Breast Augmentation

COSMETIC SURGERY OF BREASTS

The development of breasts is one of the first outward signs of transition from girlhood to womenhood. The breasts symbolize sexual attraction and are means of nurturing children. It is no wonder they are a focal point of attention for both women and men.

Women want to alter the shape and size on their breasts for many reasons and should tell their physician what they desire before embarking on surgical procedures. Physicians should clear up any misconceptions about the surgery and its effect on body image and ensure that there are no unrealistic expectations about what the surgery can do.

The reasons for a breast change play an important role in whether or not the outcome will be satisfactory. It is unrealistic to expect a breast change to maintain or establish an interpersonal relationship, obtain a job promotion, save marriage, or change of a lover’s behavior. There is no such thing as an emergency breast change .The decision to change the breasts should be self motivated. The surgeries which are undertaken to improve breasts are basically meant for three kind of problems.

· Small Breasts

· Large Breasts

· Drooping Breasts



SMALL BREASTS

The cosmetic surgery which corrects small breasts is called Augmentation Mammoplasty. Women typically seek breasts enlargement to improve their self image to look better both in & out of clothing.

Lack or loss of breast volume could be due to underdevelopment of breasts weight loss, post pregnancy or breast feeding.

Breast enlargement is achieved with the help of a pair of implants instead underneath the breasts. This is a daycare procedure and does not require any hospitalization on most of the cases.
Before
After

 

Implant Selection:
Size: Size is determined by the woman’s desires and the surgical possibilities. The size of the pocket in which the implant is placed is determined by the size of the breast and chest wall. The implant must fit comfortably into the pocket. An oversized implant is not stuffed into a small pocket and a small implant is not placed into a large pocket. The implant must it the breast. This will normally create a breast in keeping with the patient’s build and chest wall size. Women who request breast size larger than average will require exceptionally large pockets fashioned under the muscle with subsequent insertion of an oversized implant. The result may not be very attractive.

Type: Basically there are two kind of implant available for breast augmentation.

 · Silicone gel Implants.

· Saline filled implants.

Silicone gel implants
Until recently most physicians used silastic-silicone gel implants, which are made of a silicone gel encased in a bag made of a silicone elastomer. At a molecular level the bag is distinguished from the gel by the amount of cross-linked molecules. The bag has more of these molecules giving it a rubber like texure. The purpose of the bag is to prevent the silicone gel from coming into contact with the breast tissue, however, it does not provide a complete seal resulting in microscopic leakage. This leaves a slight film of gel on the outer surface of the implant known as a silicone bleed. In the newer generation of implants, the amount of silicone bleed has been significantly reduced by increasing the thickness of the bag. There are some question, however, as to whether the bag itself also sheds silicone into the body over time as it gradually deteriorates.

It has been suggested that the introduction of silicone into the body may play a role in human adjuvant disease (HAD), which is implicated in such conditions as rheumatoid arthritis, systemic lupus erythematosus, dermatomysosities, polymyositis, and perhaps even chronic fatigue syndrome. At present a definitive causal relationship has not been established and the current data would suggest that there is no relationship. However, as with all statistics, the data can be interpreted to either support or refute the claims that silicone contributes to HAD and hence the controversy.


Saline filled implants
Saline implants are currently the most popular alternative. A saline implant is made of a salt and water solution encased in a bag made of silicone elastomer. These implants are not as popular because they do not look or feel as natural as the silicone gel implants. The saline can also leak through the silastic bag but is not implicated in the HAD controversy because the salt water is simply absorbed into the body. The only concern with the leak is that the implant may decrease in size over time. The question of the shedding of silicone from the bag remains. Because the amount is so microscopic over a long period if time, the risk is considered to be very low.

However, the situation is being carefully monitored by the medical profession and the regulatory bodies for any adverse effects.

 

Implant Placement
The implant may be placed under the breast tissue (subglandular augmentation mammoplasty) or under the muscle (submuscular augmentation mammoplasty). The Submuscular technique involves the insertion of an implant into a pocket created under the muscle over which the breast sits and has been the preferred technique for a number of years. The submuscular technique had been more popular in the past because the breasts look and feel more natural, have natural cleavage and the incidence of subsequent breast hardening is dramatically reduced as compared to the subglandular approach with the use of smooth surfaced implants

The submuscular implant however, has drawbacks as well. There tends to be more discomfort immediately after the surgery. On contraction of the chest wall muscle (pectoralis major), the implant underneath the muscle is squeezed flat and pushed sideways. Some women find this unattractive. Submuscular implants affect the performance of such athletes as competitive swimmers and professional weight trainers, who depend on the pectoralis major muscle. Some muscular placement also gives unnatural feeling while swimming as the breasts float separately from the implant.

