Through the years many different types of incisions have been described for breast enlargement surgery also known as augmentation mammaplasty.

Currently, most plastic surgeons favor the breast crease incision. When using saline implants the incision is 3.5 cm (less than 1.5") and is nicely hidden in the breast fold. These incisions usually heal very well because they run along the normal skin lines.  As a patient ages and the breast fold deepens, the incision is even less visible. When a silicone gel implant is used, the incision is lengthened to about 6 cm (2.5"). This longer incision is important to allow insertion of the implant without traumatizing the implant.  If the implant is forced through a smaller incision this could result in small tears as the implant is placed and this can be the cause of future rupture of the silicone gel implant.

Another incision used is the peri-areolar approach in which the implant is placed through the areola. The peri-areolar approach for augmentation mammaplasty is often used when a breast left is done at the time of breast enlargement surgery. This incision can be used for a saline implant however it is usually too small for a silicone gel implant.

The armpit scar has fallen out of favor with most plastic surgeons. With this approach, it is somewhat more difficult to properly dissect the lower portion of the breast. In addition it is also more difficult to control bleeding through this incision.

When a surgical revision is done it is usually done through the breast fold approach even when the original incision was elsewhere. This gives the best visibility of the breast implant pocket.

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When patients have breast hang in addition to small breasts, a frequently asked question is if the two operations can be done together.  The answer is "it depends".

A breast enlargement operation (augmentation mammaplasty) expands the breast tissues whereas a breast lift (mastopexy) reduces the amount of breast skin. This can be thought of as a "push pull operation". On the one hand we are making the envelope of breast skin larger by placing an implant, on the other we are tightening the breast envelope.

The size of the implant and the amount of skin that needs to be removed will influence the decision if the two operations should be done together or as separate procedures. These concepts will be discussed during your consultation. Further, the various types of breast lift will also be discussed according to how much skin needs to be removed, and how this will influence the final scars needed to shape the breast.

The final result of what is called augmentation mastopexy is usually quite pleasing to the patient. Even though all patients worry about the scars, and certainly scars can heal poorly, we have found that there is a high level of patient satisfaction when combining a breast lifting operation with breast enlargement.

Other types of surgery may also be combined with breast lifting and breast enlargement such as an abdominoplasty (tummy tuck), liposuction, arm lifts and neck lifts.

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Now that several years have passed since the FDA gave approval for gel filled implants for augmentation mammaplasty, we have gathered quite a bit of experience understanding the benefits of gel filled implants in comparison to saline filled implants.

When I'm asked the question of which implant I prefer, my immediate reaction is that gel filled implants give the softest most natural felling results. We have had very few problems with rupture and capsular contracture. They are somewhat more expensive than saline implants and require a larger incision to insert. Both types of implants can be placed either on top of the muscle or under the muscle.

Saline has withstood the test of time, and if it ruptures the saline is absorbed into the system without problems. The implant is easy to remove and replace. Saline implants are more likely to demonstrate wrinkling which can be felt through the skin.

More information on the differences between saline and silicone breast implants can be found by linking to our website’s resource articles:

• Ban on Silicone Gel Implants Lifted
• Silicone Gel vs. Saline                                                             

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submitted by Daniel A. Sterling, M.D., FACS

Do breast implant sizers accurately demonstrate final results of surgery?

Going through the sizing procedure in our office requires trying on multiple implants of various sizes to get a sense of the final result.  It is an estimate that is usually very close to demonstrating the final result.  However, it must be remembered that the implant is placed on top of the breast during sizing but it is under the skin, breast and pectoralis muscle afterwards, thus a slightly larger implant is used than that during sizing.  In addition to sizing in the office, it can be done at home using Ziploc bags filled with sugar with the appropriate volume to estimate the size of the breast implant.

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submitted by Daniel A. Sterling, M.D., FACS

What size sports bra should I buy after breast augmentation?

It is best to wait until after your breast augmentation before you buy bras.  It is very difficult to judge the proper bra size due to the fact that different bra manufacturers have different measurements.  A sports bra is only used in certain cases, with the vast majority of cases not wearing a bra at all for the first several weeks.  A sports bra can be worn if it holds the implants in place and does not displace them in an upward direction for any prolonged period of time.  If a “push up” bra is worn in the early post operative period it can cause the implants to heal abnormally high.

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submitted by Daniel A. Sterling, M.D., FACS

Is there a difference between anatomical and full projection round breast implants?

