Minneapolis, Minnesota Breast Enlargement with Implants (Breast Augmentation)
Breast enlargement (augmentation mammoplasty) is the second most common cosmetic operation performed in the United States – over 399,000 women requested this operation in 2007, up four percent from 2006 and up 295 percent from 1997 [American Society for Aesthetic Plastic Surgeons Data]. Breast enlargement has been the most common operation performed at Minneapolis Plastic Surgery, LTD. in Minnesota for the past four years; every year several hundred patients undergo the one-hour outpatient breast enlargement operation. The breast implants are placed in our office surgical facility. In addition, our surgeons provide breast enlargement patients with a lifetime of rechecks at no charge.
Candidates for Breast Enlargement
Some women who choose breast enlargement do so to restore breast volume lost as a result of pregnancy, breastfeeding, weight loss, or aging. Others request this outpatient operation to improve symmetry in breasts that have never matched in size, and many women simply seek the improvement in self-image or clothing fit that fuller breast size gives them.
Whatever the reason for requesting information about this operation, you must understand that this operation is appropriate for you if and only if:
- You have realistic expectations regarding potential risks vs. benefits.
- Your breast development is complete (for younger women).
- You have decided to undergo this operation to feel better about yourself, not to live up to the expectations of anyone else.
- You are not pregnant or breastfeeding.
Basic Facts
- Breast implants do not increase the risk of developing breast cancer.
- Mammography and breast self-examination can be performed on augmented breasts.
- Augmented breasts both look and feel normal in the majority of women.
- Breast implants do not harden, nor do they automatically need replacement after ten years.
- Nipple sensation and the ability to breast-feed are preserved in most patients.
- Breast implants (both silicone gel and saline) do not cause or increase the risk of developing arthritis, lupus, scleroderma, or connective tissue diseases.
- Saline implant leakage and deflation is uncommon and can be dealt with when it does occur.
- Silicone gel implants are now available for use in first-time breast enlargement patients over the age of 22. They are “cohesive” and cannot deflate.
Your Consultation
Any patient considering breast enlargement with implants must have a personal consultation, during which she will discuss her individual cosmetic goals and concerns with Dr. Richard H. Tholen or Dr. Douglas L. Gervais at our Minneapolis, Minnesota office. A complete medical and surgical history will be obtained from all patients interested in breast enlargement or breast implants and should include information about allergies to any medications. You must inform your surgeon of all prescription or over-the-counter medications, including herbal, vitamin, nutritional supplements, and appetite suppressants. Some of these can interfere with proper blood clotting and increase the risk of bleeding after surgery. Breast enlargement patients must avoid aspirin or ibuprofen-containing products, Aleve™, additional vitamin E (the dose in a single daily multivitamin is acceptable), and any herbal remedies for a full two weeks before and after surgery.
Your pregnancy, breastfeeding, and mammographic history is important, as is physical examination of your breasts, nipple-areola position, and skin and muscle tone. If there is excessive ptosis (sagging of the breast skin) or malposition of the nipple-areola complex, a breast lift (mastopexy) procedure may be necessary. After examination, your surgeon will determine the exact type of breast lift that will be necessary and explain the additional incisions and resultant permanent scars that are involved. Other conditions such as nipple inversion, tuberous breasts, significant asymmetry, Poland's syndrome, or changes due to prior surgery, can be corrected or improved. Augmentation with breast lifting requires additional operating time, incisions, and cost, but will be necessary for women with more breast ptosis (drooping or sagging of the breast skin) or nipple position below the inframammary crease. Consultations are complimentary at Minneapolis Plastic Surgery, LTD. To schedule your consultation, please contact our staff.
Choosing Your Breast Implants
Breast implants come in smooth and textured surfaces, and also round or teardrop ("anatomic") shapes. While some plastic surgeons prefer the teardrop-shape implants in some situations, the smooth round implants are generally the softest, most natural in appearance (upright and lying down), least likely to be felt externally, and (for saline implants) least likely to leak.
Textured surface implants have a thicker shell, are more likely to be felt externally, and do have a somewhat higher leak rate (saline implants) because of the innate weak areas in the tiny peaks and valleys of the shell surface. Since teardrop-shaped implants must have proper positioning and must stay in that position (sloped part up, rounded part down) to take advantage of their innate shape, by necessity they are textured so that the body's tissues can adhere to and maintain the proper position of the implants. Thus, the teardrop implants do not move as the patient changes from a standing to a reclining position. Also, the teardrop implant remains teardrop-shaped when the patient is lying down, whereas the natural breast flattens out and assumes a round appearance. Teardrop implants are also more costly than round smooth implants.