More recently the use of textured surface implants as reduced the chances of contracture formation even with subglandular placement of implant. So this technique has again come in popular demand as the subglandular approach gives better feel of the augmented breasts.

Procedure:

The incision for breast enlargement may be made in the inframammary fold under the breast where it attaches to the chest wall, around the nipple (known medically as peri-aeolar), from the outer edge of the armpit (the transaxillary approach) or directly across the nipple areola. The most common incision is a cut 4 centimeters (1⅟₂ inches) in length along the inframammary fold. This makes it easy to create the implant pocket under the muscle, does not disturb the breast tissue too much, and the resulting scar is inconspicuous. The transumbilical (TUBA) technique places the incision in the umbilicus or belly button. The pocket for the implant is created through an endoscope and the silicone bag is out in place. The saline solution is pumped into the bag to achieve the desired size and shape.

Once the implant is in place the incision is usually closed with absorbable sutures and skin tapes. It is then covered with a light dressing, and a soft elastic bra is placed over the breasts.

Augmentation of both breasts take approximately one hour. The patient returns home in the evening of the day of surgery and should be accompanied by an attended (driving is not allowed on the day of surgery). Some cases are kept overnight in the hospital, for closer post operative monitoring, and discharged the following day.

· Post Operative Pain:
Some discomfort may be experienced over the breast and the front of the armpit for approximately 3or 4 days. This discomfort gradually subsides. By the seventh day most discomfort disappears, although occasional shooting pains may be felt in the breast area. This might occur for up to 6 months following surgery but the frequency gradually decreases as the breasts heal.

· Potential Problems
All the surgery has potential complications. The degree of risk must be weighed with the desired outcome. A breast augmentation can cause the following problems.

· Breast Hematoma:
When blood collects in the implant pocket it is called a hematoma. One or both breasts swell and marked pain and tightness is felt as well. Any suspicion of a hematoma, even if small, should be investigated by the surgeon. If a hematoma is present, the pocket of the breast is reopened and the blood is drained. As drainage occurs the breast becomes soft again. If a hematoma remains untreated, a capsular contracture that hardens the breast will almost invariably occur.

· Capsular Contracture:
When a layer of fibrous tissue surrounds or encapsulates the implant it is called capsular contracture. Occasionally, excess scar tissue develops around the implant resulting in a hard, often tender breast. This may progress to the point where breast asymmetry occurs, necessitating a second operation through the same incision to remove the fibrous tissue. With the advent of submuscular augmentation, the incidence of capsular contracture has markedly decreased approximately 1 in 20 women (5%) will develop a firm breast capsule. The exact cause of breast capsular contracture is unknown.

With submuscular breast enlargements, most breasts that are softat 6 weeks remain that way, although a delayed fibrous contracture may develop in the odd case. This is most likely due to an unrecognized hematoma in one breast causing an increased amount of scarring around one of the implants. To re-establish breast symmetry, surgical correction is necessary.

· Decreased Breast sensation :
It is common to notice a change or decrease in breast sensation for the first 3 to 6 weeks following surgery. Usually, normal sensation returns. Approximately 1% of women, however, will gave a permanent change in nipple sensation. This is usually caused by damage to the nerves of the nipple, which could be due to surgical injury or compression by the impact or scar tissue.

· Infection:
This is such a rare complication of breast surgery that most surgeon do not place their patient on pre-or post operative antibiotics. It is possible that a low grade infection around the implant is responsible for capsular contractures, but this has not been scientifically confirmed.

Some individuals mistakenly associate the above complications as signs of human adjuvant disease (HAD). This is not the case. These are localized problems related to the surgery and unrelated to immune system.

FAQs:

· How much bigger will the breast be?
Most women increase one or two breast sizes; that is from a 34A to a 34B or C or from a 36A to a 36B or C. A larger breast may be made if so desired.


· How soon after surgery may activity be resumed?
Normal activity is possible soon after a breast augmentation provided it does not cause discomfort and pain.

Strenuous activities should be avoided. Patients who do not heed this warning experience much more discomfort and run the risk of developing a hematoma in the implant pocket. A gradual buildup to a full range of activities, such as aerobics, jogging, and swimming, may take place over a 6 week period.

