Breast Augmentation: About the Procedure, Risks & Recovery

INTRODUCTION
If you are thinking about breast augmentation, you are not alone. Last year more than 125,000 women chose to enhance their looks through a procedure that is now the second most popular of all cosmetic plastic surgeries. In fact, doctors have been performing—and perfecting—the procedure for thirty years.

Breast augmentation (also called mammaplasty) is a surgery to contour and enlarge breasts using implants. Many women choose the procedure because they feel their breasts are too small for their body. Some women lose breast size after childbirth or breastfeeding. For others, nature was not overly generous to begin with. And there are other women who are bothered by uneven breasts and would like a more naturally balanced look.

Is It Vain to Consider a Surgical Procedure That Can Change Your Appearance?
Certainly not. To want to look good, to have an appearance that is inviting to others, and to look attractive in clothing is only natural. Nothing is wrong with a heightened sense of self-esteem, and breast augmentation has given many women a greater confidence and better feeling about their own femininity and body.

Do They Look Natural?
Implanted breasts tend to be rounder and firmer than breasts that have not been augmented—characteristics that some people think are actually improvements on mother nature. What breast size is your ideal? We usually think “cup size” when we think breasts. After all, that’s how we choose our bras and bathing suits. If you tell your doctor you want a “C” cup, he or she will understand the general size you wish to be after breast augmentation. But in reality, implants don’t come in cup measurements—they come in “cc's” (cubic centimeters, a measurement of volume) as well as a few different shapes. There are some things you can do to more clearly convey the breast size you wish to be, although your body size and proportions will be a determining factor in the breast size and shape that is right for you.

Most often breast augmentation takes place in an outpatient surgical clinic or hospital under general anesthesia. In some cases, the surgery is done using a local anesthesia combined with sedation so you are awake but drowsy and relaxed. You and your doctor will discuss these options. The surgery usually takes from one to two hours. After surgery, you’ll be taken to the recovery room for several hours before you are able to go home. Plan to have someone accompany you; you’ll be drowsy and feel discomfort. Pain medication will be prescribed which you will probably want to take for a few days.

The Implant
A soft, pliable implant—(imagine a clear plastic pillow filled with Jell-O or salt water) is placed in a pocket the surgeon has formed in your tissue either behind the pectoral muscle or in front of the muscle wall.

Placement of the Implant
Your own anatomy helps determine what placement position is right for you. As a rule, implants behind the muscle are less likely to form a hardening called capsular contracture and less likely to show a rippling on the skin. They usually result in a more natural, softer looking bosom, and this placement is often preferable because it can allow for a better mammogram. Most implants are placed behind the chest muscle.

On the other hand, women with very droopy breasts may have better results when the implant is placed on top of the muscle because that can give their bust a rounder and firmer appearance where the chest was once flattened out.

The Incision
In order to place the implant in your breast tissue, the surgeon will need to make a surgical incision. The incision can be made around the areola (periareolar )— the darker skin that surrounds your nipple; in the armpit; or directly under your breast.

When the incision is made in the areola, usually the scar is barely noticeable, the tiny line blends into the surrounding skin. An incision made under the breast (inframammary) can be inconspicuous as well because the breast itself will hide the scar. Armpit (axillary) incisions may be noticed when the arm is raised, and some surgeons find that it is more difficult to accurately form the pocket that the implant is tucked into from this entry point. Some surgeons use an endoscope, a surgical instrument consisting of a long, thin, lighted tube, to aid them in the insertion of breast implants.

TUBA Method
Some newer endoscopic procedures involve making an incision in the navel (“TUBA” or “transumbilical” or periumbilical method). One tiny half-moon incision is made in the navel and the surgeon then creates a tunnel to the breast area. A "pocket" in the breast tissue is formed that will hold the saline implant. (Endoscopically-assisted surgery allows the surgeon to see on a video screen the pathway and placement site.)

When the pocket is ready, the surgeon will guide the implants-which at this point are empty thin sacs that are rolled up like a cigar-into place. The implants are filled with sterile saline solution; when the surgeon removes the filling tube, the saline implant port self-seals.

"The big advantage is there is no visible scar and it appears that patients have less pain. They seem to recover rapidly," reports Dr. Robert Gerson, a board-certified plastic surgeon who practices in Illinois and Wisconsin and is one of the few doctors in the US trained to perform the procedure. He believes that the TUBA method results in less chance of damaging nerves that can lead to loss of feeling in the breasts.