The smooth round implant does just what a natural breast does: it is teardrop-shaped when the patient is upright, and flattens and drops slightly to the side when the patient reclines. Thus, the round implant is actually more "anatomic" than the teardrop or so-called anatomic implant.
What is the Right Size for You?
Final breast size can be estimated in a number of ways; one of the best techniques for choosing implant size is for the patient to bring photographs of models with the desired (final) breast size. The proper size implant to most closely achieve this appearance is then chosen in the operating room. This has proven to be much more accurate than the patient requesting a letter cup size, or trying to find a similar person via internet search whose anatomy and/or results approximate your goals. Trying on implants in a brassiere can provide some idea of desired final breast size and the implant volume needed to achieve that size; however, it is essential not to become overly attached to a specific bra cup size (B, C, D, etc.) or implant volume (400cc, etc.), since your own breast tissues and chest muscle will conceal an implant's impact on your appearance significantly more than a cotton stretch bra or lace brassiere. Typically, a woman who chooses a specific cc volume implant that she feels looks good in her bra will be too small after surgery if that exact volume implant is used in her body. A good general rule of thumb is to add 50 to 100cc to the implant volume you feel looks good if you choose to size in a brassiere. In other words, if you like how a 400cc implant looks in a bra, it will take a 450-500cc implant to look about the same size in your body.
Since what this surgery accomplishes is volume increase, your own skin brassiere (pre-surgery breast shape) will determine your final breast shape after implants increase your breast size. Size will also determine just how much breast mass extends to the side of the chest (armpit area), or into the cleavage region, since proper implant positioning is determined by the position of your nipple areola complex.
For instance, a woman with widely spaced nipples will need to have her breast implants positioned more laterally (towards the armpit area), since the implant pocket and final breast mound must be properly centered beneath the nipple areola complex. If the implants were simply placed close together in the center to give the full cleavage look, each nipple areola complex would then be too far lateral, giving a "wall-eyed" appearance.
Similarly, a woman who has more medial nipple position would have a "cross-eyed" appearance if she requested lateral fullness and her implants were placed laterally without taking into account the nipple position atop the new breast mound.
Your surgeon and you determine size and position; your own anatomy determines shape (unless you also need a lift, where incisions are made to lift or otherwise shape your breast skin).
Most women requesting this surgery emphasize that they do not wish to be "too large" after augmentation. There is a natural hesitancy to make a change that is so dramatic that "everyone will know" or that might embarrass you at the health club, swimming pool, relative's home, or church meeting. Most patients have these concerns, and many verbalize this. However, 6-12 months after surgery, when these concerns evaporate, and the social settings where "someone might notice" are successfully overcome, a surprisingly large number of patients admit they now wish they had chosen larger implants. Some undergo another operation to place new (larger) implants. Fortunately, the surgical pocket for the implant is already healed, and recovery is quicker when size change is requested. Although the choice of size is entirely up to each individual patient (with some anatomic limitations), choosing just slightly larger than what you consider to be optimal preoperatively will help you to avoid reoperation for size change, including the cost of new implants, operating room, and anesthesia.
Types of Implants
Breast implants come in numerous sizes, configurations, surface characteristics, and fill material. However, the material inside breast implants is what gives them their “feel,” and choice of filler material has generated much controversy and media interest, not to mention scientific debate.
Silicone or saline?
Saline identical to intravenous fluid was the most common type of filler material used in the United States from 1992 to November 2006, when the FDA approved the use of silicone gel-filled implants. Prior to the 1992 FDA restrictions, silicone gel implants were utilized in over 85% of all breast augmentations in this country, and remain the most commonly used implant worldwide. Other types of filler material have been evaluated over the years, and one or more problems are associated with these. Paraffin, sponges, and other unusual materials were used in early efforts to enlarge breasts; results were dismal until silicone came into use in the 1960’s. More recently, soybean oil-filled implants were studied extensively, and were used in many patients in Europe, as well as a few US patients in FDA studies. Breakdown of the oil, rancid smell, and other concerns ultimately led to withdrawal of this implant (Trilucent™) in the US and in Europe. Fat as implant fill material has the same concern, and is not done. Fat graft injections of a patient's own liposuction fat (directly into or beneath the breasts) have been proposed by some physicians. The American College of Surgeons and the American Society of Plastic Surgeons condemn this procedure because it can cause microcalcifications within the breast and interfere with the mammographic detection of breast cancer. A recent study confirms that fat cells removed via liposuction are mostly destroyed and non-living; freezing the fat kills even more cells (ice crystals puncturing cell walls kill the fat cells), so this is worthless and potentially harmful.
