The New Breast Book: New Breasts for a New Look and a New Outlook

Breast Enlargement

Breast augmentation, or augmentation mammoplasty, is one of the most frequently performed procedures in aesthetic surgery. Even the smallest breasts can be made larger. Breasts that are too small or sagging can be reshaped and enlarged to provide a balanced, whole appearance for the patient.

Breast augmentation is effective if the patient's breasts did not develop to the size that meets expectations or body size. One breast may be smaller than the other. Often, after weight loss, childbirth, or because of aging, the breasts lose volume and their shape changes. Breast augmentation can enhance your breast size and shape and give you a more proportional figure.

You are a good candidate if:

• You are bothered by the feeling that your breasts are too small.
• Your clothes fit well around your hips but are often too large at the bust line.
• You feel self-conscious wearing a swimsuit or form-fitting top.
• Your breasts have become smaller and lost their firmness or are drooping.
• You have lost weight and the size and shape of your breasts has changed.
• One of your breasts is noticeably smaller than the other.

Implants

Breast augmentation involves placing an implant behind the breast to enhance its shape and increase its volume. The controversy concerning silicone breast implants has in no way diminished the desire or need for breast augmentation and reconstruction surgery. In fact, it is more popular now than ever.

Silicone rubber (methyl-methyl siloxane) is a relatively inert material that is made by combining several organic (methyl) molecules with silicone. It was developed in World War II to provide a rubber-like inert material for sealing aircraft instruments.

In 1955, the first medical application for silicone was the development of an implanted valve in the brain of hydrocephalic babies. It has been a lifelong success for those children who had previously died at age five or six from "water on the brain." Now they live nearly normal lives because of their silicone rubber implants.

Silicone rubber can be made so soft that it is a free running fluid, so hard that it is as stiff as metal, or somewhere in between (like Jell-O). This is done by cross-linking the molecules into short (liquid), medium (gel), or long (stiff) chains.

Silicone rubber has always been the material of choice for the shell of breast implants. Early models were saline filled, but they leaked because of faulty valves. Silicone gel felt good and did not need a valve. Modern development has improved the valves, so other filling materials are now possible.

When to have a Breast Augmentation

Breast augmentation can be performed at any age after the breasts are fully developed. A good candidate is emotionally mature, understands personal motivations, has realistic goals and is doing this to please herself, not someone else.

Patti was 28 years old, happily married and the mother of two children. Her breasts were always quite small, but during pregnancy they grew to what she thought was a wonderful size and shape. But once she finished breast-feeding her second child, she was astonished at how much they deflated. She described them as "drooping." In fact, her small breasts were stretched out from pregnancy and were just empty. Luckily, her nipples were above the fold of the breast and therefore it was possible to improve the contour of her breast without any lifting. After her surgery, she said that it had completely changed her outlook on life. It made buying clothes a joy instead of a chore. Now, she could fill out her blouse and feel like a normal woman. Now, she does not have to buy two sizes of clothes—one for above the waist and one for below the waist.

When women who have grown up with small breasts suddenly have a full figure, they develop a new flair for life and deeper sense of pride in appearance. They feel more fulfilled and less cheated by nature's small endowment. It is no wonder that women who watch fashion models and movie stars with full breasts have a desire to be what the world considers more attractive. Part of life's challenge is to feel a rich sense of acceptance. Breast augmentation surgery alone will not accomplish this anymore than a nose change or liposuction will, but it does contribute to the overall satisfaction of feeling more feminine and lovely. That is why so many women in today's world seek the procedure.

Two groups of women generally seek breast augmentation. The first includes women in their late teens or early twenties who have never enjoyed a well-proportioned bosom. The second includes women in their late twenties all the way to their fifties. They may have lost breast size and shape after child bearing and/or breast-feeding. Or they may be women who have at least come to terms with their dissatisfaction with their figures. Now that they can afford the surgery, they want the results that this procedure can bring. Both groups of women desire a pleasing shape that is usually associated with a more youthful body.

Breast augmentation is usually associated with cosmetic surgery. There is an important difference between cosmetic surgery patients and others. Cosmetic surgery patients, by definition, are people who want to look their best. Those patients who have surgery for eradication or disease often have few choices—surgery may be the only way to eliminate a serious problem. Cosmetic surgery, on the other hand, is elective surgery. This means the patient and doctor may choose when and what type of procedure, and within some guidelines, be certain of the outcome.

