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Who is an ideal candidate for breast augmentation? Even though one might want one’s breasts enhanced, not everyone is the best candidate for breast augmentation. Ideal candidates include women over 18 who are in good physical and mental health. They have realistic expectations and understand that although their breasts will be larger, they might not be perfect. Specifically, breast augmentation will not improve nipple asymmetry, change the position of breasts or lift saggy ones. Other surgical procedures can remedy these conditions (i.e., breast lift, nipple repair, etc.). Those who are not eligible for breast augmentation include women that are pregnant or nursing or those who currently have breast cancer. What are the different types of breast implants? Implants are generally classified into smooth and textured implants. Smooth implants were commonly used in the majority of breast augmentations. They are less likely to be rippled in appearance, and because they are made with thinner walls than a textured implant, they are more natural to the touch. Textured implants were designed to lower the chances of capsular contracture. The textured surface was designed to “prevent scar tissue fibers from laying down uniformly in a parallel fashion and thus tightening up.” How do I select the implant size? Perhaps the most complex decision patients must make is choosing their implant size. It is a tricky choice because so many factors play a role in the final result. First, it is important to know that implants come in many different sizes, but they are not sized like bras. A, B, C, D, and DD implants do not exist. Rather they are labeled according to their volume, which is measured in cc (cubic centimeters) or ounces. For reference, 1 cc=1 mL and 250 mL = 1 cup. Implants can range from 125 cc to 1200cc. Traditional cup sizes are not used because the original breast size of the patient contributes to the final breast size. For example, to get to a D cup in the end will require different size implants on someone with original A cup versus a patient with an original C cup. Next, one must understand that implants can also be filled to different volumes. The same size implant can have different amounts of saline injected depending on patients’ specifications. Many surgeons and implant manufacturers recommend overfilling a smaller implant rather than under filling a larger one. Overfilling helps prevent rippling, deflation, and sloshing. The manufacturer will provide the doctor with a range of recommended ccs for each implant. Furthermore, the location of the implant in relation to the muscle will contribute to the final size and appearance of the breast. Although implants under the muscle tend to look smaller, they have a more natural slope whereas implants above the muscle tend to have a more “fake” look or “roundness” to them. Neither look is good or bad, just personal preference. Finally, there should be an extensive dialogue with the doctor on one’s size expectations to insure that the patient and the doctor have the same goals. Also, keep in mind that according to much literature on the Internet, after all was said and done many women wished they had gone larger with their implants. With larger implants one can anticipate increased pain, bruising, and stretch marks. What's more, the larger the implant one chooses, the more breast tissue that is necessary to adequately conceal the implant. If there is not enough breast tissue present, the edges of the implant may be visible through the skin or it may be felt more easily. What are the different implant placement locations? Obviously, all implants are placed in the breast tissue. However, a distinction is made depending on the exact location of the implant and its relationship to the pectoralis muscle in the chest. There are actually three potential placement sites for the implants:
Subglandular (Below the glands) The implant in this case is placed on top of the pectoral muscles in the chest. This procedure is also referenced as overs, retro glandular and sub mammary. As with any decision, there are pros and cons. The benefits of a subglandular placement are mostly contributed to the fact that the muscle has not been disturbed. These benefits include a shorter surgery time, less recovery time, and less pain. Implants will sag in tandem with the breasts, so a “double bubble” is not the result. Also, because the implants are not behind the muscle, they will be more accessible for the inevitable re-operation due to either their replacement or removal. This lack of concealment also contributes to several disadvantages. For instance, “overs” are more palpable and potentially visible depending on the amount of breast tissue of the patient. The more breast tissue the less chance one has to see or feel the implant. Subglandular placements also make for more difficult mammogram readings because the implant obscures some of the glands. Additional views are necessary and insurance won’t always pay for them. Also, capsular contracture, a common complication, is more likely to occur in subglandular placements. Complete Submuscular The implant in this case is placed under the pectoralis muscle which is located between the chest wall and the breast tissue. However, in the complete subglandular the entire implant is covered and supported by the pectoralis and serratus muscles in addition to the abdominus rectus fascia. With a complete submuscular placement, the surgery takes longer, more recovery time is needed, and it is more painful because the muscle has been distressed. Furthermore, the implant will be more difficult to access during either future replacement or removal of current implants. Because there is more support than just skin, the chance of “bottoming-out” is reduced. Although implants placed under the muscle are initially high, they settle to look very natural because the more natural tissue that covers an implant, the more natural it will look and feel. This “natural cover” reduces rippling and palpability. What are the different incision sites? The implant can be inserted into the body through four different incision sites. Two leave scars on the breast, while the other two leave scars away from the breast. All of the incisions are small, generally measuring less than one inch. The physician will lift the breast tissue and create a pocket for the implant either behind the muscle or behind the breast tissue. The method one chooses will depend on one’s anatomy, expectations, breast condition, implant placement and physician’s recommendations.