There are many types of breast implants that are used for augmentation mammoplasty.  However, by far the most common are smooth, round implants.  Anatomical implants are used primarily for breast reconstruction, although they can be indicated in certain types of augmentations. Excellent and consistent results have been achieved for many years now using smooth, round implants for primary augmentation either using silicone gel or saline.  Anatomical implants can be problematic in that they are not symmetrically shaped and if they rotate can give a very deformed appearance. This can be corrected, however requires a subsequent operative procedure.  Many profiles are available for smooth, round implants including low, moderate and high profile depending upon the chest parameters.

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submitted by Daniel A. Sterling, M.D., FACS

How painful can a breast lift combined with an implant be?

Augmentation mammoplasty, otherwise known as breast implants, can be combined with a mastopexy, otherwise known as a breast lift.  A mastopexy is not a particularly painful procedure due to the fact that the only tissues involved are skin, fat and breast tissue. The breast augmentation portion of the procedure can be a bit more painful but is readily managed in our practice using pain catheters, as well as short term narcotics and antiinflammatory medications.  Usually, the period of discomfort lasts only for one to two days with rapid improvement over the course of the first week.

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submitted by Daniel A. Sterling, MD, FACS

Is it possible to have a breast lift through the armpit or transaxillary incision?

A breast lift, otherwise known as a mastopexy, cannot be performed through the armpit or a transaxillary incision.  Breast augmentation or breast implants can sometimes be inserted through an incision in the armpit but is not routinely performed.  Regardless of where the incision is placed it can be seen depending upon the angle it is viewed.  Most scars on the breast heal very nicely and if a nice size and shape is the result of your procedure, most women are unconcerned with the scars which eventually remodel and heal very nicely.  Many different types of breast lifts are available including a Wise pattern mastopexy, vertical mastopexy, and periareolar mastopexy, all of which can give an excellent result when the proper procedure is selected for your condition.

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submitted by Daniel A. Sterling, MD, FACS

Can I get breast implants without a breast lift?

 Breast implant surgery or augmentation mammaplasty are routinely done without a breast lift for women who do not have any breast hangotherwise known as breast sag, breast ptosis or mammary ptosis.  Some women who have breast hang will get a much better result if they have a mastopexy either at the time of augmentation or afterwards once the implant has healed well.  A breast lift is also known as a mastopexy and is usually done when the nipple has descended to a point below the inframammary fold or the area below the breast between the abdomen and the chest.  If this is the case a breast lift can be performed to reduce the size of the breast envelope or skin and bring the nipple and areola up to the correct position.  Many times adding an implant to the procedure can return the fullness to the upper breast area that many women desire.  Certainly the majority of breast augmentations is done without a breast lift but many women have a mastopexy or breast lift with or without augmentation with excellent results as well.

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submitted by Daniel A. Sterling, MD, FACS

How long before I can safely fly home if I have breast augmentation?

There are times when women will have breast implants, otherwise known as augmentation mammoplasty, in an area that is remote from their home.  The question that arises – How long should one wait to fly home after the procedure?  Although patients are discharged several hours after having their breast implant surgery, it is prudent to stay in the area for several days to be seen by your plastic surgeon and give you final instructions and make sure that you are doing well in the immediate post operative time period.  Provided you are returning to an area that has medical facilities close by, it is possible to fly home after a period of three to five days post operatively provided you are doing well.  Many plastic surgeons refrain from doing this as follow up is difficult but as long as you keep in touch with your plastic surgeon and follow up at some point within the first three to six months the procedure can be done safely and with excellent results.

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submitted by Daniel A. Sterling, MD, FACS

Is it safe to get breast implants if one has supraventricular tachycardia?

Breast augmentation or breast implants or augmentation mammoplasty is a very safe procedure that is performed under general anesthesia.  All patients undergoing elective cosmetic surgery are required to have some form of pre-operative clearance from their primary care physician along with routine laboratory results.  There are patients who are very healthy yet still have a relatively benign arrhythmia, one type of which is supraventricular tachycardia.  Since your safety is of primary importance during an elective cosmetic procedure, every variable must be controlled so as to prevent even the slightest of complications.  Most patients who have a SVT are well controlled with medications that they take on a routine basis.  As long as the condition is well controlled and clearance is obtained by a cardiologist, there is no reason that someone with a SVT could not have breast implants.

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Submitted by Daniel A. Sterling, MD FACS

For a patient, what fear is generally associated with a breast augmentation?