Women who lift weights should avoid pectoral curls or other exercises using the pectoral muscles, as this may tear the scar tissue which forms around the pocket after the incision heals. Vigorous stress on these muscles may cause of the muscles to tear, resulting in capsular contratures.

A car may be driven the day following surgery, although a standard shift is often uncomfortable to use. There is no restriction on flying.


· Is breast-feeding still possible?
Both submuscular and subglandular breast implants are behind the breast tissue, which means they are out of the way of the breast’s most important function, that of nurturing a baby. The breast responds to pregnancy induced hormones and enlarges and produces milk. With the increased volume and stretching of the breast during pregnancy, some loss of breast posture may occur, just as it does in the breast which is not augmented.


· How long the implant remain in the body?
The implant is medically inert and remains intact for longer than human tissue. The breasts continue to age, with a gradual loss of tone. The scar tissue around the implant, in fact, may actually act as an internal bra, providing some support to the breast. These days the recommendation from the manufacturers is to change the implant every 10 years.

· What can be done about hard and unattractive implants?
Closed capsulotomy , which is non-surgical method is an outdated procedure these day as the implant rupture rate was unacceptably high.

The only treatment now a days is open capsulotomy. Here the implant is removed through the incision of the original surgery. The scar tissue that has enclosed or encapsulated the implant is opened and partially removed. The implant is then reinserted.

 

· Do breast implants cause Cancer?
Currently there is no scientific evidence to suggest that the incidence of cancer increased with the introduction of implants into the breasts.


· Will it still be possible to detect cancer after an augmentation?
Breast augmentation does not increase or decrease the incidence of breast cancer. In the case of subglandular implant, some breast tissue atrophy and thinning occurs from compression of the implant on the breast substance. This makes detection of masses or cancer on standard mammagraphy techniques must be used. With submuscular implants, there is a minimal amount of thinning of the breast tissue. Therefore, concern over cancer detection using standard mammography is less of a problem. Another advantage of submuscular augmentation is that a breast biopsy may be performed without disturbing the implant is often damaged during a biopsy due to its more superficial location.



· Will an augmentation rid the breast of stretch marks?
Stretch marks cannot be eliminated by enlarging the breast, although they often appear less noticeable because the stretch marks are flattened over the larger breast mound.



· What are the alternatives to surgery?
The only alternative is to wear a padded bra. Exercise will not increase the breast size itself. The muscle beneath the breast will enlarge with certain types of exercises which, in effect, increases breast projection but not breast size. Any other external techniques to increase the breast size as is advertised do not offer any effective solution and are highly misleading.



LARGE BREASTS
Unlike augmentation which is done purely for cosmetic reasons. Breasts reduction is performed because of frequent functional problems which neck shoulder and back discomfort poor posture and rashes under the breasts.

Large, pendulous breasts are often unattractive because gravity causes them to lose their shape and the nipples are lowered. It is also difficult to find clothes and bras that fit and to enjoy physical activity. Beyond these physical problems, psychological stress may be suffered, due to the attention large breast attract.

 


PROCEDURE

A variety of techniques are available to reduce breast size. The Specific technique varies from surgeon to surgeon and depends on breast size and shape, the patient’s age and associated medical problems, and the results desired. The essential steps are as follows:

· A keyhole incision is made around the nipple and down to the inframammary fold. With most techniques the incision extends along the inframammary fold to leave an inverted " T" shaped scar pattern. The nipple areolar complex and its underlying breast tissue with the accompanying blood supply and nerves are preserved in order to maintain sensation and circulation to the nipple.

· Excess breast tissue and skin within the incision is then removed and in some cases fat is sucked out using a liposuction technique. The nippleareolar complex is raised to the planned height, and the incisions are closed.

· Drainage tunes are usually inserted into both breasts. This enables any accumulated fluid or blood to drain into the dressing. The drainage tubes are removed and the dressings changed 48 hours after surgery. Normally, the incisions heal within two weeks, and no further dressings are necessary. Women who smoke, however, tend top heal more slowly, particularly at the juncture of the inverted "T". This is due to the constriction of the small blood vessels within the skin caused by the nicotine, as well as a reduced blood supply caused by the incision and the tension exerted upon the breast skin at the point of closure. Women are cautioned not to smoke for ideally 5 months but minimally 2 days prior to surgery and a week or 2 following surgery.



Possible Complications

The following are the potential problems that, may occur after breast reduction.

