What is the best breast implant?

Breast augmentation remains one of the most popular plastic surgery procedures in Beverly Hills.

The topic of breast augmentation can be extensive. There are many different types of breast implants on the market today. Choosing to have breast augmentation can be a daunting experience if you spend the time to do your research – and you should. There are silicone breast implants and there are saline (salt-water-filled) breast implants. Today’s silicone breast implants are mostly form stable, meaning that they generally don’t leak from a compromised implant shell.

You may have heard of gummy bear implants. These are cohesive gel implants made by a company called Sientra. Sientra is the new guy on the block in the breast implant world. Their breast implants may cause less rippling than their competitors. However, they may cost a little bit more which may be factored into the cost of your augmentation. Sientra is unique in that it sells it’s devices only to plastic surgeons. While this may seem like a rather obvious rule, that is far from the case. Sientra’s competitors, Allergan and Mentor, sell their breast implants to unqualified physicians performing breast augmentations. This topic is a large and complex one, and I have devoted an entire section to explore this growing problem.

Back to implants. There are textured implants and non-textured implants, also called smooth implants. The shape of the implants may also vary. Breast implants generally come in profiles, which is the ratio of width to projection. For instance, let’s say a woman desires a C cup breast size. If she is an A cup, she may require 400 cc to achieve this desired size. However, her breast width may be narrow, as is the case often with very thin women. A 400 cc low profile implant will give her the desired volume, but be too wide for her chest. To achieve this same volume but with an implant that will fit her native anatomy, a high profile implant with a more narrow base may be more appropriate. The trade off, of course, is that 400 cc will be distributed with more projection. So in many ways, a high profile implant may better be called narrow base implant.

To complicate matters more, Sientra has developed shaped breast implants (see photo). These breast implants are shaped like a breast, with more volume positioned the lower portion of the breast. While shaped implants are not new, they have recently become more popular with Sientra’s product. Shaped implants come textured. Textured implants in both traditional round and shaped models integrate into the breast tissues preventing rotation. Rotation of a round implant won’t change breast shape, since round is round is round in any position. However, if a shaped breast implant rotates, the breast shape will inherently change. A deformed breast from rotation generally requires surgery for correction.

For this reason, many plastic surgeons are reluctant to use shaped implants. Moreover, the shaped implant offers less advantage with naturally larger breasts. The most practical use for shaped implant is a woman who has smaller breasts to begin and will settle for nothing other than the most natural-looking breasts obtainable. Not surprising, shaped implants cost more than their round cousins.

Why choose saline breast implants over silicone implants?
  1. They cost less. Saline implants cost about a thousand dollars less per pair than round silicone breast implants.
  2. They can be placed through a smaller incision. Because saline breast implants come empty (unfilled) and silicone breast implants come filled, saline implants can be placed though smaller incisions. Saline implants are filled when they are placed into the body. It is not uncommon for a saline implant to be 2.5 cm while a large silicone implant may be as large as 5.5 cm.
  3. Smaller incisions provide more incision options. Small areolas often can’t accommodate the passage of large silicone breast implants. That is, the incision is limited to the size of the areola. Saline implants can easily be introduced through peri-areolas incisions, axilla (armpit), fold (inframammary fold), and belly button (TUBA approach).
  4. It is easier to correct size discrepancies. Because saline breast implants are filled, one can easily adjust size discrepancies. With silicone implants, some guess work is required, because the implants come pre-filled in certain sizes.
  5. You want a more unnatural look. Some women prefer the perky, round breast implant look. Large saline breast implants often have a more round, perky appearance than silicone implants. The properties of silicone behave, look and feel more like the natural breast than saline implants.
  6. Your breasts are slightly droopy. Saline implants can lift a droopy nipple more than silicone implants.
  7. You desire a fuller lower pole breast. Saline implants generally drop more than silicone implants, particularly the textured silicone implants. While silicone implants drop and form a natural looking breast, they often result in more fullness in the upper portion of the breast than their saline counterparts.
  8. You are getting a breast lift with your augmentation. It is easier for the surgeon to use saline implants while performing a breast lift. Since skin is being removed during the lift, sometimes it is helpful if the surgeon can adjust volume once the implants are placed. Not all surgeons subscribe to this ideology, but it ultimately makes for a safer approach to a combination of mastopexy and augmentation. If the implants are too large for the pocket, poor wound healing and ugly scarring can develop.
Why choose silicone breast implants over saline implants?
  1. You want a more natural look and feel to the breast. There is no doubt that silicone breast implants provide that benefit over saline implants.
  2. You have thin breast tissue. Saline breast implants can cause rippling (especially textured models). While rippling (folds) can be seen with silicone implants, they are far less noticeable than with saline. The Sientra silicone breast implants may provide the greatest protection from rippling overall.
Why choose textured over smooth breast implants?
  1. Textured breast implants protect against capsular contracture better than saline breast implants. For more on capsular contracture, click here.
  2. You are getting really big implants. There might be an advantage in choosing textured implants over smooth implants if your implant size is really big. Textured implants integrate into the tissue, so it is possible they may counteract the forces of gravity more. Gravity and time alone can lead to bottoming out, which is when the breast implant falls lower than it should on the chest wall.
Why choose a high profile implant?

