BREAST AUGMENTATION (ENLARGEMENT)
Breast augmentation is the operation to enhance a woman’s breasts using prosthetic implants. If you are considering breast augmentation, you are not alone; it is the most popular aesthetic surgical procedure in the U.S. Whether you are looking for creating a breast when very little development has occurred, enhancement of the breast tissue you already have, creation of a more attractive shape, or to fill out a “deflated” appearing breast after nursing, breast implants are applicable. They provide a powerful psychological and physical boost to women who are unhappy with this part of their figure. The vast majority of women who undergo breast enlargement are very pleased with their results (in excess of 95%) and report years later that without question they would undergo the procedure again. In fact, it is not unusual for the daughters of previously augmented patients to seek out the procedure themselves. Very few women have their implants removed later in life because the size of their breasts becomes a positive part of their self-image.
Breast augmentation is approximately a 45-60 minute procedure. You are put under a general anesthetic by a board-certified anesthesiologist. An incision is made either under the breast, in the armpit, or through the areola (pigmented area outside the nipple), depending on your preference, Dr.’s recommendation, and the implant chosen. A space is created under or above the pectoral (chest) muscle, which is later referred to as the pocket. The implant is inserted and the incision closed. After you are fully awake, you are discharged to home. Recovery is quick and you are able to be up and around that day. In fact, Dr. Creasman encourages patients to move their arms over their head in a series of exercises described in the aftercare instructions. You will be seen 2 days later after which you are able to shower. Most patients return to work in 3-5 days. Return to full activity or to work that is physical in nature takes longer.
Though complications are possible with any procedure, they are very unusual but include bleeding, infection, numbness, changes in position of the implant including rotation, and asymmetry. Over time, risks include hardness of the breast because of scarring around the implant, drooping of the breast, a change of mind about the size, and leakage or fracturing of the implant. If these problems occur, more surgery may be necessary and involve additional cost. Some women with implants may produce less milk when they try to nurse, especially when implants are inserted through the areola. Special methods are required during mammography after implants are in place.
Most of the work involved with having breast implants is in deciding if the benefits of having a prettier shape or larger breast size is worth the risks of surgery and the liability of having implants. Taking time with the doctor and other support staff in the office, involving family and/or friends as support systems, and undergoing careful, individual measurement and planning of implant size and type by Dr. Creasman is vitally important in achieving the best possible results. Dr. Creasman has extensive experience and expertise in breast augmentation and employs unique tools such as Vectra 3D imaging to analyze your anatomy so the implants fit your body and look as natural as possible. He is very thorough and listens to what you want to achieve and then takes that information to work with you to get the result you want, but in a safe and natural way. Patients who want a naturally larger look generally like Dr. Creasman’s results.
It is our opinion that it is important for patients to understand some details about how the operation is performed, what the recovery is like, what the risks of the procedure are, and what the typical appearance of implanted breasts are in the hands of Dr. Creasman. For this reason, we have developed this section of our website and an extensive photo library of patient results, all performed by Dr. Creasman. While it is impossible to show every variety, size, and shape of breast that exists, we have tried to show average results in various scenarios. Though these results do not in any way guarantee that you will obtain the same exact result, they serve to demonstrate a level of competence and expertise by the doctor, and provide a visual basis for estimating the type of implant which would provide the patient with the desired result.
1. The Incision
The most basic principle upon which the operation is based is the creation of a space, or pocket, into which the implant is inserted, thereby enlarging and reshaping the breast contour. Technically, breast enlargement is not a simple operation because often a relatively large pocket must be made through a very small incision in order to achieve an attractive result with the most inconspicuous scar. Incisions that are utilized for this operation include:
Inframammary – in the crease between the bottom of the breast and the chest wall. This is the most common and is required when using shaped, form stable (also known as “gummy bear”) implants.
Axillary – in the armpit
Periareolar – at the junction of the dark and light colored skin of the areola
Through breast lift incisions when that procedure is combined with augmentation.
Dr. Creasman performs the procedure using any of these approaches. This will be discussed during the consultation.