Other implant materials are being studied, including a more firm, teardrop-shaped cohesive silicone gel (the “gummy-bear” implant). This study implant retains its form and innate integrity even when its outer shell is punctured. This implant is more firm (like a “gummy bear” or silicone bathtub seal) than the softer “standard” silicone gel implant and requires a larger 2.5-inch incision for placement. However, the standard silicone gel breast implants presently used (as part of the more general FDA study since 1992) are softer but also cohesive, and they do not leak if the shell is cut or punctured. These silicone gel implants can be inserted via a 1½-inch incision. Cutting either of these types of breast implants is like cutting Jell-O—you get two intact parts but leakage does not occur.
With silicone gel implants, microscopic gel molecules can still enter a patient's body, just as liquid silicone does in the patient who has an injection with a needle lubricated with liquid silicone. No scientific study to date has provided credible evidence that silicone has any cause-and-effect relationship with autoimmune diseases or conditions such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant illnesses." With these studies in mind, silicone gel breast implants were FDA-approved in November 2006 for elective first-time cosmetic breast enlargement in women over the age of 22.
Smooth or textured?
The surface of breast implants can be smooth or textured, and the filler material silicone gel or saline. When silicone gel implants were used prior to the FDA restrictions of 1992, placement above the muscle was also the preferred implant position for many plastic surgeons. Texturing the surface of the silicone gel implant reduced the incidence of capsular contracture in this position (above the muscle and just below the breast tissue). However, after the FDA restriction on silicone gel implants and the switch to saline-filled implants, placement above the muscle led to unacceptable wrinkling that could sometimes be felt or seen. This led to most surgeons switching to placement of saline breast implants below the muscle to increase tissue coverage and reduce these concerns. Even placement of saline-filled implants below the muscle will not always make it impossible to feel or see implant wrinkles or ripples, particularly in thin patients and/or patients with very little overlying breast tissue. Now that silicone gel implants are again available, more patients will be able to avoid the “water-balloon” feel and visible or palpable rippling seen in some saline implant patients.
Using textured breast implants below the muscle can cause unnatural adherence to the chest and restricted natural movement of the breast. In addition, the lack of gel to act as a lubricant inside the implant (saline is a poor lubricant) can allow flexing and creasing of the implant shell surface with each movement or breath of the patient, ultimately leading to a higher risk of failure at one of the low spots in the textured surface, with leakage and deflation of the saline implant. The textured implant shell is also thicker and more palpable. Submuscular placement already reduces the incidence of capsular contracture, so smooth breast implants in this location are preferable to adherent textured-surface implants. The smooth-shell saline-filled implant placed below the muscle is soft, less palpable, and less likely to deflate (if properly filled), and has low rates of capsular contracture formation. It also moves with the patient's position and is therefore more natural and breast-like.
However, smooth-shell silicone-gel-filled implants are even more homogeneous with breast tissue and provide the softest, most breast-like, and most natural “feel” of any implant.
Anatomic (teardrop-shaped) or Round?
Implant shape is another frequent question. The so-called "anatomic" or teardrop-shaped implant has a textured surface and a sloped upper pole with fuller lower pole projection. It has been suggested that this implant has a more natural look than the round implant, and much advertising and marketing has been used to promote this implant to the public. The implant is a perfectly good device, but it is more expensive than the smooth, round implant, and whether or not it is truly more "anatomic" is questionable. A recent study compared actual women with smooth, round implants to women with textured, teardrop-shaped implants. Mammograms were performed in upright and supine (lying-down) positions, and digital tracings computerized and compared. Both the round and teardrop-shaped implants had a sloped, teardrop shape when the women were upright. In fact, the two types of implant were indistinguishable on X-ray. But when a woman is lying down, the natural non-augmented breast flattens, drops to the side of the chest, and assumes a round shape, as does the round smooth implant. The teardrop-shaped implant stays teardrop-shaped in the lying-down position, which makes this actually less anatomic than the round implant! Still, in rare situations, the textured or teardrop-shaped implant may be an appropriate choice.