If you are very thin and want large volume implants. High profile implants offer more volume for more narrow implants. They generally don’t provide as much cleavage as the lower profile implants. Many plastic surgeons don’t like them because they tend to look less natural (in their opinion) than moderate profile implants. Moderate or moderate plus breast implants are the most common profile of breast implants used.

What are the different ways to do breast augmentation?

When plastic surgeons talk about different breast augmentation techniques, we can really spend an entire conference dedicated to this topic. However, most prospective patients want to know about incision placement, under or over the muscle (or combination of both approaches as in the “dual plane” approach)’ and implant selection.

There are five incisional approaches to breast augmentation: inframammary (breast fold), periareolar (sometimes erroneously referred to as “around the nipple”), transaxillary (armpit), trans-umbilical (through the belly button, also known as TUBA), and through an abdominoplasty incision where the tunnel is created above the ribs and under the skin flap.

Largely, incision placement is based on surgeon preference when all other factors are equal. Each approach has its own set of advantages and disadvantages. None of them are perfect. I have performed all of them. In some cases, certain approaches are impossible. For example, one can’t put silicone breast implants through the belly button. But more often than not, there are always two good approaches to each case. For this reason, I think it is important to engage any prospective breast augmentation candidate in the decision-making process.

First, let’s look at the inframammary fold approach. This is a bit of a misnomer, since it is nearly impossible to place the incision right in the fold for two reasons. First, the fold position immediately changes with the addition of a breast implant because the skin stretches. Second, the implant will ultimately drop on the chest wall, resulting in an incision that rides higher on the breast mound. Moreover, one wouldn’t want to place the incision right in the fold even if he or she could with precision. Why? The fold is often visible with certain bikinis. The incision, ideally, will end up (and I stress end up because there is an unpredictable nature to healing and breast implant maturity), resting a few millimeters above the fold so that it isn’t visible in a frontal view in a standing position, or in a lying position with a bikini top.

The advantages to an inframammary incision are that it is very well hidden. In fact, with larger implants, it is generally only visible when the nude woman is on her back. Other advantages include ease of surgery, although this doesn’t mean some plastic surgeons can’t perform breast augmentation through other approaches just as successfully, or even that other approaches are relatively difficult.

However, the inframammary approach provides the advantage of direct pocket access. Direct pocket access translates into pocket dissection control and ultimately, precise implant placement. There is no guesswork involved, as there is with the trans-umbilical approach. And there is certainly less visualization issues than are inherent with the remote approach of transaxillary breast augmentation. For this reason, the inframmary approach remains the most common AND predictable approach. While some argue that the scar can be poor here, the counter argument is obvious. The scar can be poor around the areola or in the axilla, too. However, if the scar is poor around the areola, it is visible in virtually every position. In fact, it is visible on the central part of the breast. Periareolar scars are also more difficult to revise. Pigment changes amplify the challenges inherent with scar modification in this area. Medical tattooing may be necessary to adequately camouflage lightened areas to reduce scar visibility.

Scars in breast folds can certainly be unsightly too, but scars in this region are more forgiving to revision. Also, their location keeps them much more hidden than scars on the central point of the breasts. For this reason, I almost never place incisions around the areola in dark-skinned women when I have other reasonable approaches.

Scars in the axilla are generally hidden well. They are only visible when a woman raises her arm. A poor scar heal will lend itself to razor cuts with shaving. Laser hair removal may be a wise option if this becomes an issue.

Poor scars from TUBA may be of a different flavor. While TUBA has been touted as scarless breast augmentation, poor healing (or scarring) may manifest as track lines from the belly button to the breast. While rare, this deformity can be unsightly and very difficult to correct.

Scars from an abdominoplasty approach exist along the waist line from the tummy tuck. While abdominoplasty and breast augmentations are often done in combination, this approach has never really gained traction. For one, it is somewhat laborious to connect a tunnel from the abdominoplasty to the breast. Two, visualization is poor, making this approach remote. To gain adequate exposure to the pocket dissection, excessive disruption of the native breast fold is a real risk. This can lead to a condition called bottoming out, which is described under the complications section.

