Breast Augmentation

Breast augmentation surgery aims to achieve larger breasts or restore their volume after weight loss or childbirth. In most cases, breast augmentation is performed using breast implants. Since the 1960s, millions of women have turned to this procedure to enhance their appearance. Today, it is the most common procedure performed in cosmetic surgery. Patient satisfaction is very high, and self-confidence increases significantly. Before the surgery, you will be asked to follow a series of instructions provided by your doctor. These instructions are very important and must be followed with the utmost care.Otherwise, the risk of complications increases. Before surgery, you should avoid aspirin and anti-inflammatory medications for at least 10 days, as these medications increase the risk of bleeding during and after surgery. If you smoke, you’ll need to quit at least one month before surgery, as nicotine slows down the healing process. It’s recommended that you purchase the medications prescribed by your doctor before surgery. When you arrive for your procedure, it is recommended that you wear loose-fitting clothing that is easy to put on. It is also a good idea to have someone (a family member or friend) drive you home afterward and stay with you for the first 24–72 hours while you recover.During the preoperative consultation(s), the choice of implant is made together with your doctor. This decision is very important and takes into account both the patient’s wishes and the doctor’s recommendations. Decisions are made regarding the type of implant, its volume, its placement, and the incision site.

3.a. Types of Implants:

1. 1. saline implants (filled with saline solution)
   2. silicone implants
   3. highly cohesive silicone gel implants

1. Saline implants

These were used exclusively in the United States from 1992 to 2006. Since 2006, silicone implants have also been used in the United States.
They can be ordered in volumes ranging from 120 cc to 850 cc, and most are filled with saline solution during surgery.
Advantages:

• They are very safe, in the sense that if they rupture, the leaking saline is rapidly absorbed by the body without any adverse reactions; furthermore, a rupture is immediately detected by a decrease in breast size
• they are less expensive than silicone implants
• they can be inserted through a smaller incision because they are filled with saline solution during surgery.

Disadvantages:

• they carry a higher risk of capsular contracture
• They carry a higher risk of visible and/or palpable folds, especially in thin patients and in those in whom the implants are placed subglandularly

2. Silicone
   Implants Advantages:

• They provide a more natural-looking breast contour because the silicone gel has a consistency very similar to that of normal breast tissue. Thus, especially when placed subpectorally, they are nearly undetectable to the untrained eye.
• Due to the higher viscosity of silicone, they have a lower risk of fold formation on the implant surface—folds that may be visible and/or palpable

Disadvantages:

• In the event of an implant rupture, it may remain undetected for a long time because the silicone, having a high viscosity, will not leak but will remain within the implant pocket, causing no other adverse effects.
• They require a longer incision than saline implants because they are pre-filled
• They are more expensive than saline implants

3. Cohesive
   silicone gel implants These implants feature a silicone shell composed of multiple layers that prevent the silicone gel from leaking, unlike traditional silicone implants; the gel also has a higher viscosity, which prevents it from leaking out if the implant ruptures.
   Advantages:

• their consistency is very similar to that of a natural breast
• very low risk of capsular contracture, which is the main cause of implant rupture
• They are very safe, in the sense that if the silicone ruptures, due to its very high viscosity, it will not leak
• they retain their shape very well over time; they are very stable
• lower risk of capsular contracture

Disadvantages:

• They require a larger incision for insertion due to the gel’s high viscosity
• They are more expensive than other types of implants

 

3.b. Implant Shape

There are two shapes of implants: round and anatomical. Round implants, when placed on a flat surface, have the shape of a flattened sphere, with the same volume at any given point. Anatomical implants are pear- or teardrop-shaped, with the greatest volume at the bottom of the implant. They give the breast a more natural shape. The advantage of round implants is that the shape of the breast does not change if the implant rotates inside the pocket. In contrast, anatomical implants carry a risk of rotation, in which case another surgical procedure is necessary. Round implants offer the possibility of a fuller cleavage, while anatomical implants provide a more natural breast shape—fuller at the bottom and flatter at the top.

 

3.c. Implant Surface Texture

The implant surface can be smooth or textured. Smooth implants have a thinner shell and feel softer to the touch; they carry a lower risk of rupture and a lower risk of palpable or visible ripples. Textured implants have a lower risk of developing capsular contracture and of rotating within the pocket, as they adhere better to the chest wall. For this reason, all anatomical implants have a textured surface. Textured implants are more expensive than smooth ones.

 

3.d. Implant Size and Volume

The implants offered by manufacturers come in a wide range of volumes, from very small (125 cc) to very large (1200 cc).
The dimensions considered when selecting an implant are its base, volume, and projection. The width of the implant’s base is important because an implant that is too wide relative to the breast’s base will make its edges visible, both laterally and medially. The implant’s volume will largely determine the cup size, and its projection determines how much the breast will protrude anteriorly. The available profiles are: low, medium, and high.
When choosing an implant, it is very important for the patient to follow the surgeon’s advice, as only the surgeon can recommend an implant that suits a specific body type. In general, smaller implants carry a lower risk of complications.

