Dr. Neavin is considered one of the best breast enlargement surgeons in the Los Angeles area
Choosing a plastic surgeon to operate on your chest can be a daunting experience. Once you find a good “match”, you still have some big decisions to make. You may have heard of “gummy bear” implants, silicone implants, saline implants, and shaped devices. They can be smooth or textured, high profile or low profile. They can be placed over the muscle, under the muscle or placed via a “dual plane” approach. Your incisions may be in the armpit, the breast fold, around the areola, or in the belly button. Confused yet? Don’t be. If you did some homework (and by reading this you are), AND you find a plastic surgeon that takes their time to understand what you want, then a lot of these decisions should come rather easily.
There are typically 4 well described incisions. Dr. Neavin uses all 4 approaches. Each has its own advantage and disadvantage. Plastic surgeons are often partial to one or two approaches. Dr. Neavin prefers either the breast fold (or IMF) approach or periareolar (around the nipple approach).
Candidate’s for a breast enhancement include women who want either fuller bust, larger, perkier or more breast symmetry. Your consultation with Dr. Neavin will include going over the different implant choices, placements, and incision approaches. He will take your current measurements and collect data points to aid in the determination of implant size and shape. It is often helpful to bring into your consultation both photos of breasts you like AND images of breasts that you don’t like. Because different implants impart different “looks”, these photos can be very helpful when determining what implant may be best for you.
In addition, sometimes a lift is required to improve the overall shape. While a slight droop can be corrected often with an implant, an augmentation has its limitations when it comes to lifting the nipple. Mastopexy may be required to construct the best result possible. Dr. Neavin will review with you if lifting is necessary, and if so, develop a plan based on anatomy and implant type to create the best result with the least incisions. If you need more information about getting a breast lift, click here.
Every patient is different & the approach should be customized to their desires and anatomy.
The transumbilical or TUBA (through the belly button) approach saves a scar, but the incision and instrumentation is remote. Much of the operation with a TUBA procedure is done blindly, and the pocket dissection for the breast implant can often be imprecise. Implants tend to migrate down the road and so there is likely a higher revision rate with remote approaches such as TUBA. Also, silicone implants can’t be placed this way. For these reasons, Dr. Neavin thinks a belly button breast augmentation approach is not worth the added risk of higher asymmetry or implant malposition.
The same reasoning applies to the transaxillary augmentation approach or ‘armpit’ incision. This too, is a remote location. Pocket dissection is thus less precise, and implants have a tendency to fall out giving wide spaced cleavage. It is also very difficult to place large silicone implants through the armpit through an axillary augmentation.
Plastic surgeons that advocate these two approaches primarily do so because the scars are ‘hidden’ and the operation can often be done much more quickly. Dr. Neavin does not believe these reasons should take precedence over shape and symmetry.
Both fold incisions and periareolar incisions leave either well hidden or camouflaged scars. The incisions for these procedures provide direct access to the implant pocket. Both saline and silicone implants can usually be placed through these incisions. Results from this approach are often better down the road and often require less re-operations.
You may have also heard of smooth round, textured, and shaped or anatomical breast implants. Which one is the best? Well, that depends on your body and goals.
The most common implants used in the United States are smooth round. Smooth refers to the outer shell. It’s just that. It’s smooth. Textured breast implants have a rough surface. The advantages to smooth implants are they are more predictable in how they will “drop”. Two, they have less chance of causing rippling. (Rippling is most common among saline implants. It’s when you can see the ripples under the skin).
Textured implant’s rough surface can “incorporate” the tissues more. While this may have a slight advantage in preventing capsular contracture, they also have a slightly higher risk of becoming visible under the skin. This is especially true with saline textured implants. However, it is less common for textured silicone implants to show rippling, particularly since the new gel implants are so form stable. Textured implants may not “fall” as much as their smooth cousins. Sometimes this is good. Other times when we place implants on the larger side, this isn’t what we want.