Scars are only one component of overall aesthetic result. More important than scar visibility is breast shape, and reducing complications. As we will see, approaches to the breast pocket may have some influences on ultimate outcome.

The inframammary approach, because it lends most control over the surgery, probably has the lowest complication rate. However, the risk for bottoming out could potentially be greater since this approach to the breast pocket may interrupt attachments of the native breast fold.

The periareolar approach offers very good vision to the pocket too, but not as much as approaching the breast through the fold. Dissecting through the breast from the areoala might introduce bacteria from the ducts. It is theorized that this approach may result in a slightly higher capsular contracture rate than the breast fold approach. This alone is probably an unreasonable reason to avoid this approach, but it’s not something to ignore either. Many surgeons prefer this approach, but it remains a distant second on my list of preferred approaches to primary breast augmentation.

Large silicone breast implants cannot be placed through incisions around a small areola without either damaging the implant shell or traumatizing the tissue, which may result in a more noticeable scar. The greatest advantage to the periareolar approach is its utility in raising the nipple, or performing a minor breast lift during the augmentation if necessary. If a breast is questionably ptotic (droopy), and the size of the areola is adequate, I often choose this approach so I can have the freedom to extend this incision to perform a minor lift.

The trans-umbilical approach promises a scarless breast augmentation. However, the approach is remote and a lot of the work is done blindly. Surgeons insert tools through the belly button and rip fibers of the pectorals major muscle to create a pocket for the implant. Needless to say, one can count on a higher rate of asymmetry or improper placement of the implant. The TUBA approach never really caught on as a popular technique. Other complications from the trans-umbilical approach may include track marks (see photograph), and thankfully rare, injury to heart or lungs. In Los Angeles several years ago, there was a death related to an instrument spearing the heart. The few times I performed this procedure, I must admit there was an uneasiness when I developed the tunnel to the pocket under the muscle. The technique is rather violent, as a thick metal instrument is forcefully passed from the belly button over the ribs. Silicone breast implants cannot be placed from a TUBA approach. Beware of plastic surgeons touting scarless breast augmentations. Some will offer the TUBA through clever marketing only to convert you to a periareolar or inframammary approach. The latter two are simply superior operations.

The transaxillary breast augmentation technique remains the preferred choice of a minority of plastic surgeons. An incision is made in the armpit, and a pocket dissection is performed. This approach is also somewhat remote from the surgical site. Some surgeons perform the dissection bluntly and blindly by tearing fibers of the muscle. Others use lighted, long instruments that allow them to see the surgical site more effectively. Inherent in this technique is a tendency to over dissect the lateral (outer part) of the pocket, resulting in wide spaced breasts. In experienced hands, the transaxillary approach can be a superior approach for some patients. For women who have small areola and very small breasts with no well defined fold who desire a small implant, this may very well be the best approach. But placing large silicone implants through the armpit may be difficult.

Implants placed through an abdominoplasty incision remain the least popular method. It is so unpopular, that it was mentioned in this section just for completeness. While it sounds like a sound idea, the truth is it is laborious, difficult, and runs the risk of disrupting the breast fold resulting in a bottomed out breast. Abdominoplasty requires an extensive dissection just shy to the rib cage. From this usual end point, a tunnel is created over the ribs to the undersurface of the pectoralis major muscle. In some women this can be a 10 cm tunnel. The remaining operation is mainly blind.

The common rule among all of these approaches is:

Direct visualization from incisions close to the dissection will consistently result in the most attractive breasts with the fewest complications. The farther the incision is from the breast, the more problems one can expect.

Fat grafting is an alternative to implant-based breast augmentation. With breast fat grafting, fat is harvested from a deposit of unwanted fat in the hips or flanks and injected into the breast. While there are several fat harvesting and processing techniques, the goal among all of them remains the same; create the most natural looking breasts with no artificial devices. Sounds like a perfect operation, doesn’t it? Some day it may be, but right now it is far from perfect.

For one, many women seeking breast augmentation are thin. Thin people have very few fat deposits. The amount of fat needed to augment a breast can be rather large, so for many women, this technique isn’t even an option. For those women who have adequate fat deposits, there are still two major drawbacks to consider. First, fat grafting to the breast is notoriously unreliable. The fat survival may range from less than 10 percent to 60 percent. This means that even if 500 cc is harvested from liposuction, and 500 cc is injected into the breast, the chances are you will retain less than 250 cc. Thus, multiple fat grafting procedures is sometimes the rule. More procedures means more downtime and more money.