Expectations

Breast surgery is implemented to correct various problems. Breast reduction surgery can make large breasts smaller, sagging breasts can be lifted with a mastopexy or breast lift, and breast implants can be used to make small breasts larger.

At your initial examination, your surgeon will visually examine your breasts. She will ask what you would like corrected and help you determine what you can expect from surgery. You should come prepared to tell the surgeon just what it is you wish to achieve.

She may have some questions for you and point out what is possible and what is not. Listen carefully to what she tells you. Make mental notes of what is discussed, so that you can determine in your own mind what to expect from surgery. If you have any unanswered questions, write them down for your next visit.

Many surgeons recognize that cosmetic patients have a keen desire to improve their appearance. This is normal, healthy, and, fortunately, attainable. Be frank as you consult with your surgeon because it is important that you understand one another during the preoperative stage.

Perhaps the most important aspect of your surgical procedure will be the initial consultation with your doctor. We will go into this in more detail later in this book. However, remember that that is the time to let your fears and hopes come to the foreground. You ought to come away from the initial examination with questions answered and a clear idea of what to expect.

Remember, though, breast augmentation, breast reduction, correction of asymmetry, and breast lift assure improvement, not perfection.

Types of Implants

There are several implant manufacturers, all approved by the government regulators. It is their job to offer the safest, most natural appearing and functioning implants available. Great strides have been made in the past few years in this area. The manufacturers know that what the patient wants is the best possible appearance with the least amount of problems. Some implants are filled with a saline solution which, if a leak should develop (rare), will not cause any problem. Another filling material is a gel solution. The silicone gel prosthesis is approved for general use by the FDA.

Surgical Placement of Implants

As a rule, the surgeon selects the site of incision. She will discuss the site of implant entry and may even offer a choice, but it is wise to follow her recommendation for best results.

Implant Incision Sites

There are currently several different incision sites for inserting the implants:

• Inframammary
• Areolar
• Axillary
• Umbilical
• Abdominal

It is not possible to discuss all of the pros and cons and the many ideas, opinions, and reasoning behind all of these approaches. It is appropriate to point out a few of the most widely accepted facts and opinions about incision sites.

Inframammary Site

Traditionally, the most widely used incision has been the inframammary site. It is safely and easily performed and the incision can be enlarged as much as necessary to give direct access to the area of dissection which can be above or below the pectoral muscles.

The single greatest disadvantage to the inframammary site for insertion of implant is scarring. The scar in this location is more visible than with the areolar or axillary approaches, and this is the main reason many women do not choose this site. This is the key reason for not using this incision except in pendulous breasts, when skin is touching skin and the incision site is hidden from direct view since it is resting on the chest skin.

For the patient with drooping breasts, where the skin of the breast touches the skin of the chest wall when the patient is standing erect, the inframammary incision is placed slightly up on the breast, perhaps half an inch above the inframammary fold.

Areolar Site

The areolar incision is often called the periareolar, meaning around the areola, which is the brown or dark pink skin area that encompasses the nipple. It is not done in the white skin or lighter skin around the areola, but at the junction of the brown and white, or in the darker areola.

Our eyes normally follow a straight line more easily than a very curved line, so the surgeon with this foreknowledge places the areolar incision in the wrinkled brown area where the pigmented skin heals very well to hide the incision in the tortuous curves of a wrinkle. There is an excellent chance of an invisible or at least an unnoticeable scar. Also, any whiteness that may result from the small scar can be covered with tattoo pigment to match the areola and disguised very well.

The areolar incision is direct and allows good visibility of the area of dissection. But the small area of incision limits the size of the opening. It may make it difficult to insert a large implant through the opening. Careful evaluation prior to surgery may offer choice, but the size of implants and exact shape of the breasts following implant surgery will be determined by several factors. The areola and the nipple shape will determine final appearance. This will determine the limits of breast implant placement.