2. The Pocket – Level of Placement
In addition to several types of incisions and implants, there are also two basic techniques of breast enlargement, involving differences in the location of the pocket. In one the pocket is made beneath the breast tissue, but on top of the pectoralis muscle (figure 3, left). In the other, more common, method, the implant is placed beneath the pectoralis muscle, between the pectoralis and the ribs (figure 3, left). The advantages of placing the implant above the muscle are that it is less painful for the first few days and the appearance of the implants matures faster (because skin stretches faster than muscle). Contraction of muscle, more noticeable in body-builders, has no effect on the appearance of the breast. This technique is utilized in women with sagging breasts as the breast position relative to the underlying muscle has changed and a deformity known as a double mound is created if the implant is placed under the muscle, at the higher level.
The advantages of placing the implant under the muscle are numerous. First, it provides a more natural appearing breast with a better transition from the upper chest to the breast mound. This avoids “upper pole convexity” or roundness of the upper breast, which does not occur in nature. Second, the rates of scarring around the implant are significantly lower when the implant is placed beneath the muscle. Third, the risk of visible ripples or folds in the implant envelope (a more common problem with saline than with silicone implants) is diminished because of the greater amount of the patient’s own tissue overlying the prosthesis. Fourth, the ability to obtain an adequate mammogram is enhanced with placement under the muscle, as the mammogram technician is better able to separate the breast from the implant when the muscle is interposed. With the exception of patients who are body builders or competitive athletes, Dr. Creasman recommends placing the implants under the muscle.
3. The Implant
Significant advances and alterations have been made in the prosthesis itself since the original introduction of the silicone gel breast implant in 1962. The three main types of implants are the standard silicone gel prosthesis,the form-stable, cohesive gel (“gummy bear”), and the saline-filled prostheses. All of the envelopes are made of a solid type of silicone (Silastic), but the material inside each differs. In 1991, the Food and Drug Administration restricted the use of silicone gel breast implants to certain patients and until late 2006, access to this prosthesis was restricted to Plastic Surgeons participating in FDA sanctioned Clinical Studies. Dr. Creasman was an investigating surgeon in several of these studies. In 2006, the Food and Drug Administration lifted their 15 year restriction on the use of silicone gel implants. An implant known as the “cohesive gel” implant, which is a more dense silicone gel material, was approved by the FDA in 2012. This implant is available in various teardrop shapes and because of the greater thickness of the gel, holds its shape when upright. This provides a very natural look and better fullness in the upper breast. These implants have steadily gained in popularity among surgeons and patients.
Silicone gel implants have different characteristics than saline, some more favorable, some less. It remains clear that a more natural FEEL is achievable with a silicone gel device versus a saline device or a shaped device. Saline is not viscous like silicone so it moves around inside the pocket with more energy and this can lead to a greater tendency for the breasts to thin out over time and also for the wrinkles in the bag to be more apparent either by feel or even visually. Saline implants have about a threefold incidence of leakage as silicone gel implants. While it is obvious when saline implants leak, with silicone implants often a leakage is not obvious and there may be no symptoms whatsoever (also known as “silent rupture”). For this reason, patients requesting silicone gel implants are advised by the FDA to obtain periodic MRI (magnetic resonance imaging) of their implants to ensure that they are intact. Silicone gel implants are more expensive than saline implants. You can read more about breast implants by clicking on the following link: www.breastimplantstoday.com.
Dr. Creasman uses either smooth, round, silicone gel implants or cohesive gel shaped implants for most breast augmentations. Very few patients ask for saline implants, but in women 18-22 years of age it is the only FDA approved device. Round breast implants come in various widths and profiles (the amount they project from the chest wall – best seen when you are looking down). They are referred to as low profile, moderate profile, and high profile implants. Most patients use moderate profile implants. In very petite patients with narrow breasts who desire maximum augmentation, a high profile implant provides a means of enhancing volume without over enlarging the width of the breast. High profile implants tend to look rounder, particularly in the upper pole of the breast when looking at the side profile of the breast, and they are heavier. In women who already have a fair amount of breast tissue and wider breasts and only want a small degree of enhancement, the low profile implant may be the best choice. The figure below shows two implants of the same base width, but with the two different profiles (and of course, different volumes).