The second major drawback to this technique is fat necrosis. Sometimes when the injected fat dies, it hardens. Hard lumps in the breast generate fear and anxiety over cancer. Often enough, these masses warrant diagnosis through imaging studies or biopsy. In any woman with a family history of breast cancer, I believe this technique to be an unwise one. Fat grafting to the breast is not yet where we need it to be from an efficacy standpoint to make it a reasonable first-line choice for primary breast augmentation. The implant-based breast augmentations, when performed properly, are simply too safe and natural looking to consider alternatives. Fat grafting to the breast has a more useful role in correcting deformities such as rippling from either breast augmentation or reconstruction.

What are the risks of breast augmentation?

The American Society for Plastic Surgeons breast augmentation consent form is a rather complete list of potential problems related to breast augmentation. Not too long ago, a second consent form was developed for large breast implant augmentations. As a rule, big implants means more potential problems.

There are complications related to anesthesia, the surgery itself, immediate post-op, and long-term issues. For the sake of this forum, we will address potential complications related to the procedure itself.

A list of some of the more common potential problems include but are not limited to bleeding, infection, capsular contracture, rippling, asymmetry, malposition, bottoming out, double bubble, poor scarring, and implant rupture.

Bleeding is fortunately a rare complication of breast augmentation. The operation avoids all major vessels. However, even small vessels that are injured can bleed badly enough to be a problem. Bleeding from a breast augmentation is never life threatening. But, bleeding can cause unexpected returns to the operating room or result in a hardening of the breast called capsular contracture.

What causes unwanted bleeding from a breast augmentation? In cases where the breast pocket can be visualized (inframammary approach, periareolar approach, endoscopic transaxillary approach), the entire operative site is inspected for bleeding. Most of the dissection in a submuscular plane (when the breast implant is placed under the muscle) is actually bloodless. Most of the muscle lifts off the chest wall without the need to cut or divide any blood vessels. However, some of muscular attachments to the sternum need to be divided. The largest vessels that one encounters during this operation are found here. Fastidious attention to keeping this area blood-free is paramount. While no surgeon would purposefully leave a surgical site bleeding before completing the surgery, inadequate attention to performing the dissection may lend these vessels to post-operative bleeding, when the patient’s blood pressure or heart rate spikes after waking up or during exercise. (See the post-op care section to read about all the problems with premature return to strenuous activity after breast augmentation.)

If you are a surgeon reading this your blood may be boiling because you are thinking, “most bleeding isn’t my fault!”. I would generally agree. Most post-operative hematomas (hematoma is the medical term for bleeding after surgery) are unpredictable and have very little to do with improper surgical dissections. Statistically speaking, one to two percent of all breast augmentation cases (which is .5 to one percent of each individual breast augmentation) result in a visible and clinically significant post-operative hematoma requiring evacuation in the operating room. Most of these cases when the breast pocket is explored also reveal no visible single bleeding vessel.

After surgery in these situations, blood pressure or heart rate goes up high enough to open up small vessels that were once closed or clotted off. Blood oozes into the breast pocket around the implant and the breast swells. Blood is a major irritant and will incite pain in the chest. One of the major reasons patients experience hematomas is from inadequate post-operative pain control, since pain causes spikes in blood pressure or hear rate. Patients may also increase their risk of hematoma by returning to strenuous activity too early. In other words, surgeons can blame their anesthesiologist or patient for the complication! If you are an anesthesiologist or patient who was unfortunate enough to have a post-perative hematoma, your blood may be boiling now. And rightfully so. Pain tolerance is difficult to predict. And some surgical techniques result in more pain than others.

Moreover, even the most compliant patients get hematomas, leaving a surgeon factor and a luck factor to consider also. Under the umbrella of the surgeon factor is surgical technique. Blind dissections from the trans-umbilical or some transaxillary approaches will inevitably have a higher hematoma rate. Other factors to consider are surgeon experience. Is your surgeon a plastic surgeon or a cosmetic surgeon? If you don’t know the difference, you should. Are they board-certified? Are they board-certified in plastic surgery or something else? Read the section on this before you ever have plastic surgery.

Hematomas are easy to correct. They are never life threatening. The implant does not need to be removed and drains are generally not placed. However, because blood is an inflammatory agent, the breast has a higher chance of developing a capsular contracture.

Signs and symptoms of hematoma are one-sided swelling and pain with or without bruising – generally within the first seven days after surgery. All breasts swell after surgery, but a hematoma is generally obvious. I always like to see my post-operative breast augmentation patients the following day after surgery to check for a hematoma. The quicker it is evacuated, the less irritation of the tissues, the less pain, the less chance of capsular contracture, and the quicker recovery.

