are required to have a comfortable place to sit and sleep elevated for at least the first week. A recliner chair is highly recommended even if you have to rent or borrow one. Be careful not to use your arms to pull yourself out of the chair. This type of upper body exertion can lead to bleeding. Along with staying elevated, you must apply ice packs at least 20 minutes out of every hour for 24 hours a day the first three days then for at least 20 minutes out of every hour for 12 hours a day for an additional three days (usually during daylight hours so you can get some needed sleep). This means you will be icing for six days total.

Lastly, you must severely limit your activity for the first week. Remember, you have had major surgery requiring diligent post op care. Those patients who have a sedentary type job (i.e., a desk job) can usually return to work after 5-7 days. At the other extreme, those patients with strenuous jobs requiring heavy lifting, pushing, pulling, etc., should plan on taking 2-3 weeks off work. Post op patients are also asked to abstain from "working out" and from submerging the breasts in water for one month. You will be counseled from one appointment to the next on what you can and can't do. If you have any question about that, don't do it until you have talked with the doctor. To repeat, you will have Dr. McMenamin’s home phone number in case of an emergency, and you will usually be called or seen by him or the P.A. on a daily basis in the initial recovery period.

You will be asked not to shower or wash your hair after surgery until 24 hours after your stitches have been removed. This includes not taking a bath. Warm water can cause blood vessels to vasodilate (open up). That is what causes your legs to turn pink in the bathtub. Vasodilatation of blood vessels increases your risk for bleeding. Therefore, you are asked to sponge bathe only for the first week or so. After that, you may shower, but still not submerge your breasts.

Very rarely do any of our patients require narcotic pain medication (i.e., Darvocet) after surgery although it will be supplied to you. Local anesthetic on the chest wall and intravenous pain medication given to you at the time of surgery will keep you pretty comfortable for the first 8 - 12 hours or so. Staying elevated, icing, and keeping very quiet will help minimize swelling, bruising, and especially, pain. We do recommend that you take 1-2 Extra-Strength Tylenol (acetaminophen) every 4-6 hours even if you think you do not need them. This will help prevent the pain cascade from starting. Narcotic pain medications can cause nausea particularly if taken within the first 24 hours after surgery. They can also cause other unpleasant side effects. After 24 hours, if you are not acceptably comfortable, you may take Darvocet (Propoxyphene) for pain as long as it is taken with a meal. Do not continue to take them if you suffer from nausea, constipation, or other side effects. Do not take Tylenol and Darvocet together as Darvocet already has Tylenol in it.

You will be given antibiotics to take for 7 - 10 days after surgery. Post operative infections when a foreign body or prosthetic device (implant) is involved can be particularly serious. For that reason, antibiotics are given as a precaution. Please take them as directed and report any problems with taking them to the doctor such as nausea, change in bowel habits, muscle/tendon pain, or vaginal yeast infection. These side effects happen infrequently, but can cause considerable discomfort and should be addressed.

Long Term Care and Follow-up

At your two-week post op visit, you will be shown how to do pocket expansion exercises on your new breasts. These exercises are very simple and take less than a minute out of your day. The purpose of these exercises is to physically put pressure on the pockets surrounding your implants to help keep them open and therefore help to prevent capsular (scar) contracture. Just as importantly, by doing the exercises you will be alerted to a contracture early on. We request that you do the pocket expansion exercises every day for as long as you have implants. This will be covered with you in more depth at your post op appointments.

Additional weight from breast implants causes more stress on your natural breast tissue and the overlying skin. To help preserve the look of your breasts after surgery, we request that on a day-to-day basis you wear a very good support bra. We recommend all women with implants wear a soft “sleep” bra on a regular basis. That is not to say you cannot wear fancy, skimpy lingerie for a special occasion. We recommend that you not buy any bras until after your two-week appointment. We will go over our bra recommendations with you at that time.

We ask our breast augmentation patients to abstain from any dental work, including cleaning, for 90 days after surgery except in a dental emergency. After that and for the first year after surgery, we ask that you take antibiotics before and after dental work, including cleaning. There have been studies that show a link between bacteria in the blood and capsular contracture (scar tissue formation) of the breast implant pocket, particularly during the healing phase. It takes approximately one year for the pocket to heal completely. Therefore, again as a precaution, we ask that you take a very short course of antibiotics. This will be explained in more detail to you and a handout will be provided regarding support bras, pocket exercises, and antibiotic use.