On a patient with tiny areolae, the areolar incision may be nearly impossible to perform. Most surgeons prefer that the incision be at least 2.0 cm long. If the size of the areola calls for an incision of less than 1.5 cm and the patient insists on not having the underarm incision, then permission must be given to extend it laterally as much as 0.5 to 2.0 cm in each direction. If it is not extended, the surgeon may not be able to insert an implant of over 200 cc volume through the opening, unless, of course, it is an inflatable saline implant.

The areolar approach is the only one of the incision sites that invades the breast tissue. The thousands of surgeries performed this way have demonstrated that there is almost no danger of breast nodules or cysts developing in the lower portion of the breast when this approach is used. Many patients who have had this approach have subsequently become pregnant and have breast-fed their babies. Also, with the areolar approach there has been no greater incidence of hypesthesia (numbness or loss of feeling) of the nipple or lower breast skin than with other incisions.

In some cases, if the nipple is just below the fold of the breast, so that we only have to lift it about an inch, it is possible to perform a breast lift with only a single scar going around the areola. In this case we remove a quarter moon shaped ellipse of skin above the areola and then advance that nipple areola complex upward. We then place a circular stitch all the way around the larger outer circle and pull it tight so that it causes an ovoid to become a circle like a purse string. The only scar is circular and is at the edge of the darker pigmented areola, thus making the incision less noticeable. Now, in time this scar may spread a little bit but because it is in an area of demarcation between the normal skin and the darker skin of the areola, it is not noticed as a scar. Although this will give us about an inch of lift, it also flattens the breast a little so that it is not appropriate for every case. This is called the Binelli lift, named after Dr. Louis Binelli from France, who first described it.

After excess skin has been removed, the nipple and areola are shifted to a higher position. Areolae that have been stretched can be reduced in size. Skin that was formerly located above the areola is brought down and together beneath it to reshape the breast. The nipples and areolae remain attached to the underlying mounds of tissue; sensation and ability to breast-feed usually remain unaltered.

Axillary Site

The axillary incision is removed from the area of dissection, and yet may provide the least noticeable scarring. There can be more difficulty in accurately determining the breast shape and the position and symmetry of the newly created fold. An excellent indication for the axillary incision is the patient with small, light, unwrinkled areolae who wants the least visible scar possible. Shorter patients are a little easier to operate on in this area of the implant site.

Umbilical Site (TUBA)

It is possible to have an incision in the umbilicus or belly button, tunnel under the skin to each breast, and place deflated saline implants there. They are then inflated in place. This procedure is known as a transumbilical breast augmentation, or TUBA.

Advantages

• No mark on the breast.

Disadvantages

• The tunnels may persist as noticeable grooves.
• The manufacturers do not recommend this method.
• It voids their warranty.
• Implants cannot be easily placed beneath the muscle.

Abdominal Site

Sometimes, when a patient is having a tummy tuck, we can reach up under the skin and place implants through that incision.

Advantages

• No mark on the breast.
• Two for one—the augmentation is done through the same incision.

Disadvantages

• Not under the muscle.

The doctor and patient should have a thorough discussion on the options in incision sites. Although the doctor will allow the patient to choose with only some guidelines, she may wish to step in and correct any misconceptions about implant site introduction. Most doctors will allow patients to choose the incision site, but the final decision will be made when the surgeon has had time to examine every aspect of the implant surgery and decide what site she feels most comfortable with.

Under or Above the Muscle?

Originally, when augmentations for breast enlargement were performed in the early 1960's with silicone breast implants, they were routinely placed in the subglandular position over the pectoral muscle.

Since early type implants were firm to the touch to begin with, they were expected to be firm and capsular contracture was felt to be a major problem in the field. Actually, in those early years, some firmness was thought to be desirable. In a few years, however, in the late 1960s and early 1970s, patients were asking if something could be done about the hardness of their breasts.

Soon softer implants popped up on the market. Soon there were reports of submuscular implants in breast augmentation. As the capsular contracture problem became common with the softer implants, more surgeons shifted to the submuscular technique when indicated. Now there are many articles and opinions in the medical literature stating that the implants are softer in the submuscular position.

Drooping breasts

There are several medical procedures to correct drooping breasts. Many women's breasts are too large rather than too small. People have been brought up with an ideal concept of breast size based on media ideals. Magazine centerfolds depict women with large breasts, though, in today' s society, there is emphasis on sports and physical activities. In much of our fashion, "form follows function." Therefore, many styles are based on simple athletic garments that do not flatter large breasts.