Infection is thankfully rare with breast enlargement surgery. Infections come in many different flavors: acute, subacute and chronic.

Acute infections refer to infections developing within the first couple weeks after surgery. The signs and symptoms include one-sided redness, pain, warmth, and swelling, with or without fever. Early on, infection can be confused with hematoma. Most acute infections can be managed with oral antibiotics. If oral antibiotics fail, hospital admission for intravenous antibiotics generally subdue the infection. In cases where antibiotics fail, the implant needs to be removed for at least three months before placement of another implant can be done. This may happen in less than one percent of breast augmentations.

Why does one get an infection? Assuming one’s immune system is intact (and it should be before considering a breast surgery), somewhere bacteria was introduced into the field in a sufficient quantity to infect your tissues. Once the bacteria infect a breast implant, antibiotics don’t work well because the implant itself is not vascular and antibiotics taken orally or intravenously are delivered to a site of infection through vessels. That is why it is paramount to treat infections of the breast in women with breast augmentations quickly. It is probably safe to say that the contamination occurs during surgery in most cases, since all wounds are closed prior to leaving the operating room.

Subacute infections refer to infections that occur after a couple weeks. It is possible that contamination occurred during surgery, but routine post-operative antibiotics or a tough immune system kept the sub-clinical infection in check. Only when the bacteria overwhelms the region does a clinical infection develop. Quick to action with antibiotics is also the rule with these types of infection, which is why women should be on the lookout for signs of infection after breast surgery. Never be too timid to call your plastic surgeon!

Chronic infections are a bit complicated. Under chronic infections, is seeding, which can also result in an acute infection. Theoretically, if a woman with a breast implant gets her teeth cleaned or has an invasive procedure such as a colonoscopy, bacteria from the body can enter the bloodstream and latch on to the breast implant. Bacteria can multiply on the implant without immune scrutiny, since implants have no vessels. This process may develop quickly or more gradually, but once the bacteria multiply to reach a quantity that elicits a tissue reaction, an infection is identified. Any woman undergoing a dental procedure, endoscopy, or colonoscopy, should consult with their plastic surgeon first to see if antibiotics BEFORE the procedure are warranted.

Other chronic infections may manifest as capsular contracture, a hardening of the tissues around the breast implant, and breast implant extrusion. Capsular contracture is a somewhat enigmatic phenomenon. Only recently have plastic surgeons developed a good grasp on its causes. One is an acute or chronic infection, which predisposes the tissues to react aggressively an form a hard internal scar around the implant. For this reason, several antibiotics are generally used intraoperatively to wash out the surgical site. Some surgeons such as myself, change gloves before placing the breast implant into the pocket, and place sterile tape over the nipple to prevent bacteria in the ducts from contaminating the implant. In a related note, because we know bacteria lives in the breast ducts, the periareolar approach probably has a higher capsular contracture rate than inframammary, since these ducts may be violated during surgery, or implants may rub up against a contaminated nipple. The data on this idea isn’t strong, but it isn’t something to ignore.

Capsular contracture as a result of hematoma or infection is covered under its own section.

Capsular contracture are some of the two most dreaded words a plastic surgeon fears. Every breast implant incites a tissue reaction within the body to create a wall of scarring around the breast implant. This is normal. What is abnormal is when that wall of scar thickens and contracts, leading to a hardening of the breast, distortion of the breast, or pain. This is a capsular contracture.

Capsular contractures can develop within weeks after surgery, or they may take years to develop. The causes of capsular contracture are only now starting to be understood with clarity. Inflammation is certainly one culprit. Hematomas or blood around the implant may generate a contracture. This is why fastidious plastic surgeons spend a good deal of time irrigating the surgical site before inserting the breast implant. Blind dissections as with the trans-umbilical approach and some of the transaxillary approaches make identification of bleeding difficult. Pocket irrigation is crucial. It should be continued until the aspirant is clear. And breast implants should only be placed when the surgeon is confident that blood has been evacuated from the pocket.

One of the leading thoughts on capsular contracture involves bacterial contamination as the inciting incident. When bacteria enter the surgical site either intra-operatively or post-operatively, inflammation may develop as the body tries to ward off this ensuing infection. While the bacteria may never grow to a large enough army to cause an obvious clinical infection marked by redness, pain, warmth, and swelling, they may still generate a tissue response in the form of contracture.

How do you know if you have a capsular contracture? There are four grades of capsular contracture:

Grade 1 capsular contracture is a breast that is soft to the touch with no visible signs of contracture.