Are Silicone Breast Implants Safe? A Brief History
The modern era in breast augmentation began with the development and surgical implantation of silicone gel breast implants in a woman in 1963. In the 30 years that followed, plastic surgeons worldwide used silicone-gel-filled breast implants for both breast reconstruction and elective breast enlargement in well over one million women. Saline-filled breast implants were also used during this time, but in only about 15% of all patients receiving implants.
Breast implants were developed and utilized for more than a decade before the FDA began regulating medical devices in 1976; the safe and effective use of silicone in these and other medical products such as pacemaker insulation, lubrication for insulin needles, chemotherapy tubing, and artificial joints was well-established before the FDA could evaluate all of them. Because silicone breast implants and many other silicone medical devices were already in use prior to 1976, the ongoing use of these products was “grandfathered” by the FDA without formal evaluation and approval. None of these other silicone medical devices has been made unavailable to patients, but lack of formal FDA evaluation and approval of breast implants came into public awareness in the early 1990s.
The lay media has been responsible for spreading a great deal of information and misinformation regarding breast enlargement in the past decade and a half. Many women remember tabloid and TV talk shows' focus on the supposed problems claimed to be associated with silicone gel implants. Despite a lack of scientific data supporting these concerns, in 1992 the FDA restricted the use of silicone gel breast implants in women requesting elective breast augmentation.
At no point have silicone gel implants ever been “taken off the market,” but until November 2006 their use required enrollment in the FDA study that allowed only eligible patients and plastic surgeons access to them under strict guidelines. Since the FDA restrictions in 1992, numerous scientific studies (over 30 in the past decade) have continued to show NO cause-and-effect relationship between silicone gel breast implants and autoimmune-type illnesses (such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant" diseases). Since 1992, silicone gel implants have been used by plastic surgeons (including both Dr. Tholen and Dr. Gervais) involved in FDA-approved studies for patients undergoing breast reconstruction, breast augmentation revision (in certain patients), breast lift, and for those patients with congenital breast deformities.
After exhaustive review of the past nearly four decades of use, the FDA approved the use of saline-filled implants in May 2000.
Late in 2003, the FDA reviewed all of the available scientific data about silicone gel implants, including very detailed information from implant patients over the past decade, and heard testimony from patients, physicians, and researchers. The expert physician advisory panel to the FDA voted 9-6 to recommend that the FDA approve the use of silicone breast implants for primary elective breast augmentation. However, the FDA deferred its decision, requesting “additional information” before granting approval.
In spring 2005, the FDA again revisited the request by both of the existing implant manufacturers for approval of general use of silicone gel implants; the expert physician advisory panel recommended approval for Mentor Corporation’s gel implants. Late in 2005, Both Mentor and INAMED® received letters of “[gel implant] product approvable” from the FDA.
On November 17, 2006 the FDA approved the use of silicone gel implants from both companies in patients over the age of 22, with certain restrictions, including involvement in the FDA study that has been ongoing for the past several years.
Opponents of silicone gel implants continue to claim that they cause autoimmune illness or are unsafe, but peer-reviewed scientific studies by many researchers and institutions have shown them to be safe and effective for their intended use. The controversy about silicone gel implants has made them one of the most intensely studied products in the medical marketplace.
Timing of Surgery
Many women wonder if they should wait until their family is complete before undergoing breast augmentation. Certainly, pregnancy and breast-feeding change the breast skin, shape, and size; this is one of the main reasons many women choose to have this surgery. Should a woman who has never had a child (and plans to in the future), or a woman who wishes to have more children later, undergo augmentation mammoplasty? If your breast development is complete and you wish to have breast enlargement surgery, and then later become pregnant and breast-feed, your breasts will indeed change in appearance, just as in a woman who has large breasts naturally, becomes pregnant, and nurses her baby. Since breast implants are in most cases beneath the chest (pectoralis major) muscle, and in all cases beneath the breast itself, the presence of implants does not interfere with the function of the breasts. Whatever breast tissue a woman has prior to breast enlargement surgery will swell and respond to the normal hormonal changes of pregnancy and later breast-feeding. The degree of enlargement, skin stretch and later droop or sagging is as individual as each woman. A patient who had augmentation prior to pregnancy may choose to undergo a breast lift when her family is complete, just as the woman without breast implants. Others may simply choose a slightly larger implant to further fill the stretched skin brassiere. Or, you can indeed wait until your family is complete, and then undergo augmentation to obtain desired breast size, or augmentation plus mastopexy if a lift is needed in addition to restoring volume. What you need to know is that it is safe and appropriate to choose either way, whichever is best for you.