Cohesive gel (also known as form stable implants) shaped implants – commonly called the “gummy bear implant” – are filled with cohesive silicone gel and come in a larger variety of teardrop shapes, sizes, widths and projections. This allows the implant choice to be tailored specifically to your particular shape. Round implants don’t always fit every breast shape, so it is helpful to have this type of implant available. Recent studies have shown that the cohesive gel implants have a lower risk of capsular contracture, movement over time, and leakage. They are firmer to the feel compared to silicone gel implants, but are more natural feeling than saline implants. Dr. Creasman will show you samples of each. Read more about this implant:
Natrelle shaped (410) implants:
The following points address concerns frequently expressed by patients about implants:
There is absolutely no evidence that the breast implant predisposes the patient toward or in any way causes breast cancer.
Evaluation of breast tissue by clinical examination and mammograms is somewhat more difficult with an implant in place, but with special techniques is still very satisfactory.
The breast implants do not deteriorate or decompose in the body and the silastic bag does not migrate away from the local area of implantation. There is NO REASON to routinely replace an implant after a certain period of time (e.g. 10 years), though patients commonly believe this.
Assuming normal tissue and a properly performed operation, a breast that has been augmented will not sag any faster than a natural breast of the same size. This is not the case when excessively large implants are placed. They are heavier and the tissue may not support them. The assessment of your tissue characteristics is a very important part of the consultation with Dr. Creasman.
There is no interference with the function of the breast or the chest (pectoral) muscle, and permanent interference with feeling or sensibility of the nipple is unusual (5% or less).
Breast implants do not “lift” the breasts (we can’t fill them with helium!). They may fill out a loose envelope of skin which can create the illusion of lifting, but true lifting does not occur with implantation of a fluid-filled mass. If anything, breast implants add weight to the breasts, and women who have them must be more mindful of wearing a bra to keep them from sagging over time.
Once healing is complete, the patient loses a subjective awareness of the implant, and incorporates it as part of her body image quite rapidly.
The improvement produced by the implants is noticeable immediately, and there is very little swelling and bruising produced by them. However, the final appearance of the breast does not occur for several months because of the need for the tissues of the chest muscle and breast to accommodate to the size of the underlying prosthesis. In the interim, the breasts sometimes appear unnaturally high on the chest, and the skin feels tight. This is temporary and improves strikingly over the first three months. The most important thing to remember is that this is a normal and natural phenomenon and is unavoidable.
Changes continue to occur in the breast due to the presence of the implant for many months. Many patients report a perceived shrinkage of the breasts at a year following surgery. This is most likely due to the compressive effect of the mass of the implant on the breast tissue. This can be seen on mammograms, and is similar to a sponge being squeezed. There may also be a purely psychological tendency to adjust one’s personal preference about size after having undergone the procedure. There is a natural tendency to “want more of a good thing”. Though there are obvious examples of “too much of a good thing” in the media, suffice it to say that one invites problems with over enlargement (e.g. thinning out of the skin and wrinkling, stretching of the lower breast skin and bottoming out). This will be explored in greater depth during the consultation.
One of the most essential factors in achieving the goals of both the patient and the doctor is the individualization in planning and carrying out the surgery. The following represent aspects of this of which all patients should be aware:
Achieving ideal enlargement and consistency (softness) is more difficult in breasts that are extremely small and in which there has not been stretching of the skin from pregnancy or hormonal stimulation; however, in a high percentage of patients, this goal is still achievable.
A moderate amount of stretching of the breast skin and a slight amount of sagging as a result of pregnancy can be desirable since this permits greater enlargement without sacrificing softness.
Sizing breast implants is an important issue both for you and for the doctor. Most patients want to achieve a natural looking result. Trying to predict bra cup size when planning this operation is almost impossible. Any woman knows that depending on the manufacturer, style, and preferred fit, bra sizes widely vary for a given size breast. For this reason, and the fact that breast implants are not manufactured in cup sizes, we utilize a sizing method which is based on a woman’s own body measurements. Dr. Creasman worked with a start-up company to help develop one aspect of a 3D breast imaging system. The device he uses is called the Vectra machine. It involves taking a picture with a special camera that allows your torso to be viewed in 3D from any point of view, automatically measures you, analyzes your anatomy for symmetry (evenness), shows variations in how your ribs are shaped, and then can show you what various sizes and types of implants look like both in and out of clothing. Patients who have used it over the past several years find it very helpful in deciding with the doctor what size implant to use. A range of implant sizes is suggested to each patient, and ultimately size choice is up to each patient within the guidelines provided by the doctor. This is a collaborative process between you and Dr. Creasman, but the most useful advice is for each patient to follow her own anatomy rather than trying to aim for a particular bra cup size, which may or may not be achievable or appropriate. Read more about the 3D Breast Imaging here: http://www.creasman.com/4d_simulations.htm. With your consent, Dr. Creasman can forward the 3D images to you via a secure server maintained by the imaging company. This allows you to review the 3D images and simulations at home and show them to your spouse or other family/friends as you think through the process of coming to a decision about your breast augmentation.