3.e. Implant Placement

Implants can be placed subglandularly or subpectorally. The decision to place an implant subpectorally or subglandularly depends on the preoperative breast size. Subglandular placement involves positioning the implant above the pectoral muscle, between the mammary gland and the muscle, while subpectoral placement involves inserting the implant beneath the muscle. Each placement has its advantages and disadvantages, and the surgeon determines the appropriate approach based on the patient’s anatomical characteristics.

The risk of capsular contracture is lower when the implant is placed subpectorally. Subpectoral placement provides a more natural appearance in the long term. Subglandular placement involves a shorter surgical time and recovery period, accompanied by less postoperative pain. The immediate postoperative appearance is more natural.

Position	Subglandular	Subpectoral
Risk of capsular contracture		Low
Recovery period	Shorter
Postoperative pain	Less
Immediately after surgery	More natural
Long-term appearance		More natural

Subglandular breast augmentation

Advantages of subglandular implant placement

1. The surgery is less invasive, as it does not require manipulation of the pectoral muscle, and in the event of revision surgery, access to the retroglandular pocket is relatively easier.
2. Postoperative pain and discomfort are reduced because the muscles are left intact; only the skin and subcutaneous tissue are incised. Recovery is therefore faster.
3. A more aesthetically pleasing cleavage is achieved.
4. Subglandular placement is recommended for athletic women in whom subpectoral placement would lead to visible deformation of the implant as the pectoral muscle contracts.

Disadvantages of subglandular implant placement

5. Especially in thin patients with little subcutaneous tissue, the edges of a subglandular implant may be visible and palpable; with subpectoral implants, the edges are much less noticeable
6. Mammography is more difficult, and the detection of potential breast cancer may be impeded.
7. The rate of capsular contracture is higher.

Subpectoral (submuscular) breast augmentation

In most cases, the pectoral muscle will cover approximately two-thirds of the implant; in such cases, the procedure is referred to as partial submuscular breast augmentation. Total or complete submuscular breast augmentation is achieved by using additional muscles to cover the implant.

Advantages of submuscular implant placement

8. The edges of the implant are less visible or not visible at all and are not palpable, giving the breast a more natural appearance;
9. Submuscular placement is particularly recommended for patients with small breasts prior to surgery
10. It does not interfere with mammography
11. Lower risk of capsular contracture

Disadvantages of submuscular implant placement

12. Longer surgical procedure
13. Greater postoperative pain
14. Longer recovery time
15. Potentially more difficult revision surgeries
16. It is more difficult to create a cleavage by bringing the breasts closer together with submuscular implant placement
17. Not recommended for women who participate in competitive sports due to the risk of deformation
18. A temporary disadvantage: the implants will sit slightly higher immediately after surgery until the pectoral muscle relaxes

The incision site for implant placement is determined by the surgeon based on the shape of the breast, as well as the shape and size of the implant.

4.a. The inframammary approach is the most commonly used today

Advantages:
– the scar is visible only when the patient is lying down; it must be located immediately above the inframammary fold, so that when the patient is standing, the scar is not visible; a scar located above or below the crease will be visible even when standing
—an important advantage of the inframammary incision is that it allows the surgeon to perform any type of revision surgery in case of complications using the same approach, so that no additional scar is needed; any other approach (periareolar or transaxillary) does not allow for this, which is why, in those cases, a revision procedure requires a new scar in the inframammary fold.
Disadvantages:
– If revision surgery is performed to change the size of the implant, the location of the scars will change; thus, if the patient decides to replace the implants with larger ones, the inframammary fold will need to be lowered, and the scar from the previous surgery will be located higher up on the breast; if the patient decides to replace the implants with smaller ones, the inframammary fold will need to be raised, and the scar will be located below it, making it more visible.

4.b. Periareolar Approach

The incision is made in the lower half of the areola at the junction of the normal skin and the darker-colored areola.
Advantages:
– the resulting scar is extremely inconspicuous and usually heals very
well– this incision is useful when a periareolar mastopexy (breast lift) is also needed, since the same incision is used for both implant placement and breast lift.
Disadvantages:
– there is a possibility of postoperative scar widening, especially when large implants are placed, resulting in a more visible scar–
there is a higher risk of infection due to direct contact between the implant and the mammary gland (the glandular ducts contain bacteria)
—there is a possibility of partial loss of areolar sensitivity—
this approach can only be used in patients whose areola is large enough to accommodate the implant

