Are all the scars that I see on the Internet when I view "lifted breasts" really necessary?
A breast lift works to raise the breast by tightening the skin of the breast, and at the same time it moves and changes the size and position of the areola. There are a few different surgical methods by which this can be done, but all such operations require scars longer and often wider than the “simple small scars” used for breast augmentation. Without the scars, it would not be possible to tighten the skin of the breast and cause the desired lift.
The number and size of the scars is actually related to the extent the breast must be lifted. Hence, a small degree of lift may be associated with a smaller scar than when a large amount of lift is needed. This is another piece of information to be learned in consultation with your plastic surgeon after your breast appearance has been carefully assessed.
How is a breast lift performed?
It’s often hard for patients to understand how a breast lift (mastopexy) can actually lift the breasts to a better position and shape. It’s also difficult for the plastic surgeon to explain this process to prospective patients. Fortunately, our “American Society of Plastic Surgeons” (ASPS) has made available a very helpful animated video that shows and explains each of the available breast lift techniques. Hopefully, you’re able to access that video.
There’s an additional ASPS web page that provides an online version of the same mastopexy information packet that is frequently distributed to patients by individual plastic surgeons. Spending some time at each of those sites should help you answer your question about how a breast lift is performed.
If all I want is the breast "look" I had in the past, why must I now consider a breast lift (mastopexy)?
We must start to answer this question by agreeing that the ideal “look” of a youthful breast (with good shape, appropriate size and location of the areola, as well as smooth, unblemished, elastic skin) cannot really be created through cosmetic breast surgery. If a patient’s breasts have “dropped” over time, it’s a known fact that relaxed and stretched breast skin was necessary to allow the breast to shift in that downward direction. This “dropped” condition, known as “ptosis,” which produces noticeable breast sagging, is one of the things that makes breasts appear less youthful and which can only be improved with a breast lift. If there has only been a small amount of breast sag, and the patient’s breast skin has fairly good elasticity (provided she is also agreeable to an increase in breast size) there may be the choice of just placing implants to “tighten” the breast and improve its position.
Very often, however, the breasts have dropped beyond the level for which implants alone will produce an attractive “look” (and breast position), and the only solution then is to add a breast lift to the surgery plan. Always, the judgment regarding “just using implants” is in the hands of your plastic surgeon who, because of training and experience, can do the necessary evaluation and determine the best procedure for the improvement you desire.
Am I a good candidate for breast augmentation?
This operation can be beneficial for women who have one or both breasts smaller in size than they would like for them to be. Prospective breast augmentation patients must meet certain criteria before they may be considered as good candidates. Some examples of patient problems that adversely affect their approval for this procedure include:
- Under Recommended Age: Patients should be over 18 years old (22 years old if they want silicone gel). There are certain situations in which this rule may be modified.
- Breasts Are Too Sagged: Significant breast sagging usually means a breast lift, with or without implants, is required for the best results.
- Poor General Health: Breast augmentation, a totally elective procedure, should only be performed on patients who are sufficiently healthy to avoid posing an unnecessary surgical risk.
- Unrealistic Expectations: Some patients expect more benefit from the breast augmentation procedure than the surgeon is able to provide. Breast implants cannot make a patient’s breasts look just like another woman’s breasts. Nor can breast implants fix a deteriorating personal relationship. If expectations such as these cannot be dispelled, such patients should not be accepted for surgery.
- Existing Breast Problems: A current breast infection, lactation from recently nursing a baby, an abnormal mammogram that warrants further study—these are but a few examples of breast problems that may, at least, cause a delay before proceeding with breast augmentation
So, if you lack whatever you consider to be adequate breast size, and you don’t fit into any of the above categories, then you certainly may be a good candidate for breast augmentation. Your next step would be to arrange a consultation with me so I too can help with that decision.
How do I decide between silicone and saline implants?
The original, widely accepted implants were silicone, which became available in the early 1960’s. Those implants consisted of a silicone rubber outer shell, which was filled with a very fluid form of silicone and are now referred to as “first generation” implants. Later, in the early 1970’s, saline filled implants came into being. These were made of a similar silicone rubber shell, but they were inflated with sterile salt water (saline) at the time of surgery.