Breast  augmentation is a procedure that causes both  anxiety and excitement in women undergoing the procedure. The most common fear of breast enlargement is pain. We routinely  use pain control catheters to deliver local anesthesia during the post-op  period. Augmentation mammaplasty is one of the  more commonly performed procedures. and vast  amounts of information are readily available about the  procedure-omit.  It is  considered to be safe and the   majority of women are  happy with their results and achieve an  improved sense of self image.  We have many patients who are willing to  discuss their experience and are happy to speak to prospective breast  augmentation patients.

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Submitted by Daniel A Sterling, MD, FACS

Possible to get larger breast implants without fake look?

Depending upon your frame it is certainly possible to have large implants placed without looking fake.  Typically large implants look fake early on; however, once they descend into the proper position and become more anatomically shaped they become more natural in appearance. Women with larger frames can handle larger breast implants without looking fake. If, however, the implants chosen are disproportionately large to your frame they will look fake going forward.

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Submitted by Daniel A Sterling, MD FACS

Breast implant replacement or breast lift after capsular contracture?

The treatment for capsular contracture, depending upon the severity, is either a capsulotomy (opening of the capsule) or complete removal of the capsule (capsulectomy). Once this is done, there is no contraindication to replacing implants or performing a mastopexy with the caveat that there is a slightly increased risk of recurrent capsular contraction. A significant breast lift or mastopexy may be delayed if the entire capsule is removed for vascular protection of the nipple areola complex.

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Submitted by Daniel A Sterling, MD, FACS

How do saline breast implants look if placed over the muscle?

Breast implants placed over the muscle, also known as subglandular augmentation, is only indicated in a limited number of patients.  Body builders and women who pose flexing the upper body musculature request subglandular implants so that there is no distortion of the implants and breast appearance when they flex or lift weights.  If there is an adequate amount of breast tissue to cover the implant a saline implant may be indicated over the muscle, however, silicone implants are recommended.  Any augmentation over the muscle is associated with a higher risk of capsular contracture; however, it is still relatively low and somewhere in the 10% range.

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Submitted by Daniel A. Sterling, MD, FACS

Breast implants for C cup breasts after reduction?

Infrequently, women will seek breast augmentation after having had a breast reduction.  Usually this occurs in women who have had a breast reduction at a young age and have subsequently had children and now have significant deflation of the breasts.  Certainly, breast implants can be placed for C cup breasts to provide the fullness, fill the envelope and restore the fullness that was present prior to loss of volume.

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Submitted by Daniel A. Sterling, MD FACS

Can a Lollipop breast lift and an breast augmentation be performed in one procedure?

There are many types of breast lifts, also known as mastopexy.  A lollipop mastopexy is one of the intermediate procedures for women who do not have a significant amount of breast hang, or ptosis. The combination of breast implants at the same time as a lollipop lift is frequently done and usually results in a very nice outcome.

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Submitted by Daniel A. Sterling, MD, FACS

 Can I have a breast augmentation if I weight 70 pounds?

Depending on your height, 70 pounds may be an appropriate weight. However, if you are significantly underweight at 70 pounds due to health issues it may not be prudent to undergo an elective procedure such as breast augmentation. If however you are totally healthy and this is an ideal body weight, you are no different than any other candidate for breast augmentation. 

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Submitted by: Daniel A. Sterling, MD, FACS

Is a full C cup breast implant too large for a petite frame?

Depending upon the dimensions of your breasts as well as your chest wall, a full C cup may be fine for your frame.  The limiting factor is usually the width of the breast and the size of the breasts prior to surgery.  Very large implants can be associated with eventual breast hang and malposition, thus it is prudent to match your implants to your overall body frame.

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Submitted by: Daniel A. Sterling, MD, FACS

Do silicone breast implants cause autoimmune disorders?

Numerous studies have shown that breast implants do not cause autoimune disorders.  Thousands of breast implants were removed in previous decades due to fear of their causing autoimmune disorders.  There was no science behind this and this has been completely disproven.  Many women were caused undue emotional distress and had their implants removed for no reason. It is for this reason that the FDA has fully approved silicone implants.  They are routinely used for breast augmentation now.

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Submitted by: Daniel A. Sterling, MD, FACS

Are permanent sutures used for breast implants that have been pushed out to the side?

When implants are malpositioned, in particular are lateralized and fall into the “armpit area” revisional surgery is usually indicated.  It is for this reason that when we perform breast augmentation limited dissection laterally is performed.  If the implant needs to be moved medially (towards the stenum) because the outside portion of the pocket is too large, a closure of the capsule can be performed surgically using permanent sutures.  This is called capsulorraphy and permanent sutures are used on a routine basis for this.

