Talking About Breast Enlargement with Dr. Saltz

San Diego Plastic Surgeon
Lori H. Saltz, M.D.

Introduction

Your decision to have your breasts augmented is, on one level, a simple one. You want larger breasts. Your reasons may be numerous or even somewhat vague. It doesn't matter. The process starts with your emotions. You've probably already started talking to your friends and searching the Internet (that's how you got to our discussion here.) Your head may be filled with opinions and conflicting information. None of it makes any difference unless you begin to look at your breasts without the emotion you normally attach to them. You need to identify the realities of your chest and breasts. Your ultimate decision always involves size, but can incorporate other issues such as asymmetries, sagging, shape or a combination of these. 

It might surprise you to know that I had my breasts augmented when I was 22 years old.  Let's just say that was more than 30 years ago! No, I don't have the same implants now, but we'll discuss that later.  When I had my surgery, the breast implants were all round, smooth and filled with silicone.  They were placed on top of the chest muscle, either through incisions around the areolas or beneath the breasts. Size was never discussed with me.  At that time, plastic surgeons (predominately male) felt they were the best judges of that.

Fortunately your choices are more numerous now but the more you look into it, the more confusing it may become. I want to help you sort through the available information so you can make the best possible decision for yourself. 

First, let me give you some background information.  I've been performing breast surgery since 1990. I have done thousands of breast procedures.  In December 2008, as I ended my nineteenth year of practice, I had performed over 2500 breast surgeries including more than 1600 first time breast augmentations. 

La Jolla Cosmetic Surgery is currently the largest user of Mentor breast implants in this country.  Mentor is the leading manufactuer of breast implants. Mentor recently invited me to partipcate in their new LEAD program (Leadership, experience and development in Breast Augmentation.) Less than 30 plastic surgeons from the largest and busiest practices in the country meet regularly to discuss all aspects of breast augmentation surgery.  I toured the plant in Dallas, TX where every step of making an implant was explained and shown to me.  I even got to make an implant myself!  I met with one of the key scientists involved in the FDA approval process.  I came away with the most current, cutting edge information on breast augmentation. 

Now let's get back to you.  My goal is to guide you through the important choices surrounding your breast augmentation decision.  I have tried to put together an explanation of all the aspects of breast augmentation that I consider part of your decision-making process. I've tried to put the information in a logcal order from the foundation up.

Every plastic surgeon you talk to will have a different opinion as to what is important and what isn't. The truth is that no one can guarantee you a perfect result. Know your options, consider them carefully and make your best decision. Chances are excellent that you will get a good result and be happy you had the procedure.

• Implant Characteristics
• Anatomical Considerations
• Surgical Considerations
• Recovery from Breast Augmentation
  
• Breast Cancer and Mammograms
• Complications
• Capsular Contractures

Implant Characteristics

Inside Fill

Silicone:

The medical use of silicone arose after World War II and quickly became the gold standard for biomedical devices because of the body's lack of reactivity to its presence. In the 1950's silicone gel was injected directly into the breast tissue with large needles. The results were disastrous. Scar tissue capsules formed throughout the breast in an attempt to isolate the silicone. The breasts frequently became hard and there was no way to remove the silicone without removing the breast tissue with it.

In 1963, the first silicone implants were developed in Texas and used with vastly improved results. Breasts were soft and natural. If complications arose, the implants could easily be removed leaving the breast tissue relatively untouched. The scar tissue could also be removed fairly easily with little breast tissue attached.

In 1992, Connie Chung ran a segment about the supposed relationship between silicone breast implants and autoimmune disorders.  This "relationship" was a consumer opinion rather than one based on proper scientific studies.  The FDA responded to these complaints and by severely restricting use of silicone breast implants until appropriate studies could be conducted.

In November of 2006, the FDA lifted most of the restrictions on silicone implants. To satisfy the very vocal dissenters, they came up with a 60-page informed consent document that must be read and signed by every breast augmentation patient. I am not aware of any other drug or medical device that requires anything close to this. Many of my colleagues and I feel that there is evidence lacking to justify some of their recommendations.

The silicone gel used to fill implants has changed in the more than forty years since it was first introduced as have the coverings (what we call shells). You may be curious about the silicone we use today. You may not realize that there are three consistencies in the current fourth generation implants.