With this technique, breast implants are most successfully placed on top of the muscle wall. That may be a drawback for some: Many women, including very flat-chested patients, have better, more natural-looking results when their implants are placed behind the pectoralis muscle. But for the patient who is very concerned about any visible scarring-TUBA might be a technique to investigate and consider.

Who Is a Candidate?
Women who want an improvement to the way they look, but have realistic expectations, are the best candidates for breast augmentation.

If you are looking for a nicer appearance, but not an unattainable one, the procedure might be for you. Most women who have had the surgery say they feel more attractive and self-confident. That's not surprising-when you look good, you feel good. Breast augmentation is not without risks and some discomfort, but many women decide that the long-term benefits of more shapely, enhanced breasts are well worth it.

Of course your physician will want to make sure you are in good physical health if you are considering breast augmentation. A pre-op physical, health history and blood work-up will be done before you go in for surgery. Age is not a limiting factor as long as your general health is good.

If you are a serious candidate for this type of plastic surgery, make sure the doctor you choose is board certified. Discuss procedure, risks, benefits and treatment options. "Use this opportunity to determine whether or not you are comfortable with the surgeon and whether or not you want him or her to do the surgery," advises Gregory Mesna, M.D.

In most cases the procedure is considered elective or "cosmetic" and means you will probably have to pay for it yourself. Costs vary in different regions of the country, but average between $5,000 and $6,000.

Preparing for Surgery
Breast augmentation, as with any other surgical procedure, requires you to be in good health. Discuss any health concerns and problems that you may have with your doctor.

Before your surgery, routine laboratory tests including blood counts and blood chemistries, as well as an electrocardiogram if you are over 40 years old, will be performed.

Here are a few general guidelines that you should follow:

• Don't take aspirin or any drugs containing aspirin for at least two weeks before surgery. Aspirin can interfere with normal blood clotting.
• Don't eat or drink anything after midnight the night before surgery. Your stomach needs to be completely empty when undergoing anesthesia or sedation.
• Avoid drinking alcohol a few days prior to surgery.
• If you smoke, stop smoking before your procedure and for some time afterward. Smoking reduces the rate of healing.
• Shower or bathe the evening before surgery, but don't shave your underarms for at least 12 hours before surgery.
• The morning of surgery you may brush your teeth, but don't swallow any water.
• Wear something loose that opens in the front. You don't want to put on anything that goes over your head after surgery.
• Arrange for someone to drive you home. Arrange for a friend or relative to stay with you for 24 hours after surgery.

Pain
You will experience pain, swelling, tenderness and some bruising after surgery, but your doctor will prescribe pain medication to ease you through this time. If the implants have been positioned behind the chest pectoral muscle, expect the kind of pain you would experience with a pulled muscle—because that’s exactly what the surgeon has to do to fit the implant in its pocket. If the implant has been placed in front of the muscle, pain is often minimal.

Prescription pain medications can be used for 4 to 7 days. Take only when needed, don’t take more than prescribed, and don’t take them for more than a week. After several days, most women find that acetaminophen is all they need.

You may be prescribed an antibiotic to fight infection.

Ice packs will help reduce swelling and soothe the incision.

If at any time following surgery you experience fever, bleeding or other symptoms of infection, let your doctor know right away.

Recovery
How will I feel? When can I get back to work? When can I get back to my normal routine? Recovery time is individual, depending upon the patient, the placement and type of the implant, and the surgical technique.

However, here are some general guidelines:

• You’ll feel tired and tender for the first 24 to 48 hours. Plan to take it easy.
• You’ll probably be able to go back to work in several days if your job is not too physically demanding. If your work requires physical energy and stamina, you’ll need to allow more time for your recovery.
• Avoid vigorous exercise for six weeks.
• Your stitches will be removed in a week to 10 days. The incision scars will be firm and pink for at least six weeks, and then will begin to fade. Your breasts will remain swollen for three to four weeks following surgery. They will be tender to touch and exercise.
• No lifting for two weeks and no heavy lifting for four weeks.
• Allow about two months for “complete” recovery from breast augmentation surgery.

Following surgery, your surgeon will apply gauze bandages to your incision sites and you will be placed in a surgical bra which you will wear for about two days. You will receive instructions about changing the gauze and keeping the incision clean; positions for sleep and rest; raising your arms, breathing exercises and breast massage.

Call your doctor if:

• There is an increase in pain, swelling, redness, drainage or bleeding in the surgical area;
• You develop headache, muscle aches, dizziness or a general ill feeling and fever, nausea or vomiting.

Usual follow up after surgery is at one week, one month, three and/or six months and thereafter at annual exams.

Risks
Breast augmentation is a relatively straightforward procedure, but as with any surgery, there are risks and uncertainties.