If significant sagging of the breast has occurred (called ptosis), which is determined primarily by the position of the nipple relative to the inframammary fold, then simple enlargement of the breast with an implant will not suffice. In this case, the breast must be recontoured as well as enlarged, and this requires a different operation, which is known as a mastopexy. If this is a factor pertinent to your situation, this operation will be discussed in detail with you.
In women who have been nursing, a period of time must pass after the complete weaning of the baby from the breast. Dr. Creasman will not perform breast augmentation for AT LEAST THREE MONTHS after the last signs of milk flow. This is to avoid incising into milk producing breast tissue, which can lead to complications of a galactocoele (milk cyst), or infection, or both.
Some asymmetry (difference in size and shape) of the breasts is normal. Every attempt is made to improve or correct this asymmetry at the time of surgery, but perfection cannot be achieved. (See section on Breast Asymmetry)
Before Your Procedure
Scheduling surgery involves payment of a non-refundable deposit, as there are costs involved with preparing for your operation, and for reserving the time. A PERIOD OF AT LEAST TWO WEEKS OFF ANY MEDICATIONS CONTAINING ASPIRIN, IBUPROFEN, VITAMIN E, OR OTHER MEDICATIONS THAT COULD ADVERSELY AFFECT THE BLOOD CLOTTING MECHANISM, IS REQUIRED TO PREVENT ANY BLEEDING COMPLICATIONS. At the time surgery is scheduled, a pre-operative visit is also scheduled approximately two weeks prior to the date of the operation, and takes approximately 30 – 45 minutes. In women aged 35 and older, a baseline mammogram is recommended prior to surgery and the report faxed to Dr. Creasman. At the preoperative visit, a consent to operation is signed. The size of the implants to be used is finalized. Photographs are taken. A directed physical exam is carried out. All questions relating to the surgery are answered in detail. We will advise you which bra to purchase for your recovery.
The operation usually requires one hour of operating time and one hour of anesthetic recovery. You will have a general anesthetic. A Board-Certified Anesthesiologist provides the general anesthetic, which will give you the greatest degree of comfort during the operation. You will be completely unaware of the experience and feel absolutely no pain whatsoever. Dr. Creasman administers nerve blocks during the procedure which numbs your chest with a long lasting local anesthetic, to provide you with pain relief after surgery for several hours. At the conclusion of the procedure you will be placed into your bra.
The Recovery Period
Because of the use of sedative medications, it is absolutely essential that a responsible adult escort be available to transport the patient to and from the operation, and be available for the first 24 hours. During that time, the caretaker person will assist the patient in getting up to the bathroom, taking medications, and preparing meals. Most patients rest for the first 12 hours after surgery, but you may get up and walk around.
Dr. Creasman will generally call in the evening, between 8 – 9 pm, to check up on you. You need to anticipate some discomfort until the level of the narcotic pain medication reaches sufficient level in your bloodstream. This usually takes a double dose of the pain pills for the first two to three doses, after which a single dose is sufficient to maintain control of the pain. You may also be prescribed a non-steroidal anti-inflammatory medication that is to be taken in addition to the narcotics. Do not take any other medications unless this is cleared through our office, to avoid medication-related complications. You do not need to discontinue your birth control pills. We provide a prescription for suppositories to help fight any nausea you might have from the anesthetic. Take them only if necessary.
Activity should be restricted to no lifting, pushing, pulling or driving for 48 hours. It is not advisable to drive a motor vehicle until one is completely off narcotic pain medication and there is no restriction of upper extremity mobility. The bra is left in place until the first post-op visit, and the breasts must be kept dry. A small amount of oozing at the incision sites is to be expected. The breasts should not be manipulated in any way. One should be up and walking on the evening following surgery, and a light solid diet begun to the point of tolerance. Stretching exercises are recommended during the evening of the surgery and these will be demonstrated to you by the nursing staff.
