BREAST AUGMENTATION: seeking natural-appearing results
Performed by Board-Certified Plastic Surgeon Michael Law MD
Having practiced plastic surgery in the ‘breast augmentation capital of the world’ (Los Angeles), I have developed some fairly strong opinions about this operation. In thinking about breast augmentation surgery, I believe that the most important question for a prospective patient to ask themselves is this: am I seeking a natural-appearing result? when the goal of this operation is a natural-appearing breast enhancement, the results can be absolutely beautiful. Says Raleigh Plastic Surgeon and breast augmentation specialist Dr. Michael Law
However, if the goal is to create a breast profile which is out of proportion to a woman’s body, the results (by definition) never appear natural, and these patients not infrequently end up having a series of operations to address problems with their abnormal appearance. Overly large implants gradually stretch out breast skin and can often produce the need for a breast lift operation to correct the resulting droopiness. Women that have breast augmentation in my practice are looking to "fill out clothes better" and improve the overall proportions of their body. they do not want to look like "the gal with the boob job".
Quite a number of my breast augmentation patients are moms. after one or more pregnancies, most women experience a loss of breast volume combined with some ‘stretching out’ of the breast skin. In many of these patients, an implant of moderate size will restore a very pleasing breast contour. these patients are NOT looking to raise eyebrows at work or around the neighborhood – they just want to throw their padded bras away, and to feel better about their appearance in private.
When there is laxity of the breast skin that makes the breasts appear somewhat droopy, the addition of an implant of moderate size can ‘fill up’ the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or ‘mastopexy’). This is often a situation that exists after pregnancy and lactation, but I also see quite a number of patients with significant breast skin laxity who have never been pregnant.
In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the augmentation surgery to tighten the skin envelope of the breasts, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming.
Attention to detail
While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.
In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. if the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. as it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.
Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2" will be inadequate for a large-framed patient who is 5’10". Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.
Choosing the implant size
In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within one or two implant sizes. However, the patient and I do not decide on one particular size prior to surgery. there is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. for that reason I have a wide range of implant sizes available in the surgery center.
If a natural appearance is the goal, then the way to get the size right is to ‘try out’ different implant volumes in the operating room. Once the implant pockets have been created, I place a ‘sizer’ in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright ‘sitting’ position (chest fully upright). the sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner the exact volume that produces a full but natural breast profile is determined.
For any patient there is obviously a range of implant volumes that would be considered natural. while one patient may seek an augmentation that is ‘the small side of natural’, another may be interested in something that is more on ‘the full side of natural’. by using implant sizers in the O.R to determine exactly what breast profile is produced by a given implant volume, I am able to provide patients with the closest possible approximation of their preoperative goals.
Incisions and implant position relative to the pectoralis major muscle
Breast implants can be placed through different incisions and in different positions relative to the pectoralis major muscle. No two patients are alike, so it is important to individualize the surgical plan for each patient’s own needs. the most commonly used incisions are peri-areolar (from about the 4 to 8 o’clock position along the areolar border), infra-mammary (in the fold below the breast) and axillary (underarm area).
An advantage of the peri-areolar incision is that the color difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely. In many patients the scar is almost undetectable after only a few weeks. the infra-mammary scar works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts. as full breasts conceal the infra-mammary fold very well, the scar is never visible when standing or sitting upright. the axillary or underarm area incision is primarily used for sub-pectoral (‘under the muscle’) implant placement, particularly in patients with small areolae (where the peri-areolar incision is not ideal) and smaller breasts (where the inframammary fold is clearly visible in upright position).
The decision to place breast implants ‘on top of’ or ‘under’ the muscle is individualized to the specific needs of each patient. I think that the term "under the muscle" is a bit misleading for the following reason: when implants are placed below the pectoralis major muscle only about half of the implant surface is actually beneath the muscle – the medial/upper half – while the lateral/inferior half is immediately behind the breast and not covered by muscle tissue. Sub-pectoral placement is advantageous in patients who are slender and very small-breasted preoperatively, as the pectoralis muscle helps to conceal the implant in the most important place aesthetically: the cleavage area. In other patients, sub-muscular placement affords no significant advantage, and sub-mammary (on top of the pectoralis major muscle) placement is preferable.