Both of these implant types had their individual problems, for which subsequent “generations” of each type were eventually developed. Through the 1970’s, 1980’s and early 1990’s, both silicone and saline implants were in use, with frequent improvements in the design and performance for each product, but never achieving a problem free version. In 1992, the silicone implants of that time were temporarily removed from the market because of related health risk fears. From 1992 until the end of 2006, saline implants were the only style available for simple breast augmentation surgery. It wasn’t until November of 2006, that the Federal Drug Administration (FDA) became convinced regarding the safety of silicone implants (once again, having been re-tooled) and authorized them to be returned to the market for all suitable patients. This new generation of silicone implants differs significantly from all preceding generations with respect to the nature of the silicone gel within each implant. The new implant is filled with a very thick cohesive silicone gel, which is so thick that it stays safely inside the implant shell, even if the shell is punctured. Furthermore, one of these implants can even be sliced in half, and the silicone gel remains within each half. It can now be stated with a high degree of certainty that silicone implants are as safe to the body as saline implants.
That having been said, we now can better compare silicone with saline implants, knowing each product is equally safe for human use. Saline implants have certain advantages that make them a good choice for use in some patients. These advantages relate to the lower cost of saline implants (a pair of saline implants is approximately $1,000 less than a pair of silicone implants) and to the advantage of being able to fill the saline implant once it has been placed in the body. Because of this latter fact, saline implants can be placed through smaller skin incisions, and once placed, saline implants can be filled incrementally to varying size, allowing for better “fine tuning” the size than you can achieve with silicone implants (which are only available in an assortment of pre-filled, fixed sizes).
On the other hand, there are some disadvantages to saline implants when compared with silicone implants. The immediately apparent disadvantage of saline implants has to do with the manner in which they “ripple” when filled with saline and are placed within the body. This rippling effect necessitates positioning saline implants “behind” the pectoral muscle, in an effort to prevent the ripples from creating waviness of the breast skin located just above the “bra line.” This, however, does not prevent possible waviness from showing along the lower, outer surface of the breast, where there is no muscle to hide the ripples. Another disadvantage of saline implants is their possibility of spontaneously deflating. Wear and tear as well as occasional faulty fill valves, account for unexpected deflation of some of these implants each year. Fortunately, the implant manufacturers, for 10 years after surgery, pick up the cost of treating such an incident.
Now, what’s the latest about silicone implants?
We can easily grasp and squeeze one of these implants and see that it feels much more “natural” than its saline counterpart. When you come in for a consultation, you’ll get a chance to do just that. This implies that for patients having very small breasts, in which an implant is going to be more easily felt, the “natural” feel of a silicone implant would be the preferred choice. With regard to implant deflation, we already know that won’t happen with a silicone implant, because it’s filled with a thick “cohesive” silicone gel, which will not leak when punctured or even when cut in half, as illustrated in the following photograph.
Additionally, if one of these new silicone implants were to become significantly damaged by some form of trauma, requiring its replacement, the same 10-year manufacturer warranty also applies. From my standpoint, I believe the biggest advantage of silicone implants over saline implants has to do with the option of placing them in front of the pectoral muscles. My rationale for finding this to be advantageous is discussed in the next section.
How do I know what breast size to request?
For many patients, determining their desired breast size seems to be their greatest struggle. Most women seeking breast augmentation have never experienced breasts much larger than their current size, and they hope to achieve, not only a new larger breast size, but also a certain “look” they have in mind. Unfortunately there’s no option to first “try on” some of the new implants and then glance in a mirror at the appearance. A good compromise, however, has now been reached with the availability to “try on” silicon rubber breast sizers within the bra to assist in choosing a desired breast size. This process takes place during the preoperative consultation, several weeks before surgery.
At some point, it’s advisable for patients to step back a little from this dilemma and realize that it’s not really “all about” breast size. It’s truly much more about that certain breast “look” that resides solely in the mind of each and every patient. Only the patient really knows what that “look” would be for her and then must determine a way to convey that vision to her plastic surgeon. The challenge often becomes deciding whether or not breast augmentation alone will produce that “look,” even when we know implants can only be counted upon to increase breast size. The patient’s current breast shape and, to some extent, her overall body shape will play a very large part in establishing the final “look” that can be expected to occur after implant surgery.
As with many of the decisions concerning breast augmentation, this is really another good place for an open “give and take” discussion between the patient and her surgeon (and his assistants). To the extent that size plays a part in this decision, it is best to follow the advice of the medical professionals who deal with this procedure on a daily basis and whose goal is always a happy, satisfied patient.
