Breast Augmentation by Implant
Dr. Parikh has received a certificate from world renowned plastic surgeon Dr. Dennis Hammond for shaped anatomic implant placement.
Methods to enlarge the breast
Breast size can be enhanced using two main techniques; The preferred choice amongst plastic surgeons is usually breast implants. Implants are either saline or silicone based. There are advantages and disadvantages to each type. The other choice is fat transfer to the breast. This involves fat that is transferred from one area of the breast using liposuction and injection techniques. This can be performed in the right candidate if need be.
Breast Implant Types
Based on Implant material or filler: Saline Implants vs Silicone Implants
Saline implants are breast implants filled with saline or salt water. The implants are inserted deflated into the implant pocket and inflated with saline. The advantages of these implants are costly – they are generally cheaper, adjustable volume on the OR table and rupture detection. If the rupture is to occur with a saline implant it usually is noticeable very quickly by a size reduction on the ruptured side. The saline is then absorbed by the body naturally. Some disadvantages however are they tend to look less natural, feel less natural and are heavier then silicone implants per ml or cc.
Silicone implants are breast implants that are filled with gel silicone material. They are more expensive than saline implants, lighter, feel and look more natural. Rupture with silicone implants may be difficult to detect because of the cohesiveness of the new gel implants. The volume is nonadjustable on the OR table and fixed. Most women in the united states have silicone implants.
Based on Implant Shape: Round vs Shaped or Anatomic
Round Implants are either saline or silicone (gel) filled they have equal dimensions. They generally come in 3 types of projection (low, moderate and high) and multiple volumes and widths. There are multiple implant manufactures in the market such as mentor, allergan and sientra. The important thing is picking the right size and projection for your frame and desired goals. Choosing the right implant for your frame is half the battle of getting a great result. Technique is the other half, good technique can result in a bad outcome if the implant chosen is not optimal for your frame.
When I went to the doctor for a consultation, I was nervous. I had wanted this procedure done since I was in middle school. I finally talked my mom into taking me to a doctor to discuss a breast augmentation. I talked to Dr. Parikh and made my appointment for after my 18th birthday. After talking to him, I wasn’t nervous anymore — I was excited. A few weeks later, I went in for my surgery and came out with a full C cup — just what I wanted. I was originally an A cup. I asked Dr. Parikh to make my breasts bigger but without making me fake looking and disproportional. My new breasts fit my body correctly and look natural. After the surgery, he called me that night to check up on me. The incisions are healing nicely and my boobs look great! I am so pleased with the work he did. He never rushed us or made me feel nervous. Thank you so much for the work you did Doctor Parikh!H.S.
Shaped (Anatomic) Implants do not have a round base. They are asymmetrically shaped where the height is different than the width. They generally come in three heights; low, medium, and tall. They have a teardrop like shape where the lower part of the implant is more full. This tear drop shape is to simulate a natural breast shape. The silicone gel within the shell is generally more cohesive in nature (gummy bear) which keeps the upper part of the implant or upper pole from collapsing in the upright position. There is a marker on the lower pole of the implant to guide its direction when placing the implant. IT is important to see a plastic surgeon that has experience placing shaped implants. They are less forgiving than round implants because of the different shape they have and malrotation. They also come saline filled or silicone gel filled and are all textured on the outer surface. Texturing has shown to decrease some risk of capsular contracture. Shaped implants are more expensive than round implants at this time.
Based on texture: Smooth vs Textured
The breast implant shell or outer covering can be either smooth or textured: Textured implants feel “rough” on the surface. Texturing has shown to decrease capsular contracture rates and some argue that it helps keep the implants from descending earlier because of friction between the implant and the tissue. All shaped or anatomic tear drop impants are textured to prevent malrotation. Round implants can be either smooth or textured.
Approaches to Breast Augmentation and Incision Location
Pocket Location: There two main locations place a breast implant: Subglandular which means above the pectoralis muscle and below the breast gland or Subpectoral use is below the pectoralis muscle and above the chest wall. The discussion where to place the implants is detailed and some patients may benefit from a subglandular placement while some cannot undergo subglandular placement because of lack of soft tissue coverage over the implant. Subpectoral implants generally have a lower capsular contracture rate and are a preferred method by many plastic surgeons in a form called “dual plane technique” this involves releasing the muscle at its lower attachments so that the implant id partially under the muscle and partially not covered by the muscle. Subglandular implants ,may actually look more natural and usually have less discomfort postoperatively. Both techniques have advantages and disadvantages. This should be discussed with your plastic surgeon during the consultation.
Incision Location: Four main type – Inframmamry (IMF) , periearlor, transaxillary and transumbilical (TUBA)
IMF or inframammary incisions are located under the breast in the crease. They are well hidden if placed properly and generally unseen in the natural upright position. This is the preferred incision by most board certified plastic surgeons and the most common. It allows great exposure for pocket creation and does not disrupt the breast gland much. It is the incision that usually will be performed if there is a complication after breast augmentation such as bleeding or capsular contracture revision surgeries.