Certain events should be reported to the office immediately: A temperature over 99.5 degrees, chills or sweats, a markedly different degree of swelling between sides, and/or increasing rather than decreasing pain.
At this point in the recovery, it is normal and expected for breast implants to ride up higher on the chest than they will ultimately rest. The skin and muscle are still tight, there is swelling from the surgery, and this all needs time to resolve. Typically, this period of settling takes 3 – 6 months, but varies from patient to patient. Here are images of a typical patient pre-operatively, at 2 days, and at three months.
Patients are seen 2 – 3 days after the operation and their bandages removed and the healing assessed. Patients are then allowed to shower and to wash their hair. Tapes on the incisions can then be gotten wet, but the incisions should not be submerged, as in a tub or pool. Most patients can resume a reasonably normal activity pattern and non-exertional type job situations within 3-5 days after surgery.
With smooth implants, massage exercises are begun at the first post-operative visit and are done with greater frequency early on to displace the implant around the generous pocket, in an attempt to prevent the body from closing down the pocket and compressing the implant. It is painful at first, but quite rapidly this becomes very tolerable, and it is essential to establish this large pocket early in order to obtain soft breasts. With shaped implants, massage exercises are not done.
Risks of Breast Augmentation
Surgery of any kind, no matter how expertly performed, involves some degree of risk and this operation is no different in that respect. Having prostheses implanted involves accepting liability that was not present prior to their implantation. Some women cannot handle any further responsibilities in their lives. If this is the case, you should not have this operation. It is not for everyone.
What are the surgical risks?
Bleeding (hematoma formation) –
Abnormal bleeding into the space around the implant can occur after surgery in about 1% of patients. If bleeding occurs in any significant amount, a return to the operating room is necessary to remove the blood and control the bleeding, since not to do so would produce an abnormal shape of the breast and increase the chance of postoperative hardening.
Infection – Because the ducts of the breast contain bacteria normally and are moved around in the process of making the pocket, all patients are given a dose of intravenous antibiotics just prior to the operation to reduce the risk of infection. The implant space and the prostheses are bathed in a potent antibiotic solution as well. Dr. Creasman uses a device called the Keller Funnel to insert the implant, which completely prevents the implant from touching the skin. The protocol has kept the risk of infection to approximately 1% or less.
Loss of nipple sensation – Most patients have some partial loss of feeling of the lower part of the breast for several months following the surgery; this is due primarily to the stretching effect of the implant on the nerves in this area. It is also not uncommon for patients to develop irritability or hypersensitivity of the nipple and areola within several weeks following the surgery; this represents regrowth of the nerves that are cut where the incision is made and usually lasts only several weeks. It is unusual for any permanent loss of sensation to occur after the surgery, but it can occur in 5-10% of patients.
Malposition of implants – Particularly in patients with existing asymmetries, adjustments to the position of the inframammary folds can be done to attempt to correct the asymmetry. This is rarely perfect, and sometimes requires revision if it is possible to improve it further.
What are the long-term risks of breast implants?
Changes in breast shape over time, e.g. sagging (ptosis) – Either with or without implants, breasts can sag. This is more common after breast feeding or marked weight loss. If your breasts droop after you have implants, you may need a breast lift to correct the drooping and you may need to change out the implants. Over enlargement increases the likelihood of stretching of the breast skin, thinning out, drooping and this may increase your risk of needing more surgery.
Capsular contracture (hardening of the breasts by the presence of scar compressing the implant) – Part of the normal healing in every patient who has breast augmentation surgery is the formation of a thin membrane of scar by the body’s immune system, which is termed a capsule. This is a normal aspect of healing, and always occurs because the implant is a foreign object. What varies is the tendency of some capsules to contract or squeeze down around the implant (like “shrink wrap”). If this occurs, the breast will feel firm and can become distorted, usually by becoming more spherical and sitting higher on the chest. It can happen on one side only. It tends to occur, when it does, earlier rather than later. It can occur to varying degrees, with the most severe form actually causing breast pain. The rates of occurrence with submuscular placement of a silicone gel implant are approximately 20% of cases, but only 9% in cohesive gel implants at 10 years after surgery.The treatment is surgical removal of the scar (capsulectomy) and replacement of the implant. The problem can re-occur, as there is no definitive cure. The tendency to develop this problem is not something that can be predicted by any available test.
