Breast Enhancement
The women
who most commonly request breast enhancement include those who have had children and their breasts lost volume or women who
never had significant breast development. Other reasons for losing volume of breast tissue could be weight loss or the
onset of menopause. If sagging is significant or the breasts have an unusual shape they may be better corrected with
an implant and a lift. A breast implant is surgically placed beneath the breast tissue or chest wall muscle. Breast
enhancement can improve self-confidence, help clothes fit better, and make bodies more proportionate.
There are
a lot of benefits to breast enhancement, but there are also risks and future costs to consider before you decide to have surgery. Implants
are mechanical devices and will not last forever. Just like an artificial hip, knee, or heart valve, they eventually
wear out. You will likely need surgery again on your breasts in the future, either to remove or replace the implants. The
implants used for augmentation are saline filled in a silicone plastic envelope or silicone gel in a silicone plastic envelope.
When an implant fails, it deflates or leaks. When a saline implant leaks, it deflates over a few days or weeks. Your
body absorbs the fluid, which is intravenous saline. The breast looks smaller on that side. It is not a medical
emergency, but is somewhat easier to fix if not too much time passes before it is replaced.
You may not be able
to tell by physical exam or even mammography that a silicone implant has leaked. A special MRI may be necessary to detect
a leak. This MRI is 80% accurate in detecting silent leaks. The newer cohesive gel silicone is stickier and does
not ooze out like the old silicone gel. Older silicone implants leaked out significantly when their shell was disrupted. Many
of the older implants oozed silicone gel into the breast implant pocket through the intact silicone shell. The silicone
that leaks out of the implant is usually kept in place by the encapsulation your body builds around it. It is not a medical
emergency when silicone leaks out of the envelope. It can be removed and repaired at your convenience. The only
cause for concern is that if there is a large enough injury to your breast tissue to disrupt your body's encapsulating
scar, the silicone gel may be forced into your soft tissue. This might cause a granuloma, or scar that could be painful
and cause a lump in your breast and must be removed.
The silicone filled breast implant's advantage over the
saline filled breast implant is in its texture and appearance. If the original breast is small and the implant is large,
or if the tissue covering the implant is very thin the silicone may provide better appearance and more natural feel. Sometimes
the saline filled breast implant has a visible edge with rippling. Even a silicone implant can have some rippling if
the tissue is very thin, though it is much less visible. If you are going from a very small breast to a large breast,
are very thin, or are placing the implant on top of the muscle with very little breast tissue or fat covering it, then silicone
may be a good choice if the texture and lack of rippling is important to you. For example, a competitive body builder
or fitness contestant may do better with a silicone implant over the muscle. However, if you are increasing the size
a modest amount or if you have a moderate amount of breast or soft tissue to cover it, then a saline implant may work very
well.
The silicone implant information collected over the past fifteen years and presented to the FDA reveals no
increased incidence of immune disorders with silicone implants (i.e. rheumatoid arthritis, scleroderma, lupus, etc.). However,
a silicone filled implant does have a higher immediate cost and a higher future cost over a saline filled implant. To
place a silicone implant, the incision (and therefore the scar) must be longer than that for a saline filled implant. This
is because the silicone implants are pre-filled and bigger initially, so they require a bigger incision. The implant
itself costs about twice as much as a saline implant. In the future, an MRI may be necessary to evaluate whether or not
the silicone implant has leaked. The MRI probably will not be covered by your insurance carrier since it is related
to a cosmetic breast implant. If the implant has leaked, then silicone will be outside of the implant, coating the scar
around the implant, or may have even leaked beyond the scar into your breast tissue. To remove the silicone, it is necessary
to also remove this silicone coated scar. This capsulectomy or scar removal costs about twice as much as it would cost
to remove a saline implant and takes longer.
Another consideration is that your mammogram will be slightly affected
by the implant. Both silicone and saline filled breast implants block a portion of your breast from being evaluated by
a mammogram. Extra views are necessary for a more complete examination of your breast. The mammogram is less affected
by placing the implant under the muscle rather than over the muscle. I prefer to place the implant under the muscle if
possible, but at times the appearance of the breast is much more natural looking if the implant is placed above the muscle. This
is the case if there is mild to moderate sagging of the breast tissue.
A breast lift may be necessary for a very
droopy breast, especially if you want your implant under the muscle. This mastopexy (or lift), involves scars directly
on your breast and around your nipple that may be quite visible. These scars are permanent. To get the best shape
possible, a significant lift may be necessary. Unfortunately, there is no way to take a very saggy breast and lift it
without scarring. There is a compromise with shape of the breast and the amount of scarring.
One possible
complication of breast implants is that your body may form a tight scar or capsular contracture around them. A tight
scar can change the appearance of your breasts. This is true for either silicone or saline filled implants. It may
be necessary to re-operate to release the scar and make the breast soft again, and unfortunately it is possible that even
after a surgical release the tight scar could recur. Occasionally the use of an asthma drug, Singulair® or Accolate®,
helps to soften a hard implant scar, but it is not predictable. The FDA considers this as an "off
label" use of the drug, but may be worth trying to avoid surgery.
One recent method being advertised and promoted
that I do not feel is a safe way to enhance your breasts is injection of substances into your breasts. The FDA has not
approved of the use of any soft tissue fillers in your breasts, yet it is done by some people (most often not even physicians,
or physicians not licensed in the U.S.). Some of these substances are non-medical grade silicone injected freely into
the breast tissue; some are unknown drugs/fillers of questionable origin. The long term sequelae of these injections
are not known, but if these (often non-sterile) substances cause an infection it could be disastrous, sometimes requiring
a mastectomy to remove all the contaminating substance.
Some people promote injection of your own fat tissue into
your breasts. I do not feel that this is a safe technique of enhancing your breasts yet. Fat grafting is not predictable. It
takes a huge graft to make a breast significantly bigger, and the larger the graft the more likely you will have problems. Fat
grafting the breast with a large volume of fat tends to cause the formation of cysts of oil, areas of necrosis, scarring
and calcifications. These render a breast exam for breast cancer useless, as it causes lumps and firm areas within the
breast tissue. It will probably render your mammogram unreadable with the calcifications and cysts. That is a steep
price to pay with the incidence of breast cancer approaching one in eight women. Also, a few injections I have seen resulted
in undesirable shape and abnormal texture of the breasts. Some work is being done on these issues to find a way to enlarge
the breast with your own fat, but it is currently experimental and I do not recommend it at this time.
There are
many things to consider if you want breast enhancement. It is important to discuss the operation and other details with
your surgeon. You should choose your surgeon with care. A surgeon who is board certified by the American Board of
Plastic Surgery has had at least five years of intensive post-graduate training. The training includes academic instruction
and rigorous, supervised hands-on surgical training. The training involves not only the placement of the implants and
lifts, but also the skills to address and avoid the possible complications. There are many people performing cosmetic
procedures with little or no formal training. It is in your best interest to check on the experience and qualifications
of the physician you choose to perform your surgical procedure. A surgical suite in a physician's office can allow
for more privacy and decrease costs. If you have your surgery done in a surgical center, make sure that it is certified
by the American Association for the Accreditation of Ambulatory Surgical Facilities, or other nationally recognized certifying
agencies. The certification assures the availability of specific emergency drugs, monitors, and safety equipment as well
as established procedures in the event of a medical emergency. Breast augmentation can enhance your body and make you
more confident, but it is surgery. Understand what it can do and what to expect in the future.