Again, the decisions regarding the surgical incision and the placement of implants relative to the pectoralis major muscle are completely individualized, as no single approach is the best approach for every patient. the decisions are based upon physical examination at the time of the physician consultation, and on discussion with each patient of the ‘pros and cons’ of each alternative.
SHOULD I CHOOSE SALINE OR SILICONE GEL BREAST IMPLANTS?
In November of 2006 the FDA lifted the moratorium on the use of silicone gel implants for primary aesthetic breast augmentation. Women seeking breast augmentation may now choose between saline-filled and silicone gel-filled breast implants, and thus it is extremely important for prospective patients to understand a number of differences between the two kinds of implants. Currently in my practice about half of patients choose saline implants and about half choose silicone gel implants. beautiful and natural-appearing results can be obtained with both styles of implants, and a patient’s decision regarding saline vs. silicone gel implants usually comes down to individual preferences regarding the pros and cons of each.
I think it is important for patients to understand, in advance of choosing a type of implant, that both types of implants are safe and that claims which have been made about silicone gel implants have not held up under scientific scrutiny. a small number of women with silicone breast implants reported symptoms similar to those of known diseases of the immune system, such as systemic lupus erythematosis, rheumatoid arthritis, scleroderma, and other arthritis-like conditions; this eventually led to the FDA moratorium on their use for cosmetic patients only (during which time the FDA still allowed their use for patients undergoing breast reconstruction following mastectomy for breast cancer). to date there is no scientific evidence that women with either silicone gel-filled or saline-filled breast implants have an increased risk of these diseases. these inflammatory and autoimmune diseases appear to be no more common in women with breast implants than they are in women who do not have breast implants.
Saline implants: the basics
Saline implants remain very popular in my practice, and here’s why: saline implants of a moderate (and in my opinion, appropriate) volume look and feel natural. the implant sizes I most commonly use blend in nicely with existing breast tissue, and patient satisfaction is high. In over ten years of experience with saline implants I have not had a single patient return to say "I’m not happy with my saline implants…take them out and put silicone gel implants in their place."
Saline implants are inserted uninflated, and they can therefore be placed through a somewhat smaller incision than silicone gel implants. the peri-areolar, inframammary fold and axillary (underarm) incisions can all be used for saline implants of any volume. if a saline implant deflates it is apparent almost immediately, as the saline solution is absorbed by the body, so no ‘postoperative monitoring’ for implant rupture is required as with silicone gel implants. Saline implant deflations are relatively uncommon; I have had only one patient (out of hundreds of patients) return with a deflation in the past six years.
The primary disadvantage of saline implants is the fact that, in many patients, the edge of the saline implant is palpable under the breast. This occurs primarily in the lateral aspect of the augmented breast where there is the least amount of breast tissue present to conceal the implant. it tends to be more of a concern in slender patients with a small volume of natural breast tissue (A or small B cup), as there is less tissue available for implant concealment. In patients starting with a full B or small C cup breast volume, the possibility of implant ‘edge palpability’ is less of an issue.
There is also a somewhat higher risk of having visible implant folds or ripples with saline implants, although on occasion this problem can occur with silicone gel implants as well. In patients starting with a small a cup breast volume, I urge them to strongly consider gel implants as there is a much higher likelihood of the implant being visible through the breast skin if a saline implant is used.
Gel implants: the basics
In the time since the moratorium was lifted, gel implants have gone from being used in my practice on rare occasion to being used in about half of the breast augmentations I perform. Patient satisfaction has been excellent and I have been very pleased with the performance of the new ‘cohesive’ gel material.
Gel implants are inserted pre-filled and thus require a larger skin incision than is used for saline implants. for this reason the most commonly used incision is one placed in the inframammary fold. the peri-areolar incision is acceptable in patients with a wide areolar diameter, but does not work as well if the areolar diameter is small. an axillary (underarm) incision can be used but only for implant volumes up to 250 to 275cc.