Grade 2 capsular contracture is when the contracture is felt but not seen. Generally, one breast implant will feel more firm than the other.

Grade 3 capsular contracture is when the contracture is both felt and seen. There is a distortion of the breast shape. It looks “contracted”, sometimes shifting the implant higher on the chest.

Grade 4 capsular contracture causes pain. The breast implant feels firm, the breast looks contracted, and there is pain at rest, with motion, or with touch.

What is the treatment for capsular contracture?

Like any other medical issue, early detection produces the best outcome. This is why if you have breast implants, you should see your plastic surgeon yearly. Aggressive massaging helps break up the scar tissue, which is why women are instructed to massage their implants. In the early grades of contracture, massaging may reverse the course and soften the breast. In advanced cases, medications may help, such as steroids, anti-inflammatories, antibiotics, and leukotriene inhibitors like Accolate. Your plastic surgeon probably has a preferred cocktail of drugs for this condition. There isn’t a great deal of literature on medications for capsular contracture, but many surgeons like myself have seen the improvements with a combination of aggressive massaging and drug therapy.

In cases of advanced contracture where medication and massaging fails, surgery is the rule. Surgery involves either capsulotomy (cutting the capsule in multiple areas), or capsulectomy (excising the capsule). The choice between cutting the capsule versus removing it is often surgeon preference. One downside to just cutting it, is that the capsule may contract again. This may, however, be the procedure of choice in women who are compliant with massaging and taking medication. The downside to capsulectomy is bleeding risks, deformation of breast, and the possible return of the contracture. Many women who have had their breast implants in for many years have breast atrophy. That is, the breast tissues shrink, leaving just skin and capsule in the bottom part of the breast. Excising capsules in these thin tissues breasts may result in tissue irregularities.

What are ADMs and how are they used for capsular contracture?

Recently, there has been some evidence that the biological product, called acellular dermal matrix (ADM) may either prevent initial contracture or a recurrence of the condition. ADM are made by several different companies. You may read about Alloderm, Strattice, Allomax, Flex HD, and others. These products are all about 1 to 2 mm thick and come in strips of approximately 6 by 16 cm. They are expensive. Use of this product may add up to 3,000 dollars to your case. While the mechanism isn’t understood all that well, it appears that ADMs offer protection from contracture. How much? It is tough to say. ADMs should probably be reserved for difficult cases where tissues are thin or in patients who have had multiple capsular contracture surgeries. ADM’S are also used sometimes to fill out breast implant rippling.

Historically, one way to fix a contracture was through the technique of closed capsulectomy. In this method, the plastic surgeon would violently squeeze the implant until the scar broke. Did it work? Often. But it also was painful and could cause bleeding. It is not recommended. Incidentally, I remember seeing one woman who had a hard breast from contracture. She was waiting for her surgery date but got in a car accident. While her seatbelt prevented her from moving forward from impact, it must have crushed her capsule. She walked into the office a week later with a soft breast and we cancelled her surgery. However, I cannot recommend this as a technique.

How do I prevent capsular contracture?

Sometimes you can’t. Bacterial contamination, blood from surgery, and genetics are not under your control. However, daily massaging and regular follow ups with your plastic surgeon will help reduce this risk. Every plastic surgeon has their own massaging protocol but the ideas among them share a common goal; massage your implants to break up and soften the capsule.

Is capsular contracture surgery covered by insurance?

Usually, but it is generally only covered if there is pain involved. Without pain, the problem may seem strictly cosmetic in the eyes of insurance company. Some insurance policies cover the new breast implant as well, which leads to the next question.

Do I need my implants replaced if I have a capsular contracture?

The biofilm theory in capsular contracture states that there is a thin layer of bacterial slime around the implant. This film can never be completely removed. I have taken out implants where this film was very obvious. In cases like these I could never imagine putting the same implant back in even after I surgically removed the capsule. In early stages of capsular contracture that are clearly related to bleeding or hematoma, it may be ok to keep the implant. Every case is unique and this is a discussion you should have with your surgeon. Silicone breast implants aren’t cheap. They cost about 750 dollars each.

Why do I have wrinkles or rippling from my breast implants?

This is very commonly seen in thin women with saline breast implants, particularly on the sides when bending over, or in the cleavage area when standing. Saline implants are filled with salt water. The properties of water lend itself to rippling or wrinkling. To counteract this tendency, plastic surgeons often over fill the implant. Over filling the implant reduces rippling at the expense of making the breast feel harder. Placing the implants under the muscle also adds more padding to hide rippling. Saline implants should almost always be placed in a submuscular position for this reason.