Phase 1 implants, 1970's: The original implants had solid silicone shells and thick silicone gel inside. They were teardrop shaped and patches on the back to keep the implant in place. They were not particularly soft and 100% of the patients developed hard breasts (capsular contractures.) Now we think it was the immobility of the implant that caused the contractures.

Phase 2 implants, 1980's: Women wanted softer breasts so they removed the patches and introduced implants with thinner outer covering and more fluid like gel fill. It turned out that the thinner shells “bled” silicone into the pocket of scar tisse that surrounded the implants. Problems occured if the scar tissue tore either as the result of an accident or the surgeon squeezing the breast to break up the scar tissue. In these cases, the free silicone was forced into the surrounding tissues, where it would become imbedded and impossible to remove.In rare circumstances, the body's immune system would transport micro amounts of silicone into other parts of the body.

Phase 3 implants, 1990's: Starting in the 1990’s, manufacturers strengthened the shells, but they still “bled” silicone. The gel was similar to the phase 2 implants.

Phase 4 implants, 2000: This is what we use today. The shells are now “low bleed” (very little silicone gets through them). The gel inside is "cohesive" (stickier.) There are three consistencies, each slightly stickier than the last. In general use today, the least cohesive gel is used because it produces the softest breast. The next level is a slightly firmer gel that only comes in tear drop shapes with a textured surface. The most cohesive gel is called “form stable”  and popularly known as "gummy bears." It maintains its teardrop shape in any position. It is used in Eurpope but has not yet been approved by the FDA for use in the United States. Personally, I find them firm and less natural than what we are using now.  

Saline:

Saline filled implants became available within a few years of their silicone cousins. Early on there were problems with a high deflation rate and they fell out of favor with many surgeons. But in 1992 when silicone implants were, for the most part, removed from the market, saline implants which had been greatly improved, became the standard for breast augmentation. They, too, are soft and can give very natural looking results.

Surface: Smooth or Textured

Smooth Implants:

In the early days of breast augmentation all implants were smooth and placed in a subglandular position. The scar capsule that develops around them is highly organized. The capsular contracture rate is very high, perhaps as high as 70%. More than twenty years ago it was discovered that if smooth implants were placed beneath the pectoralis major muscles the contracture rate dropped to around 9%. The muscle only covers about half the implant and no one knows exactly why it changes the contracture rate so dramatically, but it has become the standard in breast augmentation.

Textured Implants:

The first textured implants that were used were covered with a layer of polyurethane foam. They remained very soft in most patients. Some surgeons still feel they were some of the softest breasts ever achieved with implants. As the capsule grew around them scar tissue developed within the foam in a disorganized fashion. It was felt that this disorganization prevented the contraction of the scar around the implant, keeping the breast feeling soft. When the concern about the safety of silicone arose the company that made these implants stopped manufacturing them because it was learned that the human body would breakdown the foam coating. No one had proved whether or not that presented a problem.

Other manufacturers decided to mimic the physical characteristics of the foam by texturing the silastic shell of their implants so they felt rough. The capsular contracture rate fell to somewhere between 5 and 10%, but another problem came up, that of visible rippling especially along the upper and inner aspects of the breasts. This may be due to the adherence of the capsule to the implant, which in my mind, is rather like velcro.

Shape: Round or Teardrop

Round Implants:

Round implants have been the traditional shape since the beginning of breast augmentation. As the diameter of the implant is increased the implant gets larger by the same amount in all directions. The distance the implant projects outward can also be selected. There are low or mid-profile implants that are the most commonly used in cosmetic breast augmentation and high-profile implants that are more commonly used in breast reconstruction.

In my experience I have found that the more the skin is stretched the rounder the breast will look no matter what the shape of the implant. In women with some tissue laxity who do not desire a large increase in breast size a round implant can have a very natural looking result. In a woman with no tissue laxity even a small implant will result in a rounded upper portion of the breast. Many woman are looking for just this shape.