4.c. Transaxillary Approach

The incision is made directly in the armpit, from where a tunnel is created toward the breast area.
Advantages:
– there are no scars on the breast, and the axillary scar, even if it does not heal neatly, is usually hidden
. Disadvantages:
– The main disadvantage of this approach is that if the patient requires a subsequent reoperation or revision at some point in her life, the axillary scar cannot be used, so a new inframammary incision usually must be made. Statistics show that approximately 20% of patients with silicone implants require another surgery at some point in their lives.
– This method can only be used for the insertion of
small implants— the technique is more difficult, and there is a higher risk of postoperative asymmetry compared to other approaches.Regardless of whether the surgery takes place in a public or private hospital, the procedure is performed in the same way. You will be scheduled for surgery at a specific time; the procedure lasts about 1½ to 2 hours, depending on the access route and the implant placement site. Next, the surgeon will mark the area (draw the outline).

5.a. Anesthesia

In the vast majority of cases, the surgery is performed under general anesthesia, which means that the patient will not feel, see, or hear anything at all. After surgery, some patients experience a sore throat, headaches, or vomiting—symptoms that are treated with appropriate medication and are temporary. Any unusual reactions to previous anesthesia must be reported to the anesthesiologist before surgery. (!)

5.b. Incision Site

One of the goals of breast surgery is to place the incision in a location that is as inconspicuous as possible and that heals with a neat scar. Although scars fade over time, they never disappear completely, so the surgeon’s skill is crucial in this regard as well. The choice of incision placement is discussed with the patient preoperatively and is determined based on her individual anatomy as well as her preference, after all the advantages and disadvantages of each technique have been explained to her.

5.c. Implant Placement

5.d. Suturing

The quality of the resulting scar depends on the technique used, the surgeon’s experience, and the quality of the surgical suture material chosen. Absorbable sutures are typically used, which do not require subsequent removal. The incision must be kept clean until complete healing (approximately 2–3 weeks), covered with sterile dressings; the incision should not be kept in water for long periods (bathing), and activities involving physical exertion that could put tension on the edges of the wound should also be avoided. In such cases, healing is prolonged and the quality of the scar will be suboptimal.

5.e. Drains / Dressing

Many surgeons use drainage tubes to help remove blood that may accumulate in the implant pocket. Drains are usually removed within 24–48 hours.
Dressing involves covering the incisions and using adhesive strips to support the breasts. In the following days, these will be replaced by a compression bra, which must be worn for at least one month (we recommend two months). The instructions you will receive after surgery will include plenty of bed rest and limiting your movements. Any activity that involves lifting or bending the body should be avoided, as it increases pain and delays healing.

1. 1. In the first few days after surgery, it’s a good idea to have someone with you, as it will be difficult to get around on your own.
   2. It is recommended that you get out of bed as soon as possible after surgery and take short walks in the following days; try to take deep breaths as often as possible to oxygenate your lungs.
   3. Sleep with your head and shoulders elevated at a 30-degree angle (on two pillows).
   4. Take your medication as directed.
   5. On the first day, stick to a light diet; you’ll gradually resume your normal diet later
   6. Do not make wide arm movements, and do not use your arms to get out of bed or to lift yourself up. It is recommended that someone assist you.
   7. The drains will be removed 24–48 hours after surgery. They must be carefully monitored to ensure they do not become inadvertently dislodged (air entering the drain), in which case they must be replaced.
   8. You may shower 4–5 days after surgery.
   9. It is extremely important that you DO NOT SMOKE!
   10. You must wear a compression garment for at least one month after surgery (ideally two months). Avoid underwire bras for at least 6 weeks after surgery.
   11. Avoid physical exertion for 3 weeks after surgery.
   12. You may drive 5–7 days after surgery.
   13. Do not expose the scars to the sun for at least 6 months after surgery. Apply scar-healing creams, vitamins E and A, and aloe vera to the scars twice a day for at least 3 months.
   14. In the first few months, you will experience numbness in certain areas of your breasts; these sensations will gradually subside. You may also initially feel that your breasts are too large and sit too high. Over time, the swelling subsides and the muscles relax, a process that generally takes at least 6 months.
   15. If, prior to surgery, the patient is undergoing dental treatment or has an infection, the surgeon must be informed so that appropriate postoperative antibiotic therapy can be prescribed.

Patients can return to work after one week, provided their job does not involve intense physical activity. Recovery is faster and less painful for patients whose implants were placed subglandularly.

The first 24–48 hours after surgery are the most uncomfortable for patients. Pain and fatigue are common, but this depends on each patient’s pain tolerance. Pain is alleviated by the pain medication prescribed by the surgeon.