The best way to reduce the chance of rippling is to choose a silicone breast implant. In fact, there are some new form-stable breast implants that probably don’t ripple at all. However, these new form-stable implants are firm, and they don’t always behave like breast tissue. For example, these implants don’t fall to the side when a woman is lying on her back. Most of the silicone breast implants used today are the cohesive gel implants. These are incredibly soft devices that feel similar to breast tissue. Rippling is rare even above the muscle with these products, unless the tissues are very thin from long-standing breast implant-induced atrophy.

What can I do about my breast implant rippling?

If you have breast implant rippling, you are not alone. You are probably thin, and have either saline implants, or have had saline or silicone implants for many years. Breast tissue atrophies, or shrinks over time from pressure of the breast implants. Other than gaining weight, there are some options to reduce or eliminate breast implant rippling.

Fat can be harvested from the flanks or any unwanted area where there is a sufficient amenable fat deposits and injected into the rippled areas. While it typically works very well, there are some downsides to this technique. First, the survival of the injected fat is unpredictable, making more than one session necessary for some patient. Second, in women with less tissue, there is always the risk of implant damage from the cannulas used for the procedure.

Another option is ADM. Acellular dermal matrix products such as Alloderm, Strattice, Flex HD, and Allomax may be introduced around the breast implant to add more padding. However, these products are not cheap. They can run up to 3,000 dollars alone. The surgery for ADM padding is much more extensive than fat grafting. I generally offer fat grafting as an option before using ADM.

If the implant is saline, a switch to silicone can often eliminate rippling. I never promise a one hundred percent correction, but I do assure my patients that their rippling will be substantially less with a cohesive gel implant.

Switching the pocket from over the muscle to under the muscle would theoretically help, but often does not do much. If the rippling is in the bottom middle cleavage area or lateral part of the breast, muscle coverage is not available in these areas. Moving an implant from over the muscle to under the muscle may help if the augmentation is less than a few years old and rippling is visible in the upper part of the breast. The muscle tends to shrink and get thin with aged breast implants. The padding factor becomes inconsequential many years after a breast augmentation.

The new form-stable breast implants eliminate rippling the most. However, they aren’t as soft or as natural feeling as the more popular cohesive gel implants.

My breasts aren’t symmetrical after breast augmentation. Is that normal?

Yes. Chances are they are more symmetrical now than they were before your breast augmentation, assuming you don’t have poor positioning, capsular contracture, or bottoming out. You just don’t know it. No two breasts are identical. See where your breasts stand in my breast-relationship chart.

Breast shape doesn’t change all that much after a breast augmentation; It is primarily an operation to make your breasts larger. The nipples aren’t moved unless you are combining an augmentation with a lift. Size discrepancies exist in every breast. The breast folds are never identical in position or tightness on both sides, and one nipple is always higher than the other. Smart plastic surgeons point these differences out to the patient BEFORE surgery. Discussing things like this before a procedure is an explanation. Afterwards, it looks like an excuse.

Size discrepancies can be reduced through different sized implants for your right and left breast. But here is a warning. There will be size discrepancies after surgery even with implants chosen to offset these imperfections. Sometimes the left breast starts off bigger than the right, and after surgery the right one is slightly larger. But generally, the size discrepancy is less.

I remember one woman who had a rather large discrepancy in size between her breasts. She chose saline understanding that silicone feels more natural. A few weeks later when she came in for her follow up her breasts looked very, very similar in size. In fact, I thought her left side was slightly larger than her right, and she thought the opposite. But she was unhappy. The breast that was smaller now in her eyes looked larger than its opposite, and it felt more firm. Indeed it was more firm because I added more saline to that side. Presumably, I could have chosen a larger implant rather than add more volume to the same size implant, but that would have imparted a slightly different shape and projection. It was a lose-lose from the start.

From that experience I now tell all women that I can use the same exact size implant and volume on each side understanding that it is God and not me who is responsible for size asymmetry. The other option is you can allow me to make them closer in size with either different size implants, different volumes, or a combination of the two. But they will never look and feel exactly the same.

If the size discrepancy was larger after surgery, that would be unusual. That would mean that either volume was counted wrong in the case of a saline augmentation, or a larger implant was placed in the larger side. More often than not, a woman tends to stare at her breasts with more scrutiny after a breast augmentation. Imperfections should be identified before going under the knife.

Other than volume asymmetry, there are shape and position to consider. The shape of breasts with primary breast augmentation generally doesn’t change much unless there is some type of deformity that your surgeon is correcting. An example would be the tuberous breast. This breast is characterized by constriction of the breast tissue. The breasts are more narrow and there is often puffiness in the areola from herniation of breast tissue.

