Breast Augmentation: Dreams Come True

Augmentation is a peculiar wish fulfillment. It isn't often that a dream you've had for years comes true while you sleep. It may seem strange that you can change your body shape so successfully, hard to imagine that your body can accept so much bulk almost instantly. But it can, and does. It is accepted not just as a new addition, but as the way you always imagined your body, a dream come true.

Breast Augmentation has nicely paralleled my career in plastic surgery. Breast implants were developed in Houston in 1963 by Dr. Frank Gerow and Dr. Thomas Cronin. That was the year that I entered medical school. After internship and a general surgery residency in Hartford, Connecticut I went to Houston for a Plastic Surgery Residency with Dr. Cronin.

A lot was going on in the 1960's. Gerow and Cronin developed breast implants during the Cuban missile crisis, as Betty Freidan was publishing The Feminine Mystique. It was a very different time, before the widespread physical fitness and body image concerns we now take for granted. Mansfield and Loren Trends in Plastic Surgery follow the trends in the country. If asked to describe a really good looking nose in 1960, you might talk about Marilyn Monroe. Twenty years later it would be Princess Diana. Jayne Mansfield was not only in the news in 1963, but also in Playboy: early interest in augmentation in Texas was for Mansfield-sized implants. These days, more women request a natural look. I have found that women always know what they want: this is especially true when it comes to breast size. The challenge is being able to understand when they explain what they want. Breasts are a complex shape and difficult to describe: some women bring in photos, or scour the internet for their favorite breasts. Most women start out discussing breast size in terms of bra size, but bra sizes depend upon the maker and the chest circumference. A Bali bra is not the same size as Victoria's Secret bra, and a 36C is a different volume than a 40C.

Over the years I have had the best success in determining the desired size by direct trial, and base size by direct measurement. When women come to my office for a consultation, I ask them to bring a bra that is the size they'd like to wear. The best sort of bra is an underwire, with a cup that is smooth and not too stretchy. If you are in doubt as to the size bring them all--leave the tags on and return ones you're not going to keep after surgery. We will tuck implants into your bra, increasing your breast volume in front of some well-lit mirrors, to let you decide what the best size is for you. Eventually, we'll find a size that's "too big," a size that's "too small," and the size you've always imagined. This is especially helpful in cases of asymmetry, when one implant size may be very different from the other.

The next step is to determine the base size by direct measurement. We measure the base diameter of the breast, so we'll know exactly where to place the implant: we want the implant to fit the chest wall, extending symmetrically beneath the nipple, with the nipple at the center. As the breast is made larger, the fullness extends above the nipple, producing a fullness that some women find attractive and others feel is unnatural. The nipple should remain central to the breast mound: this can often be achieved by careful attention to detail as the implant diameter and volume are selected. On occasion the inframammary crease is lowered as the diameter of the base is increased. The breast diameter affects this crease and lateral breast fullness as well, producing some of the curves of the curvaceous figure. It should be possible to find the implant size and shape that is right for you at the initial consultation; however, once you've seen yourself in all those different bra sizes, your ideas about breast size may change, or become clearer to you. It is not too unusual for women to call us the next day, arranging to come back for a second look.

One of my favorite patients spent a long time trying on one size after another with several bras of different size and brands. Finally she stopped and said "Forget natural, let's go for big." It is much easier to determine what you would like by looking at it rather than trying to visualize from photos what is essentially a three dimensional problem.

Once you have determined the right size, think about the implant material. Both silicone gel implants and saline-filled implants are now available. Neither of these implants can be expected to be trouble free for a lifetime. Implants may develop firmness, malposition, or rupture and will need to be replaced at some time in the future. The odds of problems developing are about 10% per year. If problems don't occur in the first, second or third years, the fourth fifth or sixth years or the seventh, eighth or ninth years, then they are likely to occur in the next few years.

Firmness is caused by a tight scar around the breast implant. A fibrous tissue scar always forms, but it may be thin and filmy or thick and tough. If firmness occurs with saline implants, most implants soften with exercise. Start out with jogging and a jump rope and you are likely to notice the firm troublesome implants soften as your endurance increases. I have patients who have seasonal firmness with the saline implants, as they are joggers only in the cool months and are less active in the heat. Gel implants are more apt to become firm and less likely to improve without implant replacement.

Malposition occurs when the implant is not where you wish. The implant may stay in the right spot, but the breast droops over the implant. This is often the case in a woman who has an implant, then multiple pregnancies. As her breasts sag, the implants stay in the same spot and the breast develops a "Snoopy nose" deformity. When this occurs the treatment is a mastopexy, or breast lift, which elevates the nipple to a location central to the breast and may reshape or re-drape the breast as well. Not infrequently this ptosis, or drooping, is present at the time of the initial request for breast enlargement, so a mastopexy may be suggested at the time of augmentation.

Rupture is easily diagnosed with saline-filled implants. They develop a leak, go flat, and the next morning the patient calls to get the flat fixed. However, it is very difficult to determine if silicone gel implants have ruptured. They don't go flat and they don't feel ruptured as the gel is contained by the fibrous tissue scar that forms around the implant. Even if the gel leaks out of the implant it is held in the same shape by the scar until a rent occurs in the fibrous capsule surrounding the implant. The leaked gel then extrudes into the surrounding tissues, causing a lump. With this silent leak in mind, magnetic resonance imaging or MRI's are currently recommended at three years, then every other year thereafter to follow gel-filled implants This is an expensive follow up test, currently $2100 for the MRI and $320 for the radiology interpretation each time that it is done.

In my practice, saline-filled silicone implants have been used from 1992 until the recent present. Silicone gel implants were used prior to 1992, but then were not available in the 1992-2006 interval. Many patients with gel implants who needed replacement implants during this time received saline-filled implants, and so had experience with both types. I expected these women to complain about the different "feel" of the saline implants, but I was pleasantly surprised. They were almost uniformly pleased at the warmer feel of the implants. The saline implants are warmer on a cold day and more apt to reveal a ripple or wrinkle than the silicone gel implants, especially if placed above the muscle. Gel implants are a heat sink and just as your marble top table feels cooler than the wooden table top the gel implants have a cool feel. The gel implants are less likely to have problems with ripples but are more likely to develop firmness.

Breast implants may be placed beneath the pectoral muscle, often with division of the muscle inferiorly and medially so that the upper pole of the breast is covered by muscle. This is often the choice when the patient is slender and has a small amount of breast tissue. Implants may also be placed beneath the breast tissue but on top of the muscle in a sub glandular placement. This may be recommended when the cover is thicker with breast and adipose tissue concealing the implant margins.

A variety of incisions may be used to position the implants. Inframammary incisions are beneath the breast, hidden in the inframammary crease. Axillary incisions, in the armpit, may be utilized for sub-pectoral implants. Periareolar incisions are placed at the juncture of the edge of the areola and the skin and are hidden by the change in color at this location. Each of these incisions has advantages and disadvantages. The axillary incision was nicely concealed until the general public became more sophisticated and aware that a scar in the armpit was a tip off to a breast augmentation. The periareolar incision is hidden on most occasions but is visible when the nipple is the center of attention. The inframammary incision is covered by most outfits and has the advantage of being remote from the nipple, always a landmark that is a center of interest. It is well hidden in shadow with overhead lighting and is perhaps the most direct access to the placement of the implants, allowing careful placement and positioning.

Lots of options and decisions, but the options are all good ones for the right individual and should be made on a individual basis. This decision and procedure is all about you. If this is your dream it can come true.

Asheville Plastic Surgery's Dr. James McDonough discusses breast augmentation.

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