The inframammary incision is the most common technique used. The cut is made on the underside of the breast at the inframammary fold, where the crease of the breast meets the chest. Placements above and below the muscle can be done this way as well as any future implant replacements or revisions. Many surgeons prefer this method because it allows for great control of final implant placement. The main disadvantage is a visible scar in the breast area. Also, recovery can be longer and more painful than with some other methods. It should be noted that if a patient chooses to go with bigger or smaller implants on subsequent surgeries the initial scar will be placed differently on the breast. It might not be as concealed. For example, a once hidden scar may creep up on the breast if the breast is enlarged. Periareolar The periareolar incision is made on the lower edge of the areola. This is the dark circle around the nipple, not the nipple itself. In most cases, it is the most concealed incision and the scars tend to heal well. All placements can be done this way including revision surgery. Moreover, physicians have desired control over implant placement with this incision. If one is considering a breast lift, this is the incision to opt for because the same opening can be used for both procedures. There is no other alternative for breast lift incisions. There are some disadvantages to periareolar incisions as well. For example, since the scar is located right on the breast, if there is any complication with the scar such as deformity, redness, or swelling, it will be more visible. This incision has also been associated with a greater inability to breastfeed. Generally the periareolar cut does not cause any less sensation than the others, but women with smaller areolas may notice it more because the incision might extend past the areola. Also, one is more likely to be exposed to the natural bacteria found in breast tissue with this incision. Thus it is necessary for the surgeon to use a protective “sleeve” around the implant so it will not be contaminated by the bacteria in the breast ducts. Axillary This incision site is located in each armpit. With this method, most likely an endoscope will be used although some skilled surgeons opt not to use it. It depends on the surgeon and his/her experience. One obvious advantage of the axillary incision is that the scars are tucked away in the natural folds of the armpit leaving a scarless breast. As with the other afore mentioned incisions, all placements can be done this way. There is no quantitative research that can associate loss of nipple or breast sensation to a particular incision site. Implant size and surgical technique may have more to do with decreased sensation than incision location. Remember, there is no one right incision site. It is up to each patient to decide which one is best for her. What can I expect during the recovery period? After surgery, patients can expect a variety of pains and sensations. Remember these symptoms are normal and are only temporary. Some discomforts may pass within days while others might take a few weeks. Patients might experience any of the following:
Size, surgical technique, patient diligence to post-op instructions and complications will contribute to the amount of postoperative pain and time of recovery. Luckily, most of the pain can be controlled by pain medication prescribed by the operating surgeon. Even with all of these ailments, patients will be up and moving within 24-48 hours. Patients can often return to work within days, and moderate activities can be resumed fairly quickly. It may be a couple of months before one can return to strenuous activities. Stitches are usually removed within seven to ten days. A surgical bra may then be required. Recovery may be facilitated by following these tips:
Any surgical procedure has potential risks and complications. In addition to these, there are several complications unique to breast augmentation:
Next step: Many factors decide whether you are a suitable candidate for surgery. Here are a few ways you can proceed:
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