Sometimes there can be a fold discrepancy where one breast fold is higher than the other. Most plastic surgeons tend to not alter the fold position too much because disruption of the fold can lead to a condition called double bubble or bottoming out. I generally leave mild discrepancies of less than a cm alone.

Are there any ways to get bigger breasts without surgery?

Yes. There are no magic pills, but there is an external device called the BRAVA system. This is a pump that works externally to expand breasts with the use of suction. However, one must wear the device for 10 to 12 hours a day for weeks to months to see a difference. The long term effectiveness of this device is not clear. There has been a recent surge in interest over this device as it may help prepare the breasts for fat grafting.

Fat grafting is an alternative to breast implants. Fat can be harvested from an unwanted area of the body such as the abdomen or hips and then injected into the breasts. While this sounds like an effective solution, the idea isn’t without limitations. First, the patient needs adequate fat. Many thin women simply don’t have enough fat in their body for this procedure to be a real alternative. Several hundred ccs of fat are required to see a sizable difference in the breast.

In addition, not all fat cells that are grafted will survive. Perhaps up to 50 or 60 percent of fat that is injected will die. This means that one needs to over-correct in order to end up with the desired outcome. Sometimes more than one fat grafting procedure is necessary to obtain desired results. More operations means more time and money. Fat grafting to the breast is best utilized for touch ups from the unwanted effects of implant wrinkling or rippling.

What is the downtime from breast augmentation?

Breast augmentation surgery is performed on an outpatient basis, which means you will go home the same day. General anesthesia is usually the anesthetic of choice, so you will need someone to stay with you overnight after your procedure. The next day, you are generally seen in the office to make sure there are no bleeding problems or acute infections. Everyone has a different pain threshold, but it is the rare occasion where oral narcotics can’t control pain. Some women feel very little pain at all, while others say they feel sore. Soreness generally lasts less than three days. While strenuous activity should be avoided for the first week, you could and should be walking right from recovery.

Every surgeon has their own post operative protocols, but here are some of Dr. Neavin’s general rules:

  • Stay ahead of the pain. Don’t be afraid to take oral narcotics. You won’t become addicted in a week. For the first three days, take the narcotics scheduled while you are awake. If you wait for soreness to take pain pills, you have a 45-minute lag time before they begin to work.
  • You may sponge bathe the next day, but keep the breasts and incisions dry. By day five, showering is fine.
  • Take antibiotics as prescribed for the first week.
  • You may sleep in any position but it may feel uncomfortable to sleep on your chest for the first week.
  • If one side hurts a lot more than the other, or if one side swells significantly more than the other side, call your plastic surgeon.
  • You may return to a desk job in a day or two, but you may feel drowsy from narcotics.
  • You may start to jog in two weeks and use upper body muscles more strenuously at four weeks. However, for the first week, you should just rest and allow your body to heal. Lift nothing heavier than a gallon of milk for one week. Don’t do anything that will get your heart rate or blood pressure up – this can cause some of the small vessels to open up and result in a hematoma.
What is the cost of a breast augmentation?

The range is generally $5,000 dollars to $8,500 for standard saline or silicone breast implants. This range should include the surgeon’s fee, anesthesiologist, breast implants, and all operating room expenses. If a price is advertised for below $5,000 you will want to know why. Is the surgeon a plastic surgeon or a cosmetic surgeon? The difference between the two specialties is something you will want to understand. Any revisional breast surgery adds time, liability, and cost to the procedure.

What is the future of breast augmentation?

Right now, we have a safe and natural looking way to enlarge breasts. The challenges with prosthetic breast enlargement is capsular contracture, rippling, bottoming out, and incisions (scars). The silicone implants we have now feel like natural breast tissue, but often require a 5 cm incision. In most people, that scar isn’t very noticeable. With the advent of the Keller funnel (a device that facilitates pushing an implant through a small incision), we might be able to save a centimeter of scar. Perhaps there will be implants someday that are filled with silicone after placement, just like their saline cousins. This would spare several centimeters of a scar. Fat grafting to the breast may also become more predictable and practical.

Regarding capsular contracture, we understand the causes now more than ever. Operative techniques will continue to adapt to the growing literature on the etiology of this condition. The overall rates should drop, but they will never be zero. Advances in medication may reduce the incidence even further, or even reverse the process.

There is no need to wait for a safe and natural surgery to enlarge your breasts. It’s here. Breast augmentation surgery is an effective way to enlarge and enhance the breasts today. For more information, contact Dr. Neavin at 310‑858‑8811.

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