These are not common, but you should be aware of the possible complications that include:

• Bleeding following the operation. If it continues, another operation may be needed to control the bleeding and remove the accumulated blood.
• Postoperative infection. A small percentage of women develop an infection around the implant. If the body does not respond to antibiotics, the implant may need to be removed for several months until the infection is cleared, and then a new implant is inserted.
• Changes in nipple or breast sensation. Nipple numbness may be temporary or permanent.
• Capsular contracture. If the scar or capsule around the implant begins to tighten, the breast will feel hard and sometimes result in a baseball-like appearance. The implant may need to be removed or replaced, or the scar tissue may need to be surgically removed.
• Rippling or wave-like appearance on breast that look like indentations. In most cases the ripple occurs as the implant moves.
• Shifting of the implant. The device can move from its original placement and/or push through layers of tissue and become visible at the surface of the breast. (Placing the implant beneath the muscle may help to minimize this problem.)
• Implant leaking or rupture. An injury from a blow to the chest, a compression during mammogram, or even normal movement could cause the implant casing to leak. If a saline-filled implant breaks, the implant will deflate in a few hours and the salt water will be harmlessly absorbed by the body. A ruptured or leaking implant must be replaced which requires a second surgery.

Costs
In most cases, breast augmentation is considered elective or "cosmetic" surgery, which means you will probably have to pay for it yourself. Total costs vary in different regions of the country, but average between $5,000 and $6,000.

According to the American Society of Plastic Surgeons (ASPS), in 1998, the average fee charged by the surgeon for breast augmentation was $3,077. (That does not cover anesthesia, hospital/surgical center charges, or the cost of the implant, which adds $1,500 to $2,000.)

The ASPS reports the following state-by-state averages of fees charged by plastic surgeons in 1998: California, $3,234; New York, $4,417; Florida, $2,616; Texas, $2,851.

More to Know
How will your life change after breast augmentation? Aside from the fact that there is a good likelihood that you'll be happier with your new shape, you'll find few restrictions or big changes. But here are a few things to keep in mind.

• Breast cancer screening and mammography. As for all women, you will need regular mammography exams after a certain age to detect breast cancer. Both saline and silicone implants can obscure the tissue in which a tumor may be present, making detection more difficult. However, breast implants that have been positioned under the muscle are less likely to interfere. When you book your mammogram, tell them you have implants and that you want a technician who has been specially trained. At your appointment, remind them again. Breast implants can rupture with improper mammogram handling.
• Breast-feeding. You should be able to breast-feed successfully after breast augmentation. According to La Leche League, many women with silicone breast implants have successfully nursed with no apparent harmful effect to themselves or their children.
• Implants don't last forever. Most likely you will need to replace the implants at some point down the road, which means you'll need another surgery. Discuss implant product warranty with your doctor so you are clear about what is and isn't covered in the cost of the surgery.

Types of Breast Implants
A breast implant is a silicone shell filled with either a saline (salt water) solution or silicone gel. The implant most often used today is saline-filled. Under some conditions, silicone gel implants can be used, but these are mostly used for reconstructive surgery. Because saline is similar in composition to other body fluids, if a saline implant should rupture and leak, the saline solution, which is harmless, is absorbed by the body.

There are round implants and anatomic implants. The anatomic implants may also be described as "teardrop", "anatomical",or "tapered" implants. The tapered implant is sometimes suggested for thinner women because it may result in a more natural-looking upper chest.

The rounded implant gives a fuller upper chest and cleavage. Implants of either type placed behind the muscle may provide a similar appearance.

The outer surface of the implant may be either textured or smooth. Textured implants may help reduce capsule formation around the implant. The evidence is not conclusive. Some surgeons have found that textured implants have more of a tendency to ripple. Advocates of smooth implants claim that they are less likely to cause visible rippling (especially if placed below the pectoral muscle) and are more natural to the touch.

Because there is a lack of evidence supporting the safety of silicone gel-filled implants, the Food & Drug Administration (FDA) restricted their use to primarily reconstructive procedures in approved clinical studies. Some women requiring replacement of existing gel implants may also be eligible to participate in the study. Saline-filled implants are currently under review for both reconstructive and elective purposes.

Adjustable-fill implants allow the implant size to be adjusted after the initial surgery. A self-sealing tube and valve allow the surgeon to add or remove additional fluid to increase or decrease the size, respectively. The valve is often removed surgically and the implants remain at their adjusted size.

An alternative implant filled with a purified form of soybean oil is also being evaluated and it is not known if it will be available for general use.