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Submitted by: Daniel A. Sterling, MD, FACS

What is the largest silicone implant that can be inserted through the nipple?

Breast implants are not inserted through the nipple; however, they can be inserted through the lower part of the areola which is at the edge of the pigmented portion of the breast.  Depending upon the size of your areola, relatively large implants can be inserted through this approach.  Women with extremely small nipple areola complexes, however, are limited in the size of implant that can be inserted through this incision.  In any case, all breast incisions usually heal very well. Silicone gel implants up to 350 cc or slightly larger can be inserted through areolar incisions.

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Submitted by: Daniel A. Sterling, MD, FACS

Is it safe to combine breast augmentation revision, areola reduction and liposuction?

Depending upon the extent of the revision, it is usually safe to combine the above procedures.  If the nipple areola complex needs to be moved a significant amount, it is sometimes safer to perform this procedure in stages, the reason being that the vascularity (blood supply) of the nipple areola complex can be compromised.  This would result in possible nipple areola loss or compromise.  Pure areola reduction, however, can be combined with removal and replacement of implants on a routine basis.  Liposuction combined with breast procedures is safe and can be performed readily, provided it is not a large volume liposuction.

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Submitted by Daniel A. Sterling, MD, FACS

 I had breast implant surgery six months ago and I am interested in going up a cup size, maybe more.  Just wondering how long I should wait before considering surgery?

Some women find after breast augmentation that they would like to increase the size of their implants.  Removal of prior implants and replacement with larger implants can be done with relative ease depending upon the increase in size.  Six months following the initial augmentation should be an adequate time to assess the final size and contour of the augmented breasts and the decision to have larger implants placed can be made any time after that.

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Submitted by Dr. Daniel A. Sterling

I currently have Mentor moderate profile saline implants. I would like to go larger and have read about the Mentor spectrum style implants. I understand with this type of implant the size can be adjusted if I decided to go larger. Do you offer this type of implant? Would it be costly to have the size adjusted at a later date?

Adjustable implants have been available for a number of years.  They are used very infrequently due to the fact that a port is required to inject or remove volume.  This port can be felt under the skin and can be uncomfortable.  Although this implant is available, it is used very infrequently.  The best approach is to give considerable thought with the input from our nurses, as well as the physician and choose an implant that is appropriate both for your physique, as well as your wishes for a final aesthetic result. 
.

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Submitted by Dr. Daniel A. Sterling

How do you determine if breast implants should be placed above the muscle or below the muscle?

Most breast implants are placed under the muscle (subpectoral augmentation mammaplasty) for a number or reasons: Breast X-rays (mammograms) are more accurately read when the implant is separate from the actual breast tissue. The muscle layer also helps to disguise the implant from being visible and the breast implant is less palpable. In addition, there is a decreased risk of capsular contracture (hardening of the implant) when the implants are placed under the muscle. There are specific indications for placement of the implant on top of the muscle (suprapectoral augmentation mammaplasty, also known as subglandular augmentation mammaplasty): Extremely active women involved in athletics, particularly weightlifting and body building, and woman who have postpartum deflation (loss of volume after pregnancy) with minimal breast hang (mammary ptosis) where an implant would obviate the need for a mastopexy (breast lift).

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Submitted by Dr. Daniel A. Sterling

I have lost 70 lbs through diet and exercise. I am thrilled with the results except for the fact that I no longer have breasts. I am considering breast augmentation. After visiting your website it appears I may need a breast lift, however, want minimal scarring. Is this possible?
 

Following massive weight loss there are usually significant changes to the appearance of a woman’s breasts. The vast majority of women have loss of volume (deflation) due to the loss of fat within the breast. In most cases some type of breast lift (mastopexy) will be required to bring the nipple up to the correct position and decrease the size of the skin envelope. This will improve the contour of the breast. A breast implant may or may not be required and that can usually be determined at the time of your consultation. Regarding scars, there is a broad spectrum of the type of mastopexy that can be used but in most massive weight loss patients, the type of mastopexy required will require some scarring. Most women however are very happy with the appearance of the scars because they heal well, the breasts have a better shape and the lower part of the scar is hidden in the breast fold.

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As of 12/08 we now have over 750 consecutive patients who have benefited from the long acting local anesthesia that is infiltrated during anesthesia and the pain control catheters that the patients go home with. This technique has proven to be safe in our hands during the past 12 years of use.