Teardrop Implants:

Oval or teardrop implants have been tried off and on over the years with varying degrees of success. Today's versions are sometimes referred to as "anatomical" because their shape closely resembles that of a "natural" breast with a straight slanted upper portion and rounded lower portion. The more the skin is stretched the rounder the upper portion will look. I have been pleased with the appearance of the implant in very small breasted woman with tight skin who want a natural shape. In the few instances when a woman has enough breast tissue to place the implant over the muscle this implant has also given nice results.

Two recent studies took women with both shapes of implants, sat them up, took x-rays and traced the shape of the implants. There was essentially no difference in shape between the round and the teardrop implants. This is certainly compelling evidence that spending the extra money on teardrop implants will not get you a better shape. Again the relationship of the amount of tissue laxity to implant size makes the difference whichever implant you chose. 

Anatomical Considerations

Anatomical considerations for the surgeon and patient to consider include:

Skeletal Considerations:

• Shoulder Width
• Chest Wall
• Asymmetries
• Pectus Deformities
• Scoliosis

Breast Considerations:

• Size
• Laxity
• Spacing and matters of Cleavage
• Widely Spaced Breasts
• Low Breasts
• Asymmetries
• Size
• Breast Placement
• Nipple Placement
• Shape
• Shape
• Narrow Base (tubular)

Surgical Considerations

Incision Placement

Incision Placement Options

Around the Areola (peri-areolar):

These incisions are very popular with most surgeons. Your areola is the brown skin around your nipple (the part that sticks out). Typically these incision are made along the lower edge of the areola from the three to nine o'clock positions. I prefer to make them between the twelve and six o'clock positions to stay as far away from the sensory nerves that come around the side of the breast as I can. They only need to be slightly less than two inches long so that can be anywhere from a third to half the circumference of the areola.

These incisions need to be carried down through the breast tissue to reach the plane where the pocket for the implant will be made. A few, but by no means all of the breast ducts will be cut. This could theoretically impair your ability to breast feed. I hasten to add that I know of many women that have successfully breast fed after having had these incisions. If the surgery is done within a year of breast feeding milk production may occur again and the milk may leak through the incision. In this circumstance you may want to either wait, pick another incision location or take the pills that your obstetrician can provide to dry up your milk. Milk ducts also contain small amounts of bacteria that will be released in cutting through them. There are those that feel that this bacteria may increase the rate of capsular contracture. There is, as yet, no proof that this is the case, but no one will argue that this is a more invasive approach that alters, in a small way, the architecture of the breast.

These incisions usually heal very nicely into a white line along the areolar margin. I had these incisions and they healed as well as any I have seen. I have had doctors examine me and not notice them, but I know they are there and see them whenever I look in the mirror. Given the choice today, I would choose to have the incisions hidden beneath my breasts where I would not see them. I mention this only as a personal observation.

Beneath the Breast (inframammary):

These incisions are made in the fold beneath the breast. Often the fold will drop slightly after surgery from the weight of the implant and stretch of the skin so that the scar ends up just above the fold. The length is usually about two inches long. I place these incisions a little to the side of the middle of each breast where they will be the least conspicuous. This approach is the least invasive of all the possible incisions. There is only a small amount of skin and fat to go through before you are in the right place to make the pocket for the implant. The breast tissue is not affected at all. They usually heal quite nicely and are relatively inconspicuous. Given a choice today this is the incision I would choose for myself.

Under the Arm (transaxillary):

This is a popular approach for many patients because the incision is placed under the arm and not on the breast. They are my least favorite incisions for several reasons. Because the incision is away from the breast it is more difficult to see what you are doing within the pocket. One of two approaches can be used. The more common is to do much of the operation "blindly". The initial incision and dissection is done under direct vision until the edge of the pectoralis muscle is located. Then a large blunt instrument is used to push through the tissues and create the pocket. The lower edge of the muscle is forcibly torn from its attachment to the ribs. Because this can result in bleeding the pocket is often filled with cold water to constrict the blood vessels. It is more difficult to get the lower inner aspect of the pocket shaped exactly the same on both sides.

The alternative approach to this method starts the same way, but when the edge of the muscle is reached an endoscope is used with a cautery to dissect the pocket and cut through the muscle attachment to the ribs. The cautery is the instrument we use to seal off the ends of bleeding blood vessels. Most women have some sort of asymmetries or tissue characteristics that need to be dealt with that can be more difficult of even impossible to correct through a transaxillary approach. With the addition of the endoscope the incisions must be made a little longer, about two and a half inches.