Now, we want implants to stay “fixed” when we use shaped implants. Why? If a shaped (or anatomical or tear-shaped) implant rotates, it will cause a deformity of your chest. If a round implant rotates, it won’t be visible. Thus, shaped implants should be textured. Shaped implants are most suited for very flat chested women. With the new silicone gel implants, the procedure results can look very natural even with unnaturally large sizes even with round implants. In addition, shaped cost considerably more than round breast implants. As rule, silicone cost $1,000 more a pair than saline, and shaped costs about $1,000 or more per pair than silicone. More money doesn’t mean better. It is rare that a women would be better off shaped over round.
Capsular contracture is a condition in which the tissues around the breast implant get hard. When this happens the implant can become distorted or painful. In some cases the pain or deformity is so bad that surgery is required to remove the capsule and or implant. Fortunately, the rate of this occurring is low and there are ways for you and the surgeon to reduce this risk.
There are many theories as to why capsular contracture develops. Probably, the most of common etiology is bacteria. One of the leading thoughts is that some bacteria either from surgery or even after surgery contaminate the breast implants. Following, the body responds with inflammation in the region that is contaminated. Inflammation can lead to a more aggressive scar response within the boob pocket. For this reason, meticulous care for sterility is the rule when operating.
However, even under the most meticulous circumstances bacteria can contaminate the implants. Other risk factors for capsular contracture include the type of implant, the placement of the implant, and the incision used to place the implant. Silicon may have a slightly higher capsular contracture rate that saline. At least the older generation ones may. While the differences in rates for capsular contracture between saline and silicone implants are small, it is not zero. Of either saline or silicone, smooth implants have a higher capsular contracture rate that textured implants. The differences in the capsular contracture rates are likely related to the way that textured implants incorporate into the body.
Surrounding tissues will adhere to the textured implants but not a smooth implant. This may offer more protection from bacterial growth or biofilm development. Breast implants placed under the muscle have a lower capsular contracture rate than when they are placed over the muscle, or what is called a sub glandular position. This is likely a result of the mechanical massaging that occurs when an implant is placed below the muscle. Massaging either manually or from a sub pectoral position can break up scar formation around the implant as it develops. This can keep them soft.
When an implant is placed around the areola, contracture rate is higher. This is likely related to contamination from the gland that often harbors bacteria. An inframammary incision has a lower capsular contracture rate. The armpit or axillary incision probably has a higher capsular contracture than inframmary with a rate similar to the areolar approach. This is probably because the armpit harbors a lot of bacteria as well.
Another route for bacterial contamination is from dental procedures. Women with implants should take antibiotics before any invasive procedure or dental cleaning. Dental cleaning could theoretically introduce bacteria into the blood. The bacteria from the blood can then attach onto a breast implant. Because a breast implant has no blood supply directly within itself, the bacteria can grow on the shell surface. Again, this bacterial growth can generate inflammation resulting in an exaggerated internal scar formation that is recognized as a capsular contracture.
Unfortunately, antibiotics alone often can’t reverse a capsular contracture in advanced stages. Certain cocktails of medications including anti inflammatories or leukotriene inhibitors have been shown to soften the breast and reduce the capsular contracture rate, or even reverse mild to moderate capsular contracture. But ultimately surgery is necessary in advanced cases.
Surgical removal of the capsule or scoring or cutting the capsule in addition to medical therapy have also been shown to be of benefit. Like most things in medicine, the earlier it is projected the better the outcome. For that reason women with breast implants should see their plastic surgeon every year. Plastic surgeons can often identify a capsular contracture before the patient. Breast implant revision surgery for capsular contracture can be very expensive. Sometimes new breast implants need to be purchased or an acellular dermal matrix product need to be incorporated.
Dr. Neavin tried to use the inframammary approach whenever he can, although there are times where armpit or areolar approaches are superior choices. Textured implants are used when its benefits outweigh the risks. Textured implants can cause rippling in thin women and may not “drop” like their smooth cousins.
Dr. Neavin spends extra time during surgery to re-prep the surgical field before implantation, changes into new, fresh sterile gloves, and uses a Keller funnel to reduce the amount of “potential” contamination when the implant is ready to be inserted. The nipples are even covered with plastic wrap to prevent any ductal contaminant from entering the surgical field. Extra time and care during surgery translates ultimately into better results and happier patients.