An article appeared in the Sept.-Oct. issue of Aesthetic Plastic Surgery (2008; 28; 528-533) showing the benefits of this technique in a controlled study of 150 augmentation mammaplasty patients. 75 patients had the benefit of the local anesthesia supplement, compared to 75 patients who did not. The study showed significantly reduced pain in the recovery room with less need for narcotics in those patients who had the local anesthesia.

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A study of women who breast fed was published in the 2008 Sept-Oct issue of Aesthetic Plastic Surgery (28: 534) to determine which factors were the most important causing breast hang.

93 patients met the study criteria. It was found that the most important factors were higher age, increased weight, greater number of pregnancies, larger pre-pregnancy bra size and smoking, whereas breast feeding did not appear to be of importance.

It has long been thought that breast feeding does cause breast hang (mammary ptosis) and it is often for this reason that some women choose not to breast feed. This is unfortunate because it is well known that there are many health benefits to the infant who breast feeds.

Breast hang can be corrected with a breast lifting operation.

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Breast implants for breast enlargement are available not only in different sizes and shapes, but also as textured versus smooth. Over the years many different chemicals were used for breast implant texturing to discover the best surface texturing which was thought to solve or at least help the problem of hardening of the implants (capsular contracture). Texturing in this decade consists of silicone texturing which allows for the ingrowth of scar tissue into the texturing. Textured breast implants are available both for saline breast implants as well as silicone gel implants.

Textured implants tend to be used more by European surgeons whereas smooth breast implants are the preferred choice of US doctors. In our practice we rarely have problems with capsular contracture and find that smooth breast implants serve our patients well. In addition we are advocates of breast implant movement and exercises are taught to all our breast enlargement patients to aid in a softer feeling to the final result. Breast mobility exercises are not possible for textured breast implants because of the fixation of the implant by the ingrowth of scar tissue.

Since we rarely have problems with capsular contracture, we do not use textured implants in our practice. Instead we are happy with the results of smooth saline or smooth silicone gel breast implants.

Contact Us for More Information

For confidential personalized information and advice, please call us at 1-800-640-0290 during business hours: Monday through Thursday 8:30 a.m. - 4:30 p.m. and Friday 8:30 a.m. - 4 p.m. EST. You can also visit our website on breast enlargements for more information or use the online contact form to send an inquiry. LATE AFTERNOON & EVENING HOURS NOW AVAILABLE .

Sometimes patients feel that the breasts are getting smaller with age even though they have had an augmentation mammaplasty. The implants themselves do not get smaller unless there is a leak in a saline inflatable implant. Rather there can be a loss of breast tissue with advancing age. In addition the underlying implant may cause pressure on the overlying breast tissue causing a thinning of the breast gland.

It is likely that the larger the implant, the more pressure it exerts on the overlying breast gland. Large implants may be responsible for increased loss of breast gland due to this pressure phenomenon.

We have not seen complications due to this condition, though it is always best to have good overlying padding so that the implant cannot be felt. This is one of the reasons we prefer to place the breast implants under the muscle. During your consultation measurements of the chest and breasts are taken to help determine the best size of the breast implant. The patients’ preferences are taken into account. When the sizing is correct, there are fewer complications. The complications we see are often related to excessively large implants.

Contact Us for More Information

For confidential personalized information and advice, please call us at 1-800-640-0290 during business hours: Monday through Thursday 8:30 a.m. - 4:30 p.m. and Friday 8:30 a.m. - 4 p.m. EST. You can also visit our website on breast enlargements for more information or use the online contact form to send an inquiry. LATE AFTERNOON & EVENING HOURS NOW AVAILABLE .

We have been studying pain after breast enlargement surgery and have learned a great deal about what the patient is experiencing after augmentation mammaplasty. We have written a number of published papers and have presented this information at both regional and national plastic surgery meetings.

Most patients experience pain in their breasts after the surgery, but other sites are also involved. Patients score their pain after augmentation mammaplasty, as well as indicating the area that is uncomfortable, and most have mild to moderate pain for the first 6-8 hours after surgery. After this the amount of pain subsides, and by the time they are seen the next day for their follow up examination, the pain has become more of a discomfort than actual pain.

Other sites of discomfort or pain may involve the breast bone (sternal pain), the area under the collar bone, the sides of the chest, sometimes extending as far as the armpits, and between the shoulder blades. (Published data: Pacik, P., et al Aesthetic Surgery Journal, in press. Expected publication date: November 2008.) We have found that the pain control catheters developed in our office are effective both for breast pain, and others sites that may be involved. By instilling a long acting local anesthetic (lasts 6-8 hours) patients have control over when they desire to use this medication. This can then be supplemented with other analgesics, so that after breast enlargement surgery, patients have the ability to maintain pain control every 2 hours.

