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.

Liposuction - Safe or Unsafe?

Liposuction, or liposculpture is the most common cosmetic surgical procedure in the United States. Traditionally, liposuction was associated with an outpatient surgical setting, where excess fat was removed and patients experienced rapid recovery and gratifying results.

In recent years, procedures have become more ambitious with larger amounts of fat being removed. Though this progress frequently allows for more dramatic results, it has unfortunately been associated with serious complications, including death. Because liposuction remains an attractive cosmetic procedure, patients want to know if liposuction is fundamentally safe and, if so, how they can make sure their particular procedure is done safely.

Liposuction is conceptually simple. A healthy patient with areas of excess fat has these areas reduced by vacuuming the fat through small metal tubes called cannulas. This procedure is frequently done on an outpatient basis under general anesthesia in the hospital or accredited surgical facility.

Most liposuction begins with the surgeon infiltrating a special solution into the fatty tissues to be suctioned. This solution is mostly salt water, but also contains adrenaline to reduce blood loss and may contain a local anesthetic to reduce pain. Following the injection of this "tumescent" fluid, fat removal begins. In certain cases, the initial phase of liposuction involves ultrasound cannulas that loosen the fat to be removed. This is followed by standard liposuction, where a vacuum is employed to remove the excess fat.

At the end of the procedure, the patient is placed in a compression garment to reduce postoperative swelling. In most cases, the patient is discharged home the same day and returns to work in a few days. When more significant fat removal is performed (greater than 10 pounds), patients are usually observed overnight.

It sounds so simple, so how could anything go wrong? Easy – each factor in liposuction can be critical to a safe outcome. For instance, if the patient is not healthy, even liposuction can result in significant problems, such as a heart attack or trouble breathing. If the surgeon is overly aggressive in fat removal, excessive blood loss can occur. If the anesthesia is not administered properly, too much fluid can be given with serious consequences. If the surgical facility is poorly maintained, infections can be more frequent and lifesaving equipment might not be available in an emergency.

There Are a Few General Factors that Influence the Safety of Liposuction:

Patient: Liposuction is for healthy patients who are within about 40% or their ideal body weight. Liposuction is not intended to be a strategy for weight loss. Obese patients should be considered only rarely. Patients with significant heart or lung disease are not candidates.

Doctor: Ideally, liposuction should be done by surgeons familiar with all facets of liposuction, including the tumescent technique and ultrasound-assisted liposuction. Board certification, preferably by the American Board of Plastic Surgery, is mandatory. This ensures that a national organization feels this surgeon is competent and safe. Additionally, and equally as important, the surgeon should have privileges to perform the procedure in a local hospital. Such privileges mean the surgeon has demonstrated to his or her peers locally that he or she is capable of performing the procedure safely.

Anesthesiologist: Whether general anesthesia is being used or not, all patients undergoing liposuction should be monitored by someone other than their surgeon. This is preferably done by a board-certified anesthesiologist, but can also be done by an experienced, certified registered nurse anesthetist. Experience is essential as it can be difficult to manage liposuction patients, especially during a large volume liposuction.

Facility: Liposuction should always be performed in a hospital or accredited surgery center. The surgery center should be approved by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). This certifies that the facility is of the highest quality. Frequently, I hear of patients who have undergone liposuction done under local anesthesia without proper monitoring, who have done well. I try to point out that just because the surgery was successful, it does not mean it was performed safely. Since liposuction is a real operation with real risks, the conditions for the procedure should be the same as those for any other surgical procedure such as a hysterectomy. Accepting anything less is simply making liposuction more risky than it needs to be.

Liposuction is like any operation in cosmetic surgery in that it can have unsatisfactory results. Specifically, too much or too little fat can be removed, contour irregularities can develop and swelling can be prolonged. However, when adequate precautions as outlined above are taken, life-threatening complications should be exceptionally rare. When done properly by an experienced surgeon in an accredited facility, liposuction remains an extremely safe and effective way to improve one’s shape by fat removal.

Liposuction is real surgery and involves risks such as bleeding, infection and scarring. Results will vary.

Avoiding End Hits In Ultrasound-Assisted Lipoplasty

A potential disadvantage of ultrasound-assisted lipoplasty is tissue burns. These may occur when the tip of the probe hits the undersurface of the skin. These "end hits" occur when the tip of the probe is vertically oriented to the skin surface, and they are more likely to happen when the surgeon is trying to go around the sides of the patient from centrally located access incisions.

To help avoid hitting the skin’s undersurface around the lateral aspect of an area being treated, a lateral meridian is drawn before surgery with the patient standing. The surgeon should not cross this lateral meridian when working in an anterior direction from the central access incisions with the patient in a prone position or when working in a posterior direction with the patient in a supine position. The prone position displaces this lateral line posteriorly, whereas the supine position displaces it anteriorly because the operating room table pushes up against the patient’s body.

The surgeon’s non-dominant hand assists by rolling tissue toward the probe so that its tip does not approach the skin in a vertical orientation. Early in my experience, I would sometimes push the probe too far around a contour. The surface orientation provided by the lateral line has helped prevent that problem so the tip of the probe is not perpendicular to the skin.

I limit access incisions to well-concealed sites. One or two incisions at the superior border of the escutcheon or umbilicus for the anterior abdomen and lateral flanks, and one at each of the lower lateral borders of the escutcheon for the inner and outer thighs have been adequate when the patient is in the supine position. Incisions on either side of the spine and in each buttock crease have sufficed to treat flanks and thighs with the patient in the prone position.