Breast augmentation does not generally affect the ability to breast feed. One study shows that about 54% of women without implants reported problems nursing. 93% of breast augmentation patients had their children before undergoing the procedure, so nursing was not an issue. Of the 7% who had children and nursed them after augmentation, 50% reported problems, essentially the same number as those without implants.
Some surgeons have postulated that if a periareolar (around the dark part of the nipple) incision is chosen, a smaller percentage of women will preserve the ability to breast feed. If you have never breast-fed and undergo augmentation (regardless of incision chosen), you will, in the majority of cases, retain whatever breastfeeding capability you had prior to surgery. Most women who have breast-fed prior to undergoing breast augmentation have successfully been able to nurse again after augmentation mammoplasty. However, as noted in the study above, many women are not capable of breast-feeding (irrespective of breast size), and these patients will still be unable to nurse a baby after augmentation mammoplasty.
If you have fibrocystic mastitis (this is not a "disease" since about half of all women have fibrocystic changes in their breasts) you may note tenderness or swelling in your breasts prior to your menstrual cycle. Augmentation mammoplasty does not change this for the better or worse in most cases, but it is advantageous to consider a surgery date that is just after your period rather than just before, in order to reduce pain, swelling, or bleeding tendency with your surgery.
Choice of Incision
There are four types of incisions used for augmentation mammoplasty: axillary (armpit), periareolar (around the areola – the dark skin surrounding the nipple), umbilical (belly button), and inframammary (in the skin crease under the breasts). Each of these choices has pros and cons; some surgeons use some or all of these options, whereas others have a preference based on training, experience, or habit.
- The armpit (axillary) incision is often thought to create a "hidden" scar because the scar is not visible on the breast itself. However, the armpit scar can be visible when the arm is raised while the patient is wearing a swimsuit, sleeveless top, or strap-type blouse, and this scar may be wider or more visible than other areas because of its presence in a warm, wet, bacteria-rich environment which is constantly being stretched with every arm movement.
In addition, dissection from the armpit incision requires that the arm be elevated during surgery, raising the position of the breast and potentially causing malposition of the implant with relation to the crease. A higher proportion of high nipple, "bottoming-out" augmentations are caused by improper pocket creation that results from this incision raising the breast during surgery.
One final consideration with the axillary incision is that dissection from this vantage point is somewhat more likely to cause nipple sensation loss, since the (lateral fourth intercostal) nerve to the nipple runs along this route on the side of the chest wall.
- The periareolar incision is generally made from the three o'clock to nine o'clock position at the junction between the normal breast skin and the darker adjacent areolar skin. Usually, this scar can be minimally visible when healed; however, this scar is visible when unclothed and can occasionally be unsightly, wide, thick, or irregular and it can produce a sharply visible line in an area where the areola color normally undergoes a gradual transition from dark to light. In addition, this incision requires cutting through ducts that end at the nipple, as well as the breast tissue itself, in order to create the implant pocket. This can cause internal breast scarring and/or calcification, which can make mammograms more difficult to read. Since the nerve branches to the nipple area are partially cut by this incision, a somewhat higher likelihood of nipple-areola numbness is present. Ductal bacteria may also increase the possibility of capsular contracture, so cutting through breast ducts is inadvisable, in our opinion.
- The umbilical incision involves use of an endoscope (a lighted tube commonly used to perform tubal ligations, appendectomies, gallbladder removals, and visual evaluations of the stomach or colon) to create a pocket beneath the breast or chest muscle for the implant. The implant pocket is created by blunt dissection with a temporary tissue expander. Bleeding or inframammary crease malposition can require an additional incision on the breast, which negates the main advantage of using the umbilical approach (no visible breast scar). Very few plastic surgeons utilize this incision for breast augmentation, and the learning curve is difficult, but acceptable results have been produced by reputable, board-certified plastic surgeons, so consideration of all options is reasonable. Silicone gel breast implants cannot be placed via this incision.