Except from a testimonial of one of our breast enlargement patients:

When they tell you it’s very painful, don’t take it lightly. I’m very grateful that Dr. Pacik was pro-active with all the medications prescribed to me before surgery. With the pain medication prescribed, I do have to say that the pain medicine in the catheters was the most helpful. I found that the medicine went right to the source of the pain and there was almost instant relief once massaged into the breasts. Dr. Pacik gives you the option to leave the catheters in for an extra day and my advice if you still feeling pain or discomfort, leave them in. I’m glad I did!

To read this patients entire testimonial, please click here.

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For confidential personalized information and advice, please call us at 1-800-640-0290 during business hours: Monday through Thursday 8:30 a.m. - 4:30 p.m. and Friday 8:30 a.m. - 4 p.m. EST. You can also visit our website on Breast Enlargements for more information or use the online contact form to send an inquiry. LATE AFTERNOON & EVENING HOURS NOW AVAILABLE . 

We now have over 700 consecutive patients in our ongoing pain control study.  Indwelling catheters allow patients to self administer local anesthesia after breast enlargement surgery. We have found this to be very effective and our study has shown that the effectiveness is comparable to narcotics. (Published data Pacik, P., et al Aesthetic Surgery Journal, May 2008)

All of our patients are called the evening after their surgery, and many patients have been helped by this device. We review their pain control scores the next morning when seen for their first follow up examination, and we note the degree of pain improvement after the local anesthesia has been instilled into the catheters. Most of the time the catheters are removed at this time, though about 15% of patients ask that the pain control catheters remain an additional day. In this way patients who are somewhat more uncomfortable after breast enlargement surgery or patients who are afraid of experiencing pain have additional pain control available to them.

The pain control catheters were developed at our office so that patients can treat their pain at the site of pain without having to narcotize their bodies. With almost 12 years of experience, we cannot imagine doing the surgery without these devices.

The following is a testimonial from a patient whom had an augmentation mammaplasty and used the pain catheters for 24 hours following surgery.

I am writing this letter to thank and advise you about the results of an elective pain control study I chose to participate in with regards to a recent augmentation mammaplasty surgery recently performed by you. The self-administered local anesthesia that was available for use at home in conjunction with other pain control medication was well beyond any expectations I had anticipated for relief of pain. The procedure was very easy to use, extremely convenient, and had almost immediate pain relief results. I cannot express enough the benefit and relief I received from this self-administered anesthesia. I would highly recommend this procedure to any of your patients who elect to have similar surgical procedures of this nature.

Again, thank you for your superior surgical procedure and all the support you and your staff have given post surgery.

Contact Us for More Information

For confidential personalized information and advice, please call us at 1-800-640-0290 during business hours: Monday through Thursday 8:30 a.m. - 4:30 p.m. and Friday 8:30 a.m. - 4 p.m. EST. You can also visit our website on pain after breast enlargement for more information or use the online contact form to send an inquiry. LATE AFTERNOON & EVENING HOURS NOW AVAILABLE .

Following my blog entry of March 26, 2007, another article was published also noting breast enlargement after liposuction. The first article was published in 2003¹  and noted that 34% of 73 liposuction patients reported a 30-40% increase in breast size.

The second article appeared in the April 15, 2007 issue of Plastic and Reconstruction Surgery ² and was based on a study done in the Netherlands. In this article, 48 patients had liposuction compared to a control group of 53 similar patients who had abdominoplasty. The liposuction patients were noted to have significantly more breast enlargement (23 of 48 patients = 48%), and actually confirmed in 19 patients (40%) compared to 11 patients in the abdominoplasty group (21%) and objectively confirmed in 6 patients (11%).

Reference:
1. Yun PL et al. Breast Enlargement Observed After Power Liposuction: A Retrospective Review. Dermatol Surg. 2003; 29; 165-167; discussion 167.

2. van der Lei, B et al. Spontaneous Breast Englargement following Liposuction of the Abdominal Wall: Does a Link Exist. Plastic and Reconstruction Surgery 119:1584-1589, 2007.

I came across an interesting article from the Mount Sinai School of Medicine in New York discussing breast enlargement following liposuction in the abdomen, hips and thighs.¹ In a study of 73 liposuction patients, 34% reported a 30-40% increase in breast size.

The change typically occurred several months after liposuction in the abdomen, hips or thighs, and it was associated with the extraction of a large volume of fat.