Botox Injections – Treatments for the Reduction of Wrinkles

Botox injections utilize Botulinum Toxin Type A to treat wrinkles. Botox was originally slated to treat neurological disorders; today, it is widely and successfully used to remove facial lines, especially frown lines, "crow's feet," and forehead lines.

Who is the Best Candidate for Botox Injections?

Good candidates for Botox injections include younger people with facial wrinkles and those who cannot undergo a more extensive plastic surgery procedure such as a facelift. Certain medications may alter the potency of Botox injections, increasing the likelihood of bruising and bleeding. These include some antibiotics, anti-inflammatories, and aspirin, as well as some vitamins and herbs. People with neurological disorders should avoid having Botox injections. Also, women who are pregnant or nursing should not have Botox injections, because the effects on the fetus and on breast milk are unknown.

How are Botox Injections Administered?

Botox is injected directly into the muscle surrounding the wrinkle with a very small needle. If patients experience any discomfort, it is usually minimal and only lasts a few seconds. Once injected, Botox works by preventing nerve impulses from reaching the muscle, allowing it to relax. The effects of the procedure are usually noticeable within a few days. Although the results are not permanent, they usually last for a number of months. Botox injections are performed on an outpatient basis and may be repeated when the results diminish.

Botox Side Effects

Botox injections are relatively safe for most patients. The most common side effects of Botox injections are mild numbness, swelling, bruising, or tingling in the area. Most of these do not occur when the procedure is performed correctly. The patient can help prevent bruising and numbness by refraining from rubbing or touching the treated area for the first day after the procedure is done. A small number of patients report no improvement following their Botox injections. Patients should be screened for allergy to Botox before the procedure is undergone.

If you are interested in learning more about Botox injections, contact a plastic surgeon in your local area.

Face Lift – Facial Plastic Surgery Risks

A face lift, or rhytidectomy, is a plastic surgery procedure meant to remove wrinkles and decrease the signs of aging and sun damage. While it is not a cure-all by itself and is a serious medical procedure, the results can yield a more satisfying appearance for those who deem the process worthwhile. Facelift may be combined with others, such as facial implants or a skin peel in order to improve the final results.

Sometimes a neck or brow lift may be done in conjunction with a facelift. A neck lift focuses on tightening the skin around the neck and jowls. A brow lift raises the eyebrows and tightens the skin on the patient's forehead.

Face Lift Candidates

The best face lift candidates will have realistic expectations and will follow the advice of their plastic surgeons. There is no specific age that is best for having facelift performed. Skin condition and texture are more important factors. After meeting with a cosmetic surgeon, the patient will usually be advised as to whether he or she is a good candidate for facelift or whether an alternate procedure might be preferable.

Face Lift Surgery

For the two weeks before face lift surgery is performed, patients will be asked to stop smoking and taking aspirin. They may also be given special prescription medications to use prior to the operation. Facelifts can be done either in an outpatient or a hospital setting.

The plastic surgeon begins the facelift procedure by making an incision (usually at the hairline) and separating the facial skin from the underlying tissue. Excess fat and skin are removed, and the surrounding muscles are tightened in order to improve the contours and appearance of the patient's face. The skin is then reattached, using stitches or staples, and the area is wrapped in bandages.

The healing process continues for several weeks beyond facelift surgery. During that time, pain medication is usually prescribed. Physical and social activity may be limited for the first few weeks after facelift surgery.

Face Lift Surgery Risks

There are certain risks inherent in any surgical procedure, but face lifts are considered relatively safe. Some scarring should be expected. Conditions that may occur but should prove temporary include blood or fluid retention under the skin, crusting of the scars, and numbness. The risk of nerve damage or infection is low but does exist. Neck lifts and brow lifts are less complicated procedures that usually involve less pain and lower risk than a complete facelift. The cosmetic surgeon should discuss all possible risks and complications with the patient before the surgery is performed.

Risks & Benefits associated with cosmetic and plastic surgery

As with any medical procedure, there are certain inherent risks and benefits associated with cosmetic and plastic surgery, all of which should be thoroughly considered prior to making the decision to proceed.

The benefits that can be realized from effective and well-thought-out cosmetic and plastic surgery can be very significant and positively life-altering. Regardless of your motivation to pursue a cosmetic procedure, you should be aware that there are numerous qualified physicians and professionals that are dedicated to your safety and your satisfaction, both with their efforts and with your appearance. Although the cosmetic and plastic surgery industry is often a controversial topic, it is increasingly gaining acceptance and the industry as a whole has taken great strides in recent years.

The most common risk factors that are associated with cosmetic and plastic surgery are related to the permanence of the results of the procedures. The implications of the anesthetics used (when necessary) are also important factors and all cosmetic and plastic surgery patients should be thoroughly screened for allergies to certain anesthetics and pain relievers. Of course, the selection process for a suitable and qualified surgeon is of paramount importance. Be certain to verify the credentials of any surgeon that you select and to follow-up with any references that are provided. Other important risks are associated with the patient's reaction to the sometimes drastic physical changes that are being made to their bodies.

Please keep in mind that the risks and benefits of cosmetic and plastic surgery are unique to each individual and should be considered accordingly. We strongly recommend that all individuals considering these types of procedures consult their primary physicians directly, in addition to researching objective sources of information, such as this web site.