One distinct advantage of gel implants is the fact that in almost all cases the edges and anterior surface of the implant are not palpable, and it is thus very difficult to detect by touch or feel that an implant is present. In many cases it is actually impossible to detect the implant at all. This makes gel implants a very attractive option for women who are quite slender and have a small natural breast volume, as saline implants are usually very easily detected by touch or feel in these patients.
The gel implants that are currently available are filled with a gel material that is called ‘cohesive’, which essentially means that the gel is semi-solid instead of semi-liquid. In the event of an implant rupture the cohesive gel material sticks together instead of having the ability to ‘run’ or ‘spread’ as did the older, semi-liquid gel material. because the cohesive gel material is semi-solid, cohesive gel implants feel somewhat firmer than the semi-liquid gel implants that are no longer in use, and they also feel firmer than saline implants (unless saline implants are overfilled to their volume limit).
The primary ‘downside’ of gel implants is the fact that an implant rupture can not be detected by appearance or feel. the gel material is inert and is not absorbed by the body, so the size and the appearance of the augmented breast does not change if a gel implant’s outer shell ruptures. because the body forms a fibrous capsule made of collagen around all implanted medical devices, a gel implant rupture is usually contained by that fibrous capsule, and thus the gel material is not free to migrate to other sites in the body. Escape of gel material outside the fibrous capsule following gel implant rupture appears to be fairly uncommon.
The only way to detect a gel implant rupture is by means of a radiological examination such as an MRI. the FDA has recommended that women receiving the new cohesive silicone gel implants undergo postoperative MRI scans to monitor for implant rupture. Postoperative MRI scanning is not a requirement – it is voluntary on the part of the patient. the FDA’s recommended protocol is to have the first MRI three years postoperatively, then every two years thereafter. many plastic surgeons feel that this schedule of MRI scans is excessive and unnecessary, and have requested that the FDA modify their recommendation. if an implant rupture is detected on a breast MRI scan the FDA also recommends that the ruptured implant should be removed and replaced.
So how should a patient decide?
The choice between saline-filled vs. silicone gel-filled implants obviously requires the consideration of a wide range of issues. many patients that I meet in consultation have decided on a type of implant in advance of the appointment, while some are still deciding in the interval between the consultation appointment and the date of surgery. it is a significant decision, but I do not think it should be turned into or thought of as a ‘make or break’ decision in terms of a pateint’s long-term happiness with breast augmentation. In most cases it is impossible to tell by outward appearance whether a patient has saline or silicone gel implants. and in no case have I had a patient express regret regarding the type of implant they selected.
If you are certain that you do not want an implant that requires radiologic follow-up to determine whether or not it is intact and may need to be replaced, and you are comfortable with the possibility that the edge of the implant may be palpable to some degree in a limited area of the breast, then saline implants are an appropriate choice. Once you have recovered from saline implant breast augmentation there is no long-term implant monitoring that is required. and there is no reason to have the implants changed at a later date just because a given number of years have passed. Deflation is the only likely reason you might have the implants changed at some point.
On the other hand, if you cannot tolerate the idea of the implant edges potentially being palpable in some areas, and are comfortable with the idea of postoperative monitoring (i.e. breast MRI scans) to screen for implant rupture, then silicone gel implants are an appropriate choice. you may be particularly more inclined to choose silicone gel implants if you are slender and your natural breast volume is an a to small B cup, as the surgical result is likely to look and feel much more natural with gel implants. another instance in which silicone gel implants are strongly preferable is if you prefer sub-mammary instead of sub-pectoral implant placement. Submammary placement works well with gel implants in many patients, while saline implants are most commonly placed in a sub-pectoral position (unless the starting breast volume is fairly full).
At your consultation appointment all of these issues can be reviewed in detail. your personal feelings about the concepts presented above, combined with my recommendations based on breast examination, make it fairly easy in most cases to arrive at a decision with which each patient is very comfortable. again, patient satisfaction with both types of implants is extremely high in this practice. an important part of achieving high patient satisfaction is ensuring that patients fully understand what to expect from each type of implant, so please give all of the issues presented above some serious consideration as you are making your decision.
To receive breast augmentation before and after photos via email please go to michaellawmd.com or call 919 256-0900.
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Breast Augmentation North Carolina