If you are doing fine at your two week post operative visit, we will not see you back for 4-6 months unless you have a question or problem. After that, we like to see you on a yearly basis for routine follow-up. You are urged to call if you suspect any problems and may make an appointment for evaluation. Your routine post operative care is included in your surgical fee. Our post operative patients will also not be charged for consultations regarding other cosmetic procedures

Transaxillary, Subfascial Augmentation

Important Concepts in Review

• Asymmetry and Appearance – “Sisters, not Twins”

The body is not symmetrical in any of its parts including breasts. Do not expect your breasts to be mirror images of each other. Also, the breast tissue you have prior to surgery and the shape of your torso determines the placement and appearance of your breasts after surgery. The surgeon cannot change that nor can he change how they heal over time. The larger the implants, the more noticeable asymmetries will be. Also, implants may make the areolas bigger and stretch marks (striae) more pronounced (or make new ones). Everyone who has saline breast implants will be able to feel the implants and will have visible and palpable rippling. The same is true for silicone gel implants, however for most people it will be less. The degree this may happen is determined by your preexisting tissue and the size of the implants. How your breasts look immediately after surgery and in the early healing stages is not how they will look in 3 months, 6 months, or even a year. They will continue to change as your tissue relaxes and accommodates the implants. Supporting your breasts with a good bra will help preserve your new look. Where the implant is placed, under the pectoralis muscle, under the fascia of the pectoralis muscle, or above the pectoralis muscle, affects how the implant looks and moves on the chest wall. Every effort is made at your preoperative visit(s) to help you choose the size of implant for the result you desire. However, the final decision is yours and this office makes no guarantee that you will be happy with the size or the appearance. The number one complaint nation wide by women after breast augmentation is that they are “not big enough.”

 

Ptosis – “Droopiness”

Patients who have droopy breasts before surgery will have a more relaxed look to their breasts after surgery and will tend to droop more over time especially if they are not well supported in a good bra. The larger the implant, the more weight is pulling on the tissue and the more likely ptosis will occur or worsen. Pregnancy and/or nursing can cause stretch marks, droopy breasts, and larger nipples and areolas with or without breast implants. However, implants may make it worse in some patients. Sunbathing or tanning in a tanning bed may cause permanent discoloration of the overlying skin of the breasts particularly in the first 6 – 12 months.

 

Capsular Contracture

The body sees a breast implant as a foreign body and as a result, walls it off from the rest of the body by a thick, fibrous scar or “capsule.” This is a normal part of healing and can be desirable. However, a potential complication of breast implants is for the capsule to shrink or tighten too much. This can happen at any time the implant is inside you. Infection may play a role, but more likely, it is determined by genetics and other factors. If this happens, the breast may become hard, misshapen, and/or painful. Capsular contracture may require surgical correction at an additional cost to you. Doing the postoperative displacement exercises daily with smooth implants may help to prevent this problem.

 