Large or drooping breasts may also serve as an impediment to the active woman. Whether on the beach, golf course, tennis court, or health spa, the weight and motion of the breasts may interfere with vigorous exercise or result in embarrassment. Many women consider them a physical handicap. They can interfere with jogging, climbing, and a host of other activities and make it more difficult to be an active participant. Then too, some of the women have back problems due to oversized breasts. The sheer weight of the buxom lady can be tiring.

Many times women with oversize breasts have a marked disparity between the upper and lower figure. This situation alone makes clothing selection more difficult.

Another problem frequently affects the full-breasted woman during the hot summer months. The rubbing together of two skin surfaces under the breast, especially when compounded by warm weather and perspiration, may result in a rash under the breast called inframammary intertrigo. Breast reduction surgery has provided a satisfactory correction to women of all ages from teenagers to octogenarians.

Mastopexy or Breast Lift

Although the goals of breast reduction (also known as reduction mammoplasty) and breast uplift (or mastopexy) procedures are different, the procedures can be discussed together because the preoperative preparation, surgical incisions, and postoperative course are quite similar (see page 62). With each procedure, incisions are designed to create a more youthful and natural shaped breast. In each procedure this involves elevating the nipple from a lower, more droopy position on the breast mound to a more natural, central position. Almost always, an enlarged areola is reduced in size during these procedures.

In a breast reduction procedure, breast tissue is resected in addition to the excess skin, thus reducing the final volume of the breast while elevating the nipple and surrounding tissue (areola). In a mastopexy, skin alone is resected while the nipple areolar complex is positioned in a more youthful position. Occasionally, the uplift patient may desire a small breast implant at the time of an uplift procedure if the patient perceives that the breasts are not only droopy, but are also small. In such circumstances, a very large implant should not be chosen as the added volume could put additional stress on the incisions and cause them to spread unnecessarily as healing occurs. For this reason, your surgeon may opt to add the implant during a separate procedure.

The procedure is preferably performed in an outpatient surgical facility under a local anesthetic and generally takes approximately one and a half to three hours to perform. As in any surgery, incisions are made in the skin. The end result of all incisions is the formation of scar tissue. This operation is planned so that the scars fall into the most favorable and least conspicuous locations. Many different schemes and patterns have evolved over the years; however, the most common techniques result in an incision that goes around the nipple, down the front of the breast, and follows the fold under the breast. In most patients, the redness of the incision fades over 1–2 years, but in some instances may last much longer.

Asymmetry of Breasts

All breasts are to some extent different. It can be mentioned that nature made no two snowflakes, grains of sand, or anything else we can see, exactly alike. Whether or not there is significant asymmetry is a matter of opinion. Many asymmetries exist before surgery. We try to correct what is visible and make the two breasts as symmetrical as possible during surgery. It is amazing what we can do during the operation to correct defects and set the pattern in order.

Other Factors

The one factor that can be controlled is volume. We can use implants of different volume to help correct asymmetries in size. We prefer for our patients to try on several sizes to determine how much volume is needed to approximate equality. Correction of the asymmetry in volume, combined at times with a change in the position of the inframammary fold (the underside of the breast or the smaller side) can give a pleasing balance to the breasts. The breasts will suddenly look more alike, if the problem exists. Other asymmetries, such as inverted nipple, large areola, or ptosis (drooping or sagging) on one side, can often be corrected by various techniques that the surgeon is familiar with, but not merely by doing breast implants alone.

Scars

Everyone heals differently. Pigmented skin may have light lines or dark. Some scars are raised, some sunken; others are fine, some spread. All scars fade to some extent over time.

Breast Results

Avoiding Complications

There are some minor complications that are rare in breast surgery. The most common are: infection, hematoma, noticeable scars, asymmetry, numbness, deflation with saline filled envelopes, implant rupture, and capsular contracture. Avoidance of complication by patient and doctor is a key element in this type of surgery. Because such strides have been made in recent years, this surgery is among the most successful. Remember, any type of surgical procedure carries warnings of complications. It is always recommended that the patient have a routine mammogram prior to having a breast augmentation or any other breast procedures.