These incisions often heal well, but for some time they are a nuisance to shave around and should not be covered with deodorants or anti-perspirants. In my experience it takes longer for women to feel comfortable raising their arms up over their head. Not infrequently secondary surgery must be done through a different incision resulting in more scars. 

Implant Placement: Over or Under the Muscle

Take a moment to look at the following diagram to understand the size and location of the muscles that make up your chest wall.

Notice that the pectoralis major muscle is a large fan shaped muscle. You will see that it does not cover the lower outer aspect of the chest wall. Most surgeons detach the muscle from its lower origin along the ribs when placing the implant under it. This means that only about half the implant will be covered by the muscle. The bigger the implant, the less it will be covered. The pectoralis minor muscle is much smaller and lies under the outer edge of the pectoralis major. The serratus muscle lies along the sides of your chest wall. The main sensory nerves to your breast come up between the slips of this muscle to enter the back of your breast tissue and from there the rest of your breast. Most surgeons place the implants on top of the pectoralis minor and serratus muscles, but below the pectoralis major muscles.

Implant Placement Options

Over the Muscle (subglandular) Breast Implant Placement:

Pros:

When textured implants are used the capsular contracture rate is only 5-10%. In women with a moderate amount of breast tissue (B cup or larger) this can be an excellent choice and produce very natural looking breasts that age well. The recovery is usually easier than when the implants are placed in a submuscular position. End results are usually achieved in a matter of weeks.

Cons:

The use of smooth implants in a subglandular position very frequently (up to 70%) results in capsular contracture. When textured implants are used in thinner women with small breasts rippling may be visible in the upper and inner aspects of the breasts. It is also easier to see the upper edges of the implants when they are placed over the muscle.

Under the Muscle (subpectoral) Breast Implant Placement:

Pros:

Using smooth implants under the pectoralis muscles reduces the capsular contracture rate to less than 10%. In thinner woman the added bulk of the muscle over the upper and inner aspects of the implants makes the edges less visible and the curve of the breast more natural. When textured implants are used the rippling in the areas under the muscle is usually invisible.

Cons:

The recovery is more uncomfortable for several days. The swelling takes longer to come down and for the breasts to settle. It may take several months to see the end result. When the pectoralis muscle is contracted during exercise or in some daily movements the muscle flattens the implants and pushes them outward changing the shape of the breast. Occasionally an indentation over the implant is seen along the edge of the muscle. When there is a moderate amount of breast tissue that is lax or becomes lax in time it may sag below the position of the implant which is held in place by the muscle resulting in a double bubble deformity.

Recovery from Breast Augmentation

Breast Cancer and Mammograms

Numerous studies have shown that breast implants do not cause any form of cancer in humans. They do obscure the mammogram enough that extra views will often need to be taken once you have had a breast augmentation. This does not appear to delay the diagnosis of breast cancer.

Radiologists often refer to previous mammograms to determine whether things they see are new or have remained the same since the last mammogram. They are firm in their belief that a baseline mammogram prior to any breast surgery is important. I know of very prominent plastic surgeons who require mammograms on women of any age before they will do a breast augmentation. Cancer has been found in woman as young as eighteen.

In women under thirty, I recommend they get a mammogram first, but I don't require it. In women between thirty and thirty-five, I recommend it more strongly. In woman over thirty-five or one of any age with a family history of breast cancer, I require it.

I am finding more HMO's that don't "recommend" a mammogram until forty or even fifty. This is purely a financial advantage for them. Mammograms are not particularly expensive and I have never had a radiologist refuse to do one if they know the woman is preparing to have breast augmentation. They want you to have that mammogram before surgery.

Once you get your mammogram, ask for a copy and keep it in your files. You most likely will not be going back to the same mammography center for the rest of your life. When you move, it would also be a good idea to get a copy of the last mammogram you had along with the official reading of it. The next radiologist will love you for having done so because it will make his reading more meaningful.