Surgical Risks

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. 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. Hematoma - A hematoma is a collection of blood within the pocket surrounding the implant. If the bleeding is minimal, the body will absorb it with time. However, significant bleeding accompanied by marked swelling, bruising, and/or pain will require a return to the operating room for the surgical removal of the blood at an addition cost to you. While a hematoma can happen under the best of circumstances, you can minimize your risk by following our pre and post operative instructions. Hematomas increase your risk of capsular contracture and infection, and prolong healing time. Smoking can be a cause of bleeding, hematoma, and excessive bruising. Infection - Postoperative infection is very uncommon. Most infections are mild and resolve without incident. However, if a serious infection develops, the implant may require temporary surgical removal and cannot be safely replaced for at least 3 months after resolution of the infection and subsequent healing. In rare cases, hospitalization may be required. All additional treatment will be an added expense to you, including hospitalization. It is important that you take the oral antibiotics as directed before and after your procedure and to follow all other pre and postoperative instructions. A superficial infection may require something as simple as a topical antibiotic ointment. Deeper infections require treatment with oral, injection, or IV antibiotics. Development of an abscess (a pus filled pocket) requires surgical drainage. In unusual cases, infection may lead to wound disruption or skin loss resulting in a permanent scar and/or need for a skin graft. Loss of Sensation to Skin or Nipples - Some loss of sensation to areas of the skin overlying the breasts as well as the nipple area is normal and expected following surgery. Nerves that supply skin or nipple sensation may be stretched, cut, or damaged while the pocket or space for the implant is being developed. It can happen in any part of the breast no matter how carefully the surgery is performed. Sensory loss is usually temporary with gradual recovery over 6 to 24 months. During that time, you may experience momentary sharp electrical sensations, tingling, burning, itching, and nipple/breast hypersensitivity that may be different on one side compared to the other. It is possible to have permanent numbness in some areas including the nipple. It is also possible for the nipple to lose its ability to become erect. Implant Placement - Where the implant is placed on the chest wall can determine how it appears and functions in the tissue. The three ways used by Dr. McMenamin to place implants are as follows: SubmammaryPlacement of the Implant (Above the Muscle and Fascia) - If you and Dr. McMenamin have decided to place the implants above the pectoralis muscle and above the fascia of the muscle, a different set of risks apply. During contraction of the muscle, the implants may temporarily pull upward. The influence of gravity may play a bigger role in stretching the skin causing the implants to “fall.” The risk of rippling is higher particularly in the upper and central breast regions. There is greater disruption of the skin attachments to the chest wall and therefore there is less support of the implant with greater stress on the tissue. Stress on the skin over time can result in a “rock-in-the-sock” deformity. That is, the implant may look like a rock in the bottom of a loose bag of skin. The supporting ligaments, called Cooper’s ligaments, are destroyed when the pocket for submammary placement is developed. SubpectoralPlacement of the Implant (Under the Muscle and Fascia) - If you and Dr. McMenamin have decided to place the implants under the pectoralis major muscle, a unique set of risks applies. During flexion of the muscle, the implants may temporarily be flattened and/or pulled upward and outward distorting the shape of the breast. Implants can be placed under the muscle in thin, small-breasted women or in women who have thin tissue coverage in the upper breast regions. The muscle may provide more "cover" and some dynamic tension over the implant. Placing the implants under the muscle may reduce visible rippling in the upper medial breast regions but with the risk of distortion of the breast during flexion of the muscle. Cooper’s ligaments remain intact during development of the implant pocket and there is more implant support against drooping. Post op bra support is always recommended. It is important to note that only the top approximately ½ of the implant is covered by the pectoralis muscle. The muscle overlying the upper part of the implant can cause an unnatural fullness over the top of the breast. SubfascialPlacement of the Implant (Over the Muscle, Under the Fascia (thick fibrous covering) of the Muscle and Under the Breast Tissue) – This is a relatively new way to place the implant and, in our experience, the way most patients get the best result with the least amount of distortion with movement. The subfascial placement gives you most of the benefits of placement under the muscle (better support of the implant, less trauma to the breast tissue, less rippling than submammary placement) but also gives a more natural shape to the breast and less distortion with movement. In our experience, patients have less postoperative pain and a quicker recovery than with subpectoral placement. There may be a slight increase in risk for rippling with subfascial placement but much less than submammary placement. When compared to subpectoral placement, the subfascial placement has almost always given a better post op result. Stretch Marks (Striae) - Stretch marks represent a break or crack in the dermis (deep layer) of the skin overlying 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 after surgery due to skin swelling that makes them appear more prominent but this is usually temporary and resolves once the swelling subsides. Striae can be caused by and made permanently worse with augmentation surgery. Deflation - Breast implant deflation is not common after surgery. If, for any reason, the valve or implant shell fails, the saline will leak and be absorbed and excreted by your body. This results in a painless, visible, and usually 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 replace the implant at no charge and will pay a portion of the replacement surgery if the leak is due to implant failure and not due to trauma. A warrantee booklet will be provided to you that will explain coverage provided by the company. The rate of saline-implant leakage is quoted at about 1% per year. (1 out of 100 patients.) 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. Cigarette smoking may lead to this complication due to interference with blood flow to the nipple or breast tissue because of nicotine in the blood stream. Scarring – Genetic predisposition, your general health, and other factors effect the way wounds heal. Scarring can be estimated from other scars that you may have incurred. No matter where the incision is made for your augmentation, a scar will result. If the scars are unacceptable to you, treatments can usually be done to improve them but will not take them away. Some areas on the body scar more than others and some people scar more than others. 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 surgery often with significant scarring effects. It may need to heal on its own with scar tissue and require later surgery for improvement. Wound Dehiscence – This refers to the incision line breaking open during healing and is usually due to mechanical stretching or to infection. It will usually heal without treatment, but may require surgery later to refine the result. Palpability - SALINE IMPLANTS DO NOT FEEL LIKE NORMAL BREAST TISSUE. You will be able to hold a saline implant in your hand during a consultation to give you an idea of how they feel. Breast Feeding - Many women with breast implants have nursed babies successfully. Any breast surgery can theoretically interfere with your ability to nurse. Also, some women are unable to breast feed for reasons unrelated to breast surgery. If you were able to breast feed before surgery, you are more likely to be able to breast feed after enhancement surgery. Breast-feeding usually results in even 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. Pregnant and post-partum patients are probably more likely to develop a breast infection that can affect your implants. Breast Cancer - There is no evidence linking implants and breast cancer. Some clinical studies have shown 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 women 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. Mammography - You must immediately tell the technician that you have breast implants. Special techniques can 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 either above or below the muscle. 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. It is possible you will have your implants removed and not replaced until a later time. Presence of Silicone Polymer Shell - The shell of saline-filled implants is made of silicone polymer (inert, vulcanized, silicone material). Although silicone polymer has not been implicated in any diseases and has been used in many types of implants, it is still being investigated.

Conclusion

We hope this handout has answered many of your questions about what to expect before and after breast augmentation surgery. We also hope it has brought up more questions that you didn’t even know to ask. Please call the office at your earliest convenience to make an appointment for a consultation with Dr. McMenamin. (916) 564-8888