Breast Augmentation

Let’s talk about silicone implants, why we use them, who are the great candidates for silicone implants, and we’ll start out by saying many patients come in saying they just want silicone implants. Their friends have had silicone implants, and that’s all they know, and that’s all they want. But there are other options. But when we talk about silicone implants, what we really want to talk about is the level of cohesiveness, whether they’re more liquid or more stiffer. The stiffer implants are called gummy bears, and the more liquid implants are the traditional silicone implants. They’re just a little bit more fluid. They feel very good, but if they’re too fluid, if the liquid inside is too thin, they show more ripple and wrinkles.

When we talk about who is a great candidate for silicone implants, those are usually candidates who have a very thin amount of soft tissue. Again, most all the implants placed in my office are placed below the muscle, we call subpectoral breast augmentation. Occasionally, we do put them above the muscle for very specific indications, very specific reasons, such as a bodybuilder, someone who competes in the athletic bodybuilding competition. They can’t have that implant under the muscle.

We’re going to talk about above the muscle or subglandular breast augmentation, versus below the muscle or subpectoral breast augmentation. In the United States, and in my practice, probably 95% of the patients have a subpectoral or below the muscle augmentation. There are some people though, that are good candidates for an above the muscle approach. Typically, the patient who wants an above the muscle implant is someone who’s very fitness oriented. They’re a bodybuilder, they don’t want what we call an animation deformity, which is showing the breast implant flexing when you move, when it’s below the muscle. For most patients, this is not a problem, even if you’re a heavy duty workout person, but there are some people who just had been online, and they don’t want it.

So we can go above the muscle. The key elements are you have to have enough soft tissue to cover the implant, because if you don’t, you’re going to see the edges, and you’re going to see rippling and wrinkling. It’s really a fallacy for some women who come in and say, “I read online that I might not need a breast lift if you just put the implant above my muscle.” I think that’s a fallacy, I don’t think that’s a real procedure, and I think it really is doing something inappropriate for the patient, because as soon as you load that soft tissue with an implant, which is more weight, it’s just going to stretch that skin, and it’s going to, what we call bottom out, where you’re going to have a very bottom heavy breast, it’s going to be a poor shape.

And we know factually, that whether it’s subglandular, or now, some people try to say, you can put an implant subfascial, really, really hard to do, not a very good operation, and it still has the same problems, and for many patients that much, much, much higher rate of capsular contracture. And if you have a really hard, painful, misshapen breast, you’re going to need a revision, and I always tell people, you’d rather do it right the first time, then to have to come back and try to fix something a second, or third, or fourth time.

Okay. Today we’re going to talk a little bit about breast symmetry. What really should we talk about is breast asymmetry, because all breasts are different. I’d like to say, “They’re sisters, not twins,” and so when we look at someone’s breasts, we know that they’re going to be different. Most patients don’t know this. They’re unaware of this, and when I measure them and I say, “Well, you’re five millimeters off here or a centimeter off here,” they kind of freak out and like, “Oh my gosh, I didn’t, I never knew this.” It’s normal. It’s absolutely normal. But what this means when we look at your breasts, we feel them and we look at the volume of breast tissue. I also look at your hand dominance. Sometimes it’s right, but sometimes it’s left, and sometimes that muscle is so much bigger that that’s going to come into play, that somebody just has a really dominant muscle.

And sometimes the chest wall itself is slanted or crooked, and that’s because some people have scoliosis. Some people, I joke, just have a big heart and their left side of the chest is just pushed out a little bit more. So there’s so many things that we can look at, and I measure it and evaluate. And what that means is that I’m going to adjust things as I see fit, to try to improve your symmetry. And that means that we sometimes don’t use the same implants. Sometimes we’ll use a 325 on one side, and a 350 on the other side. Sometimes if we’re using a saline implant, we’ll have a fill of 350 on one, and 365 on the other. And we’ll manipulate those volumes, and sometimes implants, to help improve your symmetry.

And I think that’s really a key important thing because some docs just say, “Hey, we’re throwing in 350s,” and you get one on each side. And the problem with that is that breast augmentation will magnify a breast asymmetry. So I’d like to try to improve it from the start, not try to explain something later to a patient, “Oh, oh, we should have done this, we should have done that,” because really, you have one chance to do it right. So let’s plan accordingly.

So now that textured implants have been voluntarily taken off the market by Allergan, the bio cell textured implant. What do you do? And while there is a disease process, we’ve all heard about breast implant associated lymphoma. We don’t want to cause a panic. We don’t want to yell fire in a crowded movie theater. But we do want to educate our patients that these implants are associated with this process. And the real key is patient comfort and patient peace of mind.

All implants fail eventually, so all implants need to be replaced eventually. So if you’ve had your implants for three years or seven years or 10 years, we know they start to fail. And so it might be something you now say, “Okay, this information’s out there. I’ve had my implants for 10 years and I want to replace them.” And this can be a very straightforward, simple process. We can replace same size, a little bigger. We can do some other things that if you want them done at the same time. Maybe a little lift if you now feel you need a little bit of a lift. But it can be done safely, effectively, and in a controlled manner. And we don’t want anyone to panic. But it is something that if you have these textured implants, you may be considering replacing them at this point in time.

Occasionally, we do have someone who does bruise more than usual. Sometimes the patient may have taken some aspirin or Motrin, and that just causes the body to bleed a little more at the time of surgery. All of your surgery is done meticulously, with essentially an electric knife, so there really is almost no bleeding during your operation. I often would say there are literally four or five drops of blood during the whole operation. Sometimes someone goes home, they come in the next day or two or three days later, and they’re pretty bruised. And that’s because a little bit of muscle edge from the subpectoral breast augmentation oozed and bruised them. The nice thing is, is that we have some treatments. We have some topical arnica gel, and most patients, in about seven to 10 days, that bruising can be all gone away with a little special additional medication.

We’re going to chat a little about avoiding complications. Bigger is not always better. There is a limit to what we can do safely, and when someone comes in and says, “I want 800 CC implants, and I want them above the muscle,” more than likely, I’m going to say, “I’m not the doctor for you.” Really, what we want to do is limit rippling. We want to limit rippling, wrinkling, poor scar formation, thinning of the tissue, so there really is a limit to what we can do safely. We’re going to take a bunch of measurements of your breasts. We’re going to discuss the different profiles and shapes of implants we can use. But the best way to eliminate things like rippling and wrinkling are to follow safe guidelines and not push the envelope of safety.