- The inframammary incision (beneath the breast in the crease) is the most common one used for breast enlargement with implants. We believe this incision provides the best exposure for creating an implant pocket with the least amount of bleeding (and the highest likelihood of controlling this bleeding should it occur), avoids the course of the nerve to the nipple in most cases, does not cut through breast tissue and/or ducts (avoiding the mammographic concerns), and leaves a short scar that is not visible clothed or unclothed unless one lifts the breast or looks from beneath. When the patient is reclining, the breast falls to the side and up, and the crease (inframammary) scar can be visible; in most cases it is nearly imperceptible. Both plastic surgeons at Minneapolis Plastic Surgery, LTD. use dissolving stitches beneath the skin surface—no cross-hatch or railroad-type marks, no sutures to be removed, and just a thin-line scar hidden in the natural inframammary crease.
Sensation after Surgery
Regardless of incision choice, creation of the surgical pocket for the implant will unavoidably cut some of the tiny sensory nerves to the breast skin, and skin sensation will be diminished or absent in the areas these nerves supply. Over time, sensation will generally recover as nerves heal, but may not return to 100% of preoperative sensation. Note that this has nothing to do with nipple erectility (response to cold or stimulation), as different nerves are responsible for this response.
In a few cases, depending on your own particular anatomy, the nerve or nerve branches to the nipple-areola region may also be cut during the surgical pocket creation, and you will permanently lose sensation to the nipple-areola complex on that side. About 5-10% of women will lose nipple-areola sensation with augmentation alone, and about 15% will lose nipple-areola sensation if a breast lift is necessary. Again, incision choice can affect these statistics: a higher number of women may lose nipple sensation with a periareolar or axillary (armpit) incision.
Implants and Breast Cancer; Mammography
Numerous scientific studies have shown that augmentation mammoplasty does not increase the risk of developing breast cancer. Even without a family history of breast cancer, a woman has an 11% risk of developing a breast cancer in her lifetime. If there is a family history of breast cancer, these risks are higher. It is important to realize that while breast enlargement does not increase the risk of developing breast cancer; neither does it reduce the risk, so every woman must continue breast self-examination, physician examination, and mammography, regardless of whether or not she has breast implants.
Mammography can still be done successfully in women who have undergone breast enlargement surgery. Most radiologists feel that they can adequately view 99% of a woman's breast tissue even with implants in place, though special techniques and additional views may be necessary to accomplish this.
Although there is a slight chance that mammography might cause leak or rupture of a breast implant, this is less likely with a soft, non-contracted breast, with smooth implants, and with submuscular placement. A radiographic method called the Ecklund technique (also known as the displacement technique) compresses the breast tissue in front of the implant, and not only increases the visibility of breast tissue in the mammogram, but also reduces pressure on the implant. We do recommend a baseline mammogram one year after augmentation, so that any scar tissue or calcium deposits within the breast are documented and available for comparison with any subsequent mammogram.
Getting Ready for Surgery
You will need to see your own physician for a preoperative physical within 10 days prior to your scheduled breast augmentation surgery. This is necessary to ensure you are in good medical condition for an anesthetic and operation. All surgeries and types of anesthesia have some risk; every effort is made to reduce risk wherever possible, particularly since this is elective surgery that you, the patient, request to be performed for you. A preoperative physical is an essential part of this process, just as a pilot's checklist is before he takes a jumbo jet filled with people into the air.
Besides being in good health prior to surgery, you must avoid aspirin-containing products (Bayer™, Excedrin™, Anacin™, Bufferin™, Ecotrin™, and many multi-symptom medications--anything with acetylsalicylic acid [ASA, or aspirin]), ibuprofen-containing products (Advil™, Nuprin™, Mediprin™, Motrin™, and similar multi-symptom medicines containing ibuprofen), Aleve™ (naprosyn), or high-dose vitamin E (this interferes with vitamin K absorption, which is necessary for proper blood clotting). The dose of vitamin E in a daily multivitamin (usually 400 units) is not a problem, and a multivitamin in the weeks before surgery is a good idea. Except for the daily vitamin, all of the above medications should be avoided two weeks before and after surgery, since even one dose can interfere with proper clotting.