During the first few weeks, the breasts may be slightly tender. They may also remain swollen for up to 4–5 weeks . Intense physical activity can be resumed about one month after surgery. The scars will be darker and pink for a few months after surgery (2–3 months ), after which they will gradually lighten and fade, but they will never completely disappear. To help the scars become less visible, your doctor will recommend various creams or gels.
It is very important to avoid exposing the scars to the sun for the first 6–9 months. It is important to know that, regardless of the type of implant used or the surgical technique chosen, you may require additional surgeries due to possible complications. Choosing a qualified plastic surgeon to perform your surgery reduces the risk of these complications.

Capsular
Contracture A capsule is tissue that forms around the implant in response to its presence in the body. It is a normal reaction that occurs when any foreign body is introduced into our body. There are cases in which this capsule begins to contract, pressing on the implant, which can lead to breast distortion, hardening, and possible pain. The risk of developing capsular contracture is lower when textured implants are used (compared to smooth ones) and when the implant is placed under the muscle (compared to placement under the gland). In addition, hematoma and infection increase the risk of subsequent capsular contracture.
The degree of capsular contracture is measured using the Baker I–IV system. Grades III and IV require surgical intervention.

Palpable and/or visible folds of the implant
Irregularities that can be felt and/or seen on the skin are caused by folds in the implant’s shell. They occur more frequently with smooth-surfaced, saline-filled implants and in very thin patients with poorly developed muscles and little subcutaneous tissue, and even more so when the implants are placed subglandularly.

Infection
is a serious complication that can occur up to 6 weeks after surgery. Many infections can be treated with antibiotics alone, but in certain cases, the implants must be removed; they can be reinserted only after several months. Infection increases the risk of capsular contracture. Using sterile dressings on the incisions reduces the risk of infection; for this reason, bathing and swimming should be avoided until the incisions have fully healed (2–3 weeks).

Hematoma
: This is an accumulation of blood within the implant pocket. Large hematomas require drainage; otherwise, infections and capsular contractures may occur. The risk of a hematoma is reduced by the use of suction drains, but these do not eliminate the possibility of a hematoma forming. Thorough hemostasis performed by the surgeon, as well as the absence of coagulation disorders in the patient, are important for preventing this complication.

Changes in breast and nipple
sensitivity : Sensitivity may be reduced or increased and is due to stretching or damage to the nerve during surgery; it may be temporary or permanent, but most often lasts a few months, after which it gradually disappears as the nerve begins to heal.

Change in implant
position This occurs particularly with anatomical implants and requires a second surgical procedure.

Implant
rupture Both saline-filled and silicone implants can rupture. In the case of saline implants, a rupture is detected immediately because the breast will shrink rapidly. The saline is quickly absorbed by the body and does not cause any adverse reactions.
In the case of silicone implants, a rupture may go undetected for a long time because the silicone gel is thick and will flow slowly into the implant pocket. However, silicone gel is just as inert as saline and does not cause any adverse reactions.
Factors that can lead to implant rupture include:
– damage to the implant shell caused by surgical instruments (unlikely)
– friction between the implant and the edges of the incision during insertion due to an incision that is too small–
compression during a mammogram–
various traumas or
increased pressure–
severe capsular contracture– implant wear due to aging

Interference with Mammography
Research has shown that implants do not increase the risk of breast cancer nor do they interfere with the detection of potential cancer, except during a routine mammogram. Therefore, when you go for a mammogram, it is best to choose a center that specializes in performing mammograms on patients with implants. Before the mammogram, you must specify that you have implants so that the technician can use special pressure and techniques accordingly.

Breast Augmentation and Breastfeeding Breast
implants do not interfere with breastfeeding in any way. The only factor that might interfere with breastfeeding is a change in sensitivity in the nipple and areola (which is usually temporary); in such cases, breastfeeding may become uncomfortable. Implants inserted through an areolar incision increase the risk of changes in nipple sensitivity.

Furthermore, there is no evidence that silicone from the implant could leak into the milk produced by the mammary gland. Silicone molecules are too large to pass into the milk ducts (assuming there were a silicone leak, which is highly unlikely). Unlike complications, side effects are normal reactions that should be expected.

Implant
Settlement In the first few weeks after surgery, the breasts may appear unnatural (too high, too tight, too round). This is because the pectoral muscle and the skin need time to adjust and relax with the implant in place.

Swelling
Swelling occurs with any surgical procedure, and breast augmentation is no exception. The breasts may appear more swollen, larger, or heavier. A support bra helps reduce the sensation of heaviness and provides support for the breasts.

Bruising
Bruising may or may not occur, but it usually disappears in about 14 days.

Changes in Areola/Nipple
Sensitivity These changes may last several months, but in a small percentage of cases, they may be permanent.

Pain
Patients describe the pain as mild to moderate, but it is managed with medication. It gradually subsides as the skin and muscles relax.

Itching
: This may occur due to the stretching of the skin under the implant.