Capsular Contraction

Some scar formation around the implant is the normal body reaction to an implant. It may cause distortion in the shape or pliability of the breast and may warrant a corrective surgical procedure. The most important single fact to remember regarding this problem is that the severity is rarely symmetrical and sometimes capsular contracture occurs only on one side. When the problem is on both sides, one side is often worse than the other. Therefore, all theories of explanation of capsular contracture need to include an explanation of this fact. It is not necessary to know the cause, however, to avoid or to treat the problem.

The following are factors that will theoretically help to avoid capsular contracture:

• The type of implant
• Avoidance of infection
• Avoidance of blood clots
• Exercises or pressure on the implants
• Steroids
• Avoidance of tissue irritants and foreign bodies

Excessive Firmness

Firmness may occur but it will not always affect overall appearance. Be assured that this is not a medical problem in the usual sense. It is a matter of softness versus firmness.

Breast Cancer Detection with Implants

Most surgeons are aware of the many changes in breast cancer detection and treatment that have occurred in the past few years. The public is also aware through the media. Some government regulations require doctors to inform patients of the available alternatives for treatment for breast cancer.

Early detection is essential with breast cancer and can allow the patient to avoid radical procedures. According to researchers in breast cancer, the placement of a breast implant at the time of surgery for cancer will not interfere with subsequent radiotherapy in most cases, and therefore perhaps this can be more frequently done without interference with treatment.

Complications Are Rare

Once again, be assured that surgery of any type carries warnings. The desired results with breast implants are full, well balanced breasts that add beauty and symmetry to the female body. There must be warnings when even one patient experiences complications. The attainable goal outweighs the possible few complications that may result. All complications have remedies and your surgeon will know how to apply those remedies.

The above-mentioned complications are rare but must be considered in breast surgery. Hundreds of thousands of women each year have breast enhancement surgery all over the world. It is a proven procedure that has improved over the decades.

Infection (rare)

It is best to understand what happens with an infection, because it can happen anytime with any type of incision or cut. In the case of breast surgery, the surgeon is especially careful to avoid any type of infection. Sometimes the doctor is not necessarily in control of infection, particularly while performing surgery in a hospital. Today the modern surgical center is well equipped to handle breast surgery.

In the extremely rare cases where the breast patient develops an infection, it is usually best to remove the implant, and leave it out until all infection is gone. When the tissues are soft and pliable again (a minimum of three months in most cases) then the implants can be replaced in the breast.

Noticeable Scars

Seldom does a patient need scar revision to correct a highly visible scar following breast surgery. Most incidents include those patients with almost invisible scars who feel they are noticeable. In reality, a hundred percent of all breast implant patients have some scarring and whether or not the scars are noticeable is a matter of opinion. The beneficial results outweigh the tiny scars.

Pneumothorax

Occasionally with any anesthesia a pneumothorax (air in the pleural space or chest) ensues. This is extremely rare and either resolves spontaneously or is amenable to treatment.

Hematoma (rare)

Hematoma—pooling of blood and fluid—occurs more often in patients who have taken aspirin or estrogen and patients with elevated blood pressure. Other causes are disorders of blood coagulation and excessive heat or exertion after surgery.

This is often the result of a blood clot around the implant due to a broken blood vessel. If it happens, it occurs within the first three weeks following surgery. And should it happen, it most likely will do so immediately after surgery. Be assured that this is not life threatening, either as a blood clot or from blood loss. It is what is termed a "closed space" hematoma.

In the rare incidence that a hematoma develops, the patient will notice swelling on one side of the breast accompanied by pain and tenderness, or perhaps firmness and bruising or discoloration. Small clots can result without any of these usual signs, but this is not too likely.

Complications and Surgeons

While it is not our intention to alarm the reader or to cause undue concern, we think that it is very important to mention that complications can and do occur. In the previous chapter we discussed some of the complications specific to breast implants. There are other potential risks that are common to any surgery.

By its very nature, cosmetic surgery is elective. It is not an emergency. In fact, it doesn't have to be done at all. Therefore, when you decide to have elective surgery, you should be fully informed of the possible complications so that you can make an intelligent, informed decision.

The above text is excerpted from The New Breast Book: New Breasts for a New Look and a New Outlook co-authored by Dr. Virginia Pittman–Waller.

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