Massaging round gel implants to maintain the large size of the created pocket is the only thing a patient can do which possibly reduces the incidence of this problem, and has been very successful in Dr. Creasman’s practice.
Interference with mammography – Placing an opaque object next to the breast interferes to a variable extent with the ability to mammogram the breast for breast cancer screening purposes. By placing the implant behind the muscle, the ability to displace the implant away while pulling the breast forward into the mammography machine is increased. This technique, known as the Eklund technique, has improved the ability to see most of the breast such that the presence of implants does not represent a statistically significant risk to patients of missing an early breast cancer.
Deflation – As strong as they may be, Silastic bags can and do occasionally leak their contents, which in the case of saline-filled implants is IV grade saline (the same salt water that makes up approximately 70% of our bodies). The incidence ranges between 1.5 – 2% per year if the implant is properly “over-filled”. The usual cause of saline implant deflation is scar tissue ingrowth at the fill valve site. This is unpredictable and cannot be completely prevented, but “over-filling” places more pressure on the valve and reduces the likelihood of deflation. With silicone gel implants, there is no valve, but the shell or bag can split and release the gel contents. This is an event that occurs in about 0.7% of implants per year. Since in most patients leakage of silicone is not accompanied by any symptoms, the FDA recommends periodic MRI surveillance of silicone gel implants. The current recommendation is that an MRI be obtained at 3 years after implantation, and then every two years thereafter. Unfortunately, physical examination is not reliable in detecting silent implant ruptures. Implant manufacturers provide warranty coverage for this complication, and usually pay for some of the costs of the surgical room and anesthesia for a period of ten years as well. Though a medically harmless complication, treatment of implant leakage involves going back to the operating room and re-entering the pocket through the same incision (unless it was done through the armpit) and replacing the implant. Many experienced surgeons feel that deflation is inevitable with a saline device, but there is no reason for implants to be routinely replaced if they remain intact. In the event of a deflation, you should seek treatment promptly as the collapsed implant pocket will shrink rapidly, and if a new implant is not replaced within a week or so, this may require additional surgery to correct.
Interference with breast-feeding- Though uncommon, it is possible to divide the ducts that empty the breast gland and thus interfere with lactation when the procedure is performed via the periareolarapproach. Additionally, the breasts may be too uncomfortable when engorged, and so lactation may be hindered in this way.
Visible rippling – In very thin patients with very little native breast tissue, the saline implant in particular can reveal itself with visible folds and creases. The larger the implant, the greater the likelihood of this complication. This is a much more common problem with textured implants than with smooth implants. It is also more of a problem when the implants are placed above the muscle. The implants are actually overfilled at the time of placement to distend the envelope such that this complication is mitigated, but over time as the skin thins out from the weight of the implant, this can become worse. The treatment is replacement with a silicone implant, and even this sometimes does not completely eliminate the issue.
The female breast is an important symbol of femininity and sexuality to both women and men. Having fuller breasts often enhances clothing choices. It is therefore very natural and normal that most women would desire to maintain or achieve an attractive or pleasing breast contour. What is most attractive in practically every feature of the body though, is proportion.
That some women are more generously endowed with natural breast tissue than others is also undeniable. Some women suffer a great deal of emotional frustration and anxiety because of the small size of their breasts, because of breast asymmetry, because of sagging breasts, or because of a disproportion between the size of their breasts and other body areas. It is fortunate that in recent years our society has become more enlightened and open-minded about the desirability and reasonableness of addressing dissatisfaction with breast size and contour with plastic surgery.
Many women approach this process with feelings of guilt about excessive vanity or self-indulgence. These are normal feelings and they pass after surgery as one begins to appreciate the overall value of the results. It usually takes several months to incorporate the new look as part of one’s body image. While a breast augmentation cannot solve all of life’s problems, it can increase immeasurably one’s self-image and self-confidence, and make a significant and long-lasting contribution to a person’s overall functioning and happiness. Having heard testimonials from women now in their later years who were the pioneers in breast augmentation over fifty years ago, the vast majority state they would definitely do it again.