· Scarring: Troublesome scars can be cosmetically improved by injecting cortisone into the scar to flatten it, using the vascular lasers to remove residual redness, the pigment removal lasers to treat hyper-pigmentation and the carbon-dioxide laser to resurface uneven lumps and bumps. If the scar is dramatically white or the nipple has abnormal appearance color can be implanted into the tissue using medical tattooing techniques.

· Hematoma: A hematoma is a collection of blood. A sudden increase in swelling, pain, and tightness in one or both breasts is an indication that there is hematoma within the breast. The drainage tubes put in place after surgery remove small amounts of blood and serum but do not prevent hematomas; they must be surgically drained. It is important to realize that hematomas are a potential complication of most types of surgery and are not a reflection of the quality of the surgery. Rather, the early recognition and appropriate treatment of the hematoma is an indication of a surgeon’s skill.

· Nipple Complication : Loss of sensation in the nipple is rare and unpredictable. Women with large breasts often have poorer sensation in the nipple area than do women with smaller breasts. Therefore, the potential sensory loss in women requesting a reduction mammoplasty does not seem to be as critical as for women requesting breast augmentation.

The inability to breast-feed is a potential problem as well, and occurs in approximately 50% of cases. There is also a risk, although rare, that the nipple and areolar complex will die due to insufficient blood adjacent breast tissue. This occurs more often in older women, smokers, and women who have diseases such as diabetes or high blood pressure than in other people. This condition is usually recognized at the time of surgery because the nipple and areolar complex turns white or dark blue indicating circulation problems. When this occurs during the operation, the nipple and areolar complex is usually removed and placed on as a graft. If the problem arises after surgery is complete, the nipple and areolar complex, along with the underlying tissue, will die, and the healing process will be prolonged. Over a period of 3 months the dead tissue is removed by the surgeon, while the breast slowly heals. When the site has completely healed, a nipple reconstruction may be considered. Permanent coloration (medical tattooing) of the areola can be helpful in creating a natural appearance of the nipple, in these cases.

· Fat Necrosis: An area of fat that has died as a result of poor blood supply is called fat necrosis. It is characterized by a firm, hard lump in the breast and often some redness of the overlying skin. The body temperature usually increases for a few days mimicking an infection. If the necrosis is small, it usually resolves spontaneously over a period of weeks. If the affected area is larger it may require surgical removal of the dead fat, which could result in size asymmetry when healing is complete.

· Infection: Infection rarely occurs in breast reductions and, therefore, antibiotics are not usually prescribed as a precautionary measure after surgery.

Anesthesia:
All cases of Breast reductions are performed under general anesthesia and are to be hospitlised for 2-3 nights.


FAQs:

· Will there be a scar?
Any surgical procedure that involves the cutting of tissue leaves a scar. The way the incision heals and the scar forms is genetically determined. Therefore, some women end up with fine, barely visible white lines, whereas others have more obvious scars. Normally, however, the scars fade to white lines which look similar to stretch marks within 12 to 18 months.


· Does it hurts?
Breasts do not have many nerves, so most discomfort is experienced at the incisions. Moderate discomfort for the first few days after surgery is normal, and painkillers are provided. The discomfort gradually subsides as bruising and swelling decrease.


· How soon after surgery can normal activity be resumed?
A normal level of activity can be resumed within one week, depending on the discomfort. Normally, a return to work is possible after 1 to 2 weeks. Heavy lifting or any activity that causes discomfort should be avoided for 6 weeks. As the discomfort subsides, the level of activity may be increased.


· At what age should a breast reduction be performed?
Breast reduction can be performed in girls as young as 12 (who may have a condition known as massive gigantomastia). Women in their sixties and seventies also are candidates.


· What about breast cancer or fibrocystic disease?
The risk of developing breast cancer is the same after a breast reduction as before the surgery. But breast reduction surgery changes the appearance of the breast on mammography. Therefore, if the fibrocystic disease is being followed by serial mammography, a repeat mammogram will be required 6 months after a reduction to establish a new baseline.


· Will breast reduction get rid of stretch marks?
Stretch marks on the skin that was surgically removed will be gone. The remaining stretch marks are flattened out because the skin over the breasts has been tightened. This makes them less obvious but does not eliminate them.


· Will the breasts become smaller with weight loss?
If breast of normal size become quire large with weight gain, weight loss significantly reduces their volume. As a general rule , though, most women with marked breast enlargement due to weight gain report that their breasts were always large even when they were slimmer. In these women weight reduction has a minimal effect on the overall breast size.

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