Periareolar incisions are also quite common, but less than the IMF incision. This usually performed with an incision under the areola along the pigmented and nonpigmentated skin and is from 3 – 9 o clock position. Implants can be placed the same way, but some breast tissue will be disrupted to a greater extent. If the areolas are small this may limit the size of silicone implant that can be placed. The scarring from from this technique may be less noticeable if it heals well, but this is variable.
Transaxillary incisions are made in the armpit area. This technique is generally has less pocket creation control and sometimes performed blindly or with a scope. Dissection is commonly performed bluntly. The advantage of this technique is the scars are not on the breast at all.
Transumbulical or TUBA uses saline implants only. It involves placing the implants through the belly button towards the breast. This technique is not performed often, the main advantage is a very well hidden scar. There appears to be no other advantages to this technique.
Candidates for Breast Augmentation
In general, almost everyone is a candidate for breast augmentation. Reasons for breast augmentation may be cosmetic or reconstructive. Ideal candidates are usually healthy medically and have realistic goals. Breast Augmentation can correct small breasts, absent breasts, misshaped breasts, asymmetric breasts, sagging breasts or congenital deformity of the breast. Regarding age the FDA recommends that breast augmentation be performed on patients that are 18 or above. Silicone implants are approved for patients that are 22 years of age or above. Silicone implants can also be placed if younger than 22 years if there is a congenital deformity or for reconstructive purposes.
Breast implant monitoring:
FDA recommends an MRI starting at 3 years postoperatively, then every 2 years thereafter to assess for implant integrity or rupture.
Breast Implant Complications
Rupture can be spontaneous or traumatic. Both saline and silicone implants can rupture.
Silicone Implant Rupture: The newer generation implants have improved technology in the gel filler and barrier or shell of the implant. Ruptures may be subtle with no frank leak of gel to the surrounding breast. Some of the gels are more cohesive meaning they are more “sticky” like a “gummy bear” where even with severe rupture the gel still maintains a good shape and can minimize silicone leakage into the breast. Silicone implant ruptures can be silent or undetected clinically by the patient. These can be detected best by MRI where a “linguine sign” may be noted. If an implant shows evidence of rupture it should be replaced. The FDA recommends a MRI 3 years after silicone implant placement and every 2 years thereafter to monitor for silent ruptures.
Saline Implant Rupture: Saline implants can rupture. Usually these are clinically detectable by noticing a size difference on the ruptured side. The leaks can be slow or fast. The saline is absorbed by the body and generally has no adverse effect. If a saline implant has ruptured it should be replaced.
Capsular Contracture “scar tissue”. It is normal for the body to form scar tissue or fibrosis around foreign bodies placed in the tissues. The body reacts to the implant by forming a capsule around it. This is a normal response. However sometimes that capsules can contract or become constricting around the implant which pushes on the implant and can result in deformation of the breast or pain. Capsular contracture can be treated in different ways ranging from capsulotomy (cutting the capsule) to capsulectomy (removing the capsule). Capsular contracture may or may not recur after treatment.
There are 4 grades of capsular contracture (Baker Scale)
- Grade I — no visible or palpable changes, breast looks and feels normal
- Grade II — no visible changes, but the breast are mildly firm and the implant can be felt
- Grade III — visible changes deformity, moderately firm and the implant can be felt
- Grade IV — visible changes deformity worse, harder, tenderness and pain
The term “Rippling” in breast augmentation refers to lines or wrinkles seen on the breast mound. This is commonly due to lack of soft tissue coverage over the implant. It can occur with either saline or silicone gel implants. The capsule around the implant is adherent to the underlying soft tissue of the breast traction from the implant pulls on the capsule which pulls on the soft tissue and skin. This is different from stretch marks or striae which can be seen after breast augmentation from the excessive stretch on the skin envelope.
Malposition (Rotation of Implant)
Implants can move within the breast pocket created. Malposition is less common with round implants since the implant is circular in shape and equal in base dimension. Shaped (anatomic teardrop) implants on the other hand have different height vs width dimensions. Therefore if the implants rotate it will show deformity of the breast. Make sure that your plastic surgeon has experience with shaped implants because of the technical issues (pocket dissection) that can arise with these implants.
Need for Revision or Reoperation Surgery
Revision or reoperation can occur with breast augmentation. The most common indication for revision surgery is a size change of the implant. Other reasons for revision include malposition, rotation or bottoming out of the implant. Revision surgery can involve lifting the breast tissue (mastopexy), treating asymmetry between the breasts, removal of the implants, or removal of the implants and exchange. Many techniques can be employed in revision surgery such as fat transfer or the use of mesh (acellular dermal matrix ADM)
With any surgical procedure complications can occur, but are generally low. We encourage that you ask about complications during your visit with Dr. Parikh. Dr. Parikh will ensure that your safety is first and discuss any concern in great detail that is tailored to your specific medical history.