Breast enlargement, or augmentation, enhances the body contour of a woman who is unhappy with her breast size. It may also be used to correct volume loss after pregnancy, or to help balance breast size asymmetries, as well as a reconstructive technique following other breast surgery. An implant (Silicone) is placed through an incision, under the breast tissue or under the muscle. The incision can be made under the breast, around the nipple or in the armpit. It generally takes one to two hours to complete the entire procedure. The outer surface may be smooth or textured, and implants come in various shapes to meet the individual woman’s needs.
While breast augmentation will enlarge the breasts, it will not alter basic defects in breast shape or form. Major asymmetries may be improved, but will not be completely corrected. A slight difference in the size or shape of the two breasts is considered normal and should not be a cause for concern. If breast size or nipple position asymmetries are severe then additional procedures to further improve symmetry may be necessary. Long experience with this operation has demonstrated it to have highly satisfactory results for the majority of patients who are considered suitable candidates for the surgery.
There are several ways in which the patient can help determine their desired size. During your consultation and pre operative visits to our office, Dr. Copty will help you determine the implant size by placing actual filled implants of various sizes in special surgical bras to help estimate the size you desire. You may want to bring different shirts to see how your new look appears in different clothing. We also recommend that our patients purchase a soft non-padded bra in the approximate cup size that they believed they would like to achieve. Padding the bra by using baggies filled with bird seed or rice to estimate the approximate additional volume they desire can help estimate the size implant that would be required to achieve their desired result. The final decision, of course, will be made during the time of surgery, based upon the patient’s desires, as well as which implant seems to look and fit best. In some cases, this could result in the breast being augmented slightly more or less than the patient had anticipated.
The breast normally covers a muscle on the chest wall called the pectoralis muscle. Breast implants can be placed above or below this muscle. When implants are placed below the muscle, it is called a submuscular placement or a subpectoral placement. When the implant is placed above the muscle, it is called a subglandular or submammary placement, meaning that it’s below the mammary gland.
Rippling following breast augmentation is a common problem with saline filled implants in women with only a small amount of natural soft tissue padding as previously described. This is often the case in women who have nursed children and lost breast substance known as post partum atrophy. A good way to minimize this problem is to place the implants beneath the muscle. While this technique adds to the postoperative pain, it typically does not lead to any long-term decrease in muscle function. At our facility, submuscular augmentation is preferred by most of our patients.
A possible advantage of submuscular placement is that it may allow better mammography. It is generally felt that there is less chance of missing a lesion on mammography when the implant is below the muscle. The pectoralis muscle tends to hold the implant against the chest wall during mammography. Another advantage of submuscular placement is that the implant is entirely beneath the breast tissue, decreasing the possibility of interference with breast function.
It is also felt that submuscular implants are less likely to develop firmness (capsular contracture). This may be the result of pressure or internal message of the muscle around the implant and its associated scar tissue (capsule). While this has not been definitively proven, it is our feeling that patients have less capsular contracture when implants are placed in the submuscular position.
Disadvantages of submuscular implant placement include a more painful recovery than the subglandular approach and longer healing times. Although soreness is typically somewhat more that for submammary implants, the increase in discomfort is not long term and most patients feel back to near normal in 2 weeks. The most severe pain last for one week on average. We tell our patients to avoid lifting anything over 5 kilograms the first week and 10 kilograms the second week. Patients should also avoid raising their elbows above shoulder level the first 10 days. Over use of the arms and pectoralis muscles can cause the submuscular implant to ‘ride up’ initially. And, submuscular implant position does require more time to settle than submammary implants. Slight flattening beneath the breast should be expected initially. This requires one to two months on average for the breast tissue to stretch and soften in order for the breast to ‘round out’ in the lower half.
There are several ways in which the breast implant can be inserted. An incision can be made under the breast (inframammary), in the armpit (transaxillary), or around the bottom of the areola (periareolar). Dr. Copty offers all of the three incision choices.
The periareolar incision is made in a semicircular fashion around the lower half of the areola approximately 4-5 centimeters in length. When placing implants above the muscle, we often make the incision around the areola. Although this technique is somewhat more difficult, it offers the major advantage of a smaller and much less noticeable scar. It also offers additional advantages of keeping the incision far away from the implant and allowing good surgical exposure of the entire pocket. The incision may have a slightly higher risk of more sensory compromise to the nipple/areolar complex compared the transaxillary incision, but remains an excellent incision option. If a simultaneous breast lift is required this incision is often used since there will likely be nearby incisions that are already going around the areola
Dr. Copty likes the transaxillary incision because it offers several advantages. The incision is approximately 4 centimeters in length placed high in the armpit. The incision usually heals very well leaving no visible scar on the breast itself. Because of its distance from the breast, an endoscope can be used for direct vision dissection and much better visualization of all muscle, nerves and vessels.
Since blood around the implant can organize and eventually lead to thickened scar tissue, it is important to perform the surgery in as bloodless a field as possible. The use of endoscopic surgery has allowed us to carry out breast augmentation with more precision and less bleeding. Special instruments designed for this purpose allow us to work through very small incisions, monitoring the operation on a video screen. The dissection is performed under close observation using an endoscopic telescope with a built in video camera to project the inside of the pocket on a large operating room screen. The pocket is then tailored under direct vision rather than the traditional blind dissection. The improvement is obvious since it is always better to see clearly what one is cutting.
Full activity is resumed within two or three weeks but no vigorous bouncing type activities (jogging or horseback riding) is recommended for 6 weeks. Although the breasts usually look good almost immediately after surgery, there is an improvement in the shape over the following several months.
- Hospital or in-office procedure?
- Recovery time (home rest)?
- Incision and Scar?
- Operation time?
- Discharge from hospital?
Hospital or in-office procedure?
Recovery time (home rest)?
Incision and Scar?
Patient choice: Armpit incision, under the breast or areola-nipple incision.
Discharge from hospital?
Same day of surgery.
- Breast Procedures