Is there any benefit, prior to surgery, from patients providing pictures of other women’s breasts that seem to possess that desired “look”? Absolutely! That’s an excellent way to assist by graphically displaying the desired look following their breast augmentation surgery.
Is it better to have implants placed in front of or behind the muscles?
The purpose of surgeons choosing to place breast implants behind the pectoral muscles is the thought of being able to minimize implant visibility in the upper portion of the breast. This became particularly important with the use of saline-filled implants, which characteristically develop “ripples” when placed inside the body. Such implants positioned in front of the muscles frequently cause noticeable “waviness” above the bra level. It has, therefore, become customary to place most saline implants behind this muscle.
Silicone implants naturally have much less likelihood of rippling within the body, and for most patients, they can be placed in front of the muscle without experiencing visible breast waviness. In some patients, however, with negligible breast fat or even breast tissue, it may also be advantageous to position silicone implants behind the muscle. This is done in these patients to minimize visibility of the curved outline of the implant in the upper breast.
Over years of treating implant problems in patients with “behind the muscle” saline implants, I have learned that for many such patients, the implants are not tolerated well in a position behind that muscle. Repeated activity of the pectoral muscle, whose action is to pull the arm forcefully toward the side of the body, causes the implants of many of these patients to gradually shift in a downward direction and eventually come to rest at a level too low in the breast. This condition (called “bottoming out”) causes the breast to look abnormally proportioned, and surgery is then required to attempt to properly reposition the implant. This sequence of events can most often be avoided by placing implants in front of the muscle and away from the line of force of the pectoral muscle. This, in my opinion, is a valid argument to use silicone implants and to strongly consider placing them in front of the pectoral muscles.
The trend toward “subfacial” implant placement…
A further refinement in implant placement is the new concept of positioning it in front of the pectoral muscle, but behind the muscle’s surface-covering layer, called facia. This is considered a “subfacial” implant placement, which maintains some of the appearance advantage of submuscular placement but eliminates the muscle’s ability to displace the implant in a downward direction. I now routinely use a subfacial position for all those implants which I plan to place in front of the pectoral muscles.
Which of the several possible skin incisions is best for breast augmentation surgery?
When the periareolar incision heals properly, the scar becomes extremely inconspicuous.
The photograph shows the appearance of the scar after only eight weeks of healing, and by the end of a year, it will be barely visible. Even more important, though, this incision gives me, as the surgeon (trying to create the optimum result for my patient), the best perspective of the surgical area, allowing me to position the implant exactly where it should be placed and with the greatest degree of precision. Finally, I also like the periareolar incision because, when re-operation is required to correct a problem, I can carry out most required procedures, re-using that very same periareolar scar and avoid the necessity of an additional scar elsewhere on the breast. It should also be noted that the periareolar incision does NOT hurt more, does NOT interfere with nursing babies and does NOT cause a greater likelihood of having numbness after the surgery. Having stated my overall preference for the periareolar incision, I’ll now discuss the other two incisions I also use frequently.
Many patients state their preference for inframammary (located in the crease under the breast) incisions.
Their reasons are varied, but are usually result of a strong desire to not have the areola area of the breast “violated” by surgery. Also many feel the inframammary location is more hidden, because it lies behind the slight overhang of the lower margin of the breast.
Regardless of other considerations, the inframammary incision does rise to importance, from my standpoint, when a patient possesses very small areolae that severely limit the possible size of periareolar incisions that can be made along their borders. For these patients, the areolae are too small to permit passage of silicone implants and, in some cases, even saline implants. The inframammary incision in this situation is a better choice, because a sufficiently long incision for implant placement can always be created within the generous length of an inframammary crease.
The final incision I use with any frequency is the axillary (armpit) incision.
This location is suitable for patients who want to keep the incision completely off the breast, who have breasts with tight skin that will act favorably when implants are placed in this fashion and who require “behind the muscle” placement of implants (silicone implants aren’t practical with this incision because of the limited incision length). The scars created by axillary incisions are very inconspicuous.
So, as it turns out, the incision choice is a bit of a “give and take” decision that depends on the patient’s desires, the type of implant to be used and the physical characteristics of the breast. A discussion during your initial consultation will usually help with this decision.