You must also discontinue all herbal preparations you may be taking, as many of these remedies contain blood-thinning agents that can cause bleeding and require reoperation. Even over-the-counter appetite suppressants or “natural” diuretics can cause increased risk for anesthesia, and must be stopped a full two weeks before surgery.
Tobacco use of any kind should be stopped completely two weeks before surgery to prevent post-operative coughing that can raise your blood pressure and increase the risk of bleeding or capsule formation, which can cause hard or painful breasts and require reoperation. If you are having a breast lift, the incisions needed to shape and lift the breasts may cause reduced circulation and difficulty healing; smoking even one cigarette, using nicotine gum, or exposure to second-hand smoke may cause areas of the breast skin or areola to die because of lack of circulation. Prolonged dressing changes, skin grafts, or additional surgery may be necessary if you continue even minimal tobacco or nicotine use or exposure.
On the day of surgery, wear loose-fitting clothes, preferably something with front zipper so that it can be put on and taken off without raising one's arms. You must bring a driver as you should not drive a car for the first two days after surgery or while on pain medications. Someone must also be with you the night of surgery, but this person does not need to be a nurse, just someone who can help with medications, ice bags, assist you to the bathroom, or answer the phone.
Anesthesia and the Operation
Minneapolis Plastic Surgery, LTD. has employed the same certified registered nurse anesthesia (CRNA) provider group for the past 15 years. Our team of CRNAs are the best of the best, and use state-of-the-art techniques and the most effective (not the least expensive) anesthetic medicines for your surgery, as well as complete continuous monitoring of blood pressure, EKG, pulse, temperature, oxygen in your bloodstream, exhaled CO2 , and fluids during surgery and your recovery. Our CRNAs, recovery room RNs, and plastic surgeons are all ACLS-certified (advanced cardiac life support) as part of our accreditation process.
You are fully monitored during surgery, and most patients prefer a general anesthetic so they are completely unaware of any discomfort during surgery. Anesthesia choices range from local anesthesia with sedation to general anesthesia; your surgeon and anesthesia provider will determine your exact anesthesia after discussion with you.
Since we utilize intravenous anesthetic medications rather than inhalation anesthetics (gas and nitrous oxide) for virtually all cases, our post-operative nausea and vomiting (PONV) rate is significantly lower than the hospital and/or surgicenter rate of 7-28%. We have tracked our own patients after surgery for the past decade, and our present PONV rate is between 1.5 and 2.5% (for all our surgeries, including complex and longer operations). When you feel better, you do better, bruise less, have fewer bleeding concerns, less capsular contracture, and a much more comfortable experience — not to mention a softer and more natural breast augmentation result.
Dr. Tholen and Dr. Gervais see each of their patients prior to surgery for preoperative measurements and markings. Your preoperative photographs should have been taken during your consultation, or when you arrive for surgery, but before marking. You will meet with your anesthetist, and an intravenous (IV) line will be started. A family member may be with you until you are taken into the operating room. Breast augmentation surgery takes about an hour; recovery takes another hour or so. A breast lift involves more incisions and surgical closure, and will require correspondingly longer operating time and cost.
Written instructions and information about your prescriptions will be reviewed with your family member or responsible adult who will drive you home and stay with you the night of surgery. A nurse from our office will call you the night of surgery to check on you and answer questions. You may call the office at any time (763-545-0443) and speak to our staff or one of the plastic surgeons on call if there are any concerns.
How to Avoid Capsular Contracture
Breast implants do not become hard, ever.
When a breast enlargement patient has abnormally hard breasts, the problem is the scar capsule around the implants—for one reason or another, the capsule has thickened and contracted, squeezing the implant into a smaller space and causing the hard “feel” to develop. The human body creates a scar around any kind of foreign body, whether it is a pacemaker, a breast implant, or an artificial hip. Since every person forms scar tissue around any foreign body, every woman undergoing breast augmentation will have a capsule, but fortunately, only a few will develop capsular contracture to a problematic degree. If the scar capsule is thin, soft, and pliable around a breast implant, the augmented breast will feel soft. Since all scar tissue contracts, an excessively thick, nonpliable, and contracted scar capsule around a breast implant can make an augmented breast feel hard. Capsular contracture can be mild (Baker grade 1) or severe and visibly deforming (Baker grade 4).