Complications

Bleeding:

Bleeding can occur after any surgery. In the case of breast augmentations it occurs very seldom, only about 2-3% of the patients. It is never a life-threatening problem, but it does have consequences. It is usually not subtle. One breast will rather suddenly become much larger than the other. Sometimes this occurs in a matter of half an hour or so. Occasionally a woman will notice it upon awakening in the morning. The effected breast will become painful and tense. I have never seen the incision break open or blood to come through it. At some point the pressure within the pocket will become so great that the bleeding will be slowed or stopped. Surgery is required. The incision is easily opened, the implant removed and the blood suctioned out. Usually a single vessel is found to be the culprit and easily cauterized. The pocket is irrigated with saline, the implant returned and the incision closed again. In all it takes about twenty minutes. The effected breast will be more swollen for awhile, but fairly soon it will look like the other one. Finally, there is a slightly higher chance that a capsular contracture will develop on the side that bled.

I ask my patients to take life easy for three weeks and not to exercise at all for at least two weeks. After that I allow walks and light weight lifting for the lower body. More vigorous exercise is started at three weeks. High impact and upper body activities including tennis, swimming, surfing, golfing, jogging and horseback riding must wait for at least six weeks and sometimes longer if indicated.

Mondor’s Cords:

Mondor’s Cords, sometimes called Mondor’s disease, is a benign condition that can occur two to four weeks following breast augmentation. Tender vertical cords develop beneath the breast from the inframammary fold downward. They are veins (thoracoepigastric to be exact) that have become thrombosed (clotted) and inflamed. They are not an infection. Treatment is supportive with warm, not hot soaks to the cords only and aspirin or ibuprofen as needed. They will disappear on their own within a few months. They were named after Henri Mondor (1885-1992), a famous French surgeon who originally described them.

Mondor's Chords

Capsular Contractures

It may seem odd to start a discussion of breast augmentation with an explanation of a complication. Almost every aspect of the procedure relates to this problem, so if you understand what it is now, everything else will make a little more sense.

In virtually every woman who has a breast implant, the body responds to its presence by forming a capsule of scar tissue around the implant. Like scars on the skin surface, the development of scar tissue is a process that starts within days of surgery and continues for a year or more. Most often, the presence of this scar capsule is not detectable and the breasts look and feel very natural. Sometimes, however, the capsule contracts around the implant. The breast will then feel firm to hard and in some cases the shape of the breast will be distorted.

Examples of Capsular Contractures

No one knows why the capsules surrounding the breast implants contract nor can they predict who will develop this problem. One hypothesis is that they occur because of an infectious stimulus. In spite of sterile techniques, bacteria are still present on the skin surface, in the air and within the ducts of the breast tissue. Every plastic surgeon has their own personal surgical ritual they believe lowers the chances of capsular contractures. Some are quite elaborate and others very simple. Some believe that avoiding incisions that go through the breast tissue (peri-areolar), antibacterial irrigation of the implant and the space it will rest in, oral antibiotics around the time of surgery, minimal touching of the implant and talc-free gloves reduces the incidence of capsular contracture.

Although there are studies to indicate that the rate of early capsular contractures is less, to date there are no long-term studies to show these techniques actually result in fewer capsular contractures overall. Other factors such as implant placement above or below the pectoralis muscle, saline or silicone filler, surface texture of the implant and post-operative massage seem to affect the rate of capsular contracture, as will be discussed in their respective sections. Capsular contractures are not life threatening, but they certainly don't look or feel "natural." They can be painful and distorting. If they develop, they are best dealt with surgically by excising some or all of the capsule and starting over.

The chances of developing capsular contractures again is higher once you have demonstrated the propensity to develop them. Finding the cause of capsular contractures and preventing their development has become the Holy Grail of breast augmentation surgery.

Other Complications may include:

• Dissatisfaction with Size
• Sensory Changes
• Deflation
• Rippling:
  • Visible
  • Palpable
• Bleeding
• Infection
• Mondor's Cords
• Implant Placement:
  • Implant too High
  • Implant too Low (bottoming out)
  • Implants too Far Apart
  • Implants to Close Together (synmastia)
  • Asymmetry
• Double Bubble
• Calcification Around the Implants
• Unsatisfactory Scars

Learn More

• Return to Dr. Saltz's profile
• Learn more about breast enlargement surgery
• View breast augmentation before and after photos