One theory is that "there are more androgenic receptors (male hormone) in the abdomen, hips and thighs and when you remove them, you have a relative increase in the estrogenic receptors in the breast."

In my own experience, patients who gain weight after liposuction gain the weight in different parts of the body, with minimal weight gain in the area that had liposuction. Although we have done hundreds of liposuction procedures, I was unaware of the breasts getting larger, perhaps because we didn't ask the question. If any of our readers have personal experience with this please email us at info@plasticsurgerypa.com. Thank you.

Reference:
1. Yun PL et al. Breast Enlargement Observed After Power Liposuction: A Retrospective Review. Dermatol Surg. 2003; 29; 165-167; discussion 167.

A common concern of women planning augmentation mammaplasty is whether or not they will have normal nipple sensitivity after the surgery. Most often nipple sensitivity is normal after breast enlargement surgery.

Nipple sensitivity is highly variable. Women with large breasts tend to have less sensitivity whereas women who are small breasted tend to have both more sensitivity as well as more erotic sensation. Since the same number of nerves is present, a smaller breast will have a greater density of nerve fibers supplying the breast giving better sensation.

It is very rare for a patient to lose full sensation of the nipples after augmentation mammaplasty; and if this does happen, the nerves often recover partially or fully after one to two years. Reduced sensation after augmentation mammaplasty is also unusual. Most commonly, nipple sensation is normal after surgery. Occasionally, there can be hypersensitivity (increased sensation) that may be uncomfortable for a few months. This, too, usually returns to normal.

On November 17, 2006, The Food and Drug Administration ended a 14 year virtual ban on silicone gel breast implants, making the devices available to tens of thousands of women who have desired for them.

The Food and Drug Administration approved the implants made by Inamed Corp (now part of Allergan, Inc.) and Mentor Corp. The action opens the implants to much wider use by women seeking to reconstruct or augment their breasts. Since 1992, the silicone implants had been available only as part of research studies.

Silicone gel implants first went on the market in 1962, before the FDA required proof that all medical devices be safe and effective. Thirty years later, they were banned amid concerns about their safety.

At the time, there were worries about a possible connection to a variety of diseases, including cancer and lupus. Alarming cases of ruptures added to the concern. Since then, studies have failed to find a link between silicone breast implants and disease.

Proponents say silicone gel implants look and feel more natural than do those filled with saline, or salt water. Saline inflatable implants have been available without restrictions.

This news is extremely important because now women have choice in the selection of implants best suited for them.

Breast implants have grown in popularity for augmentation. Last year, 291,000 women had their breasts surgically enlarged in the United States, a 37 percent increase since 2000, according to the American Society of Plastic Surgeons.

A recent article in the quarterly newsletter of the American Society for Aesthetic Plastic Surgery (10:17, 2006) summarized a Canadian research article showing that there was no association between cosmetic breast implants and breast cancer in more than 25,000 patients.

The study compared 24,558 women who had cosmetic breast augmentation to 15,893 women who underwent other cosmetic procedures. Overall risk was similar in both groups.

Another study (J. Natl Cancer Inst. 98:557, 2006) done in Sweden followed 3,486 breast implant recipients for a mean of 18.4 years and found no association to breast cancer, brain cancer, sarcoma, non-Hodgkin lymphoma or multiple myeloma.

In our own practice, which now spans 34 years, and over 1,500 patients who had augmentation mammaplasty, we are not aware of any association of any of the cancers nor of any connective tissue disorders (collagen diseases) such as scleroderma, lupus erythematosis or rhenmatoid arthritis.

Our study on pain pumps was recently referenced in the September 2006 issue of Cosmetic Surgery  Times. The author discusses the value of having a long acting local anesthetic as an effective means of managing postoperative pain after cosmetic or reconstructive surgical procedures. Benefits involving the use of pain pumps include a "reduction of pain scores, lessening of narcotic use and associated adverse events, improved pulmonary function, and greater patient satisfaction relative to placebo-treated controls."

A study of publications describing the use of pain pumps "in patients who had undergone augmentation mammaplasty, abdominoplasty and breast reconstruction" demonstrated decreased use of oral/intravenous pain medications, lower pain scores, and earlier ambulation. "In addition, those papers indicated favorable safety, with no reports of catheter or pain pump related complications."