Many studies have been conducted over the years regarding capsular contracture, and how to control or minimize the likelihood that it will occur. With a surface skin cut or surgical incision, despite any surgeon's skill, best efforts, and technique, some patients will heal with a thick, wide, or ugly scar. This occurs rarely, and is slightly more common in patients with darker skin. Vitamin E massage, scar pads, steroid tape or injections, or even scar revision plus any or all of the above can be used to reduce visible surface scars. Radiation treatments have even been used for the most severe surface scars, known as keloids. Fortunately, these are uncommon. Similarly, internal scar contracture causing firmness or distortion of appearance is also uncommon, occurring in 5-10% of augmentation mammoplasty patients. If this occurs, surgical revision may be necessary, and contracture may in some cases recur despite careful reoperation.
Avoidance of most cases of capsular contracture is possible, in our opinion, by careful initial surgery. Any foreign body, such as talcum powder from the surgeon's gloves, cotton fibers from surgical sponges, dust or bacteria from the air of the operating room on the surface of the implant, and bacteria from the ducts of the breast, as well as post-operative bleeding or bruising, can cause an increase in scar formation. This is analogous to a grain of sand in an oyster; in humans, a pearl is not formed, just layers of scar tissue, in response to one or several of these irritants. Every effort is taken to reduce these to an absolute minimum in order to minimize the likelihood of capsular contracture. Both of our surgeons utilize a minimal-touch technique to place implants, as well as antiseptic irrigation, pinpoint cautery control of capillary bleeding, and avoidance of sponges in the pocket. Neither surgeon uses drains for breast augmentation. Drains may allow blood or fluid out of the pocket, but of greater concern is that they can allow bacteria in, increasing the risk of contracture or infection severe enough to require implant removal. Careful surgery and control of all bleeding points is preferable to a drain or a tight surgical bra or elastic wrap after surgery! Intravenous antibiotics are used prior to surgery, and oral antibiotics are continued for several days post-operatively.
Recently, a new type of medication (in use since 1999 for the treatment of asthma) known as a leukotriene inhibitor has been shown to be helpful in possible prevention, reduction of severity, or even reversal of capsular contracture. Though preliminary, the use of this medication (zafirlukast, trade name Accolate™, or a similar drug Singulair™) may be an alternative to reoperation for removal of capsular scar tissue, or may lessen the likelihood of capsular contracture recurring after surgery. If you have liver disease, this may not be a choice for you, as this medication can have hepatic side effects in a small number of patients.
As stated earlier, textured saline breast implants have been shown to have a somewhat higher leak or rupture rate than smooth saline implants. However, even smooth implants can leak or deflate, particularly if they are underfilled. Underfilled breast implants can develop wrinkles or creases that flex and bend with each movement or breath, and eventually a tiny pinhole can develop, causing leakage or deflation. Proper saline implant fill volumes have been shown to be higher than the label on the manufacturer's box; a 300cc implant filled to 300cc has a higher likelihood of leakage than a 300cc implant filled to 340cc, which is closer to the optimal fill volume. Several studies have confirmed the validity of proper “over”-filling; each type of implant has its own optimal overfill volume which your plastic surgeon will then adjust according to your own anatomy and needs. Nationwide five-year leak rates have ranged from 6.8-9.7 percent; our own leak rates are substantially lower at two to three percent. If leakage or deflation occurs, a simple operation to open the incision, remove the old implant, and place a new one can be performed without the discomfort or recovery of your initial operation. The cost of the new implant is covered by the manufacturer.
Of course, if you choose silicone gel implants, there is no intraoperative filling, as the implants come completely filled, sealed, and in many different size gradations directly from the manufacturer. Even if the outer shell of the implant were to be damaged or opened, the silicone gel within the implant is cohesive and non-liquid in nature and cannot “leak” out.
Your surgical pocket will be created larger than the implant on each side, allowing some movement of the implants beneath the breast and muscle, so that when reclining the breasts will flatten, move upward and to the sides, and remain soft like natural breasts. When the pocket is created exactly the same size as the implant, the surrounding scar will contract as it heals and matures, giving an unnaturally firm, round, high and tight appearance (the "coconut on the chest" look). Capsular contracture around an implant can also cause a crease in