Our own study (Aesthetic Surgery Journal, Vol 24, No 6, Nov/Dec 2004) was referenced as follows:  "One published study conducted in augmentation mammaplasty patients suggests that a variation on the pain pump involving intermittent self-administration of bupivicaine may offer an effective and more economical alternative to continuous anesthetic infusion. Patients in that study had an indwelling catheter for continuous infusion of bupivicaine in one breast and self-administered a bolus of local anesthetic (in the other breast) either every six hours as needed for up to two doses or every four hours routinely over 24 hours. All of the protocols appeared effective in controlling pain, according to the investigators."

A recent interesting publication in the August 2006 issue of Plastic and Reconstructive Surgery (Heden, P. et al Prevalence of Rupture in Inamed Breast Implants PRS 118:303-310 2006) attempts to define rupture rates in third generation silicone gel implants by using MRI (magnetic resonance imaging). This multicenter European study determined an incidence of about 8% rupture studying 199 implants, 10-12 years after implantation for either breast reconstruction or for cosmetic reasons.

Silicone gel implants are only conditionally approved in the United States by the FDA for use in breast deformities including correction of breast hang. They are awaiting data regarding the complication rate before widespread approval. At the present time, only 3rd generation silicone gel implants have been approved. First generation silicone gel implants were used through the mid-1970's consisting of a thick shell and thick gel. These implants generally had a firmer less natural feel and were replaced by second generation silicone gel implants used to the mid 1980's consisting of a thin shell and softer more natural soft gel, but were more prone to rupture. Ultimately, the FDA insisted on a moratorium for the use of silicone gel implants until the complication rate could be determined. The new third generation silicone gel implants, widely used in Europe, but prohibited until recently in the United States, have a multilayered low bleed shell, with a highly viscid soft gel in the interior. When cut in half, there is no flow to the gel, yet it is soft and natural in the breast.

The study is important because only third generation silicone gel implants were studied over a long time frame. This information will add to the volumes of information that the FDA will be studying.

There were a number of drawbacks to the study:

• MRI can give both false positives and false negatives. True rupture can only be confirmed with surgical exploration, which was not done.
• No distinction was made between cosmetic and reconstructive procedures.
• No distinction was made regarding the site of the incision. Trauma to the implant using a small incision such as the areolar approach is a distinct possibility and is one of the reasons we use the inframammary (breast fold) incision.
• No distinction was made between textured and smooth implants.

In our own Plastic Surgery Center, we have been given approval as investigators for the use and study of silicone gel implants. We find that the results are very soft and natural. A drawback is the large 6 cm (2-1/2 inch) incision required to introduce these implants versus 3.5 cm (1-1/2 inch) for inflatable implants. This large incision is needed to avoid excessive trauma to the implant during insertion. Long term complications are as yet unknown, though it is been shown repeatedly in the literature that silicone gel implants are not related to connective tissue disorders such as Scleroderma, Lupus Erythematosis, and Rheumatoid Arthritis.

Today was a fun day at our surgicenter. We had two women who had nearly identical operations, one with 350cc silicone gel implants, the other with 390cc inflatable and both had crescent breast lifts.

The first woke up minutes after her surgery and kept repeating "I can't believe its over" "I feel great." This of course gave our second patient lots of confidence who also had a smooth operation.

I call all my patients after their surgery. Patient one continues to do very well and patient two who is also doing well, gave a new meaning to augmentation mammaplasty when she called her new arrivals "Fun Bags." After we both had a good laugh about it, I thought today's events were worth a note!

Sometimes we notice things in our patients that are not described in the literature. One such aspect is the disappearance of a patient's natural breast tissue seemingly a result of the pressure imparted by the underlying implant which I have termed "compression atrophy." This comes up when I am doing a consult for someone who wants oversized implants.

When I re-operate on a patient who may be having a problem, or for someone who wants a size change, I have noticed that much of the natural breast tissue seems to have disappeared, and that the remaining envelope is thinner than during the first operation. All patients have a "bimanual examination" during surgery to palpate for any breast masses. With fingers in the interior dissected space, and the other hand used to press against the outside of the breast, one can feel for masses, as well as an understanding of the thickness of the breast tissues. It is during a secondary procedure that I have noticed the diminution of the breast tissue.

It is my concern that excessively large implants may cause more compression atrophy than small or normal sized implants. It is something to keep in mind when thinking about the final size you would like to be.

I have enjoyed being the "Doctor on Call" for Nicole's website http://implantinfo.com. I think she does an excellent job with her website and provides a forum for an exchange of information and education. Of the many questions that are "fired" at me, it seems that about half the questions are related to problems with oversized implants.

Compression atrophy may be one more good reason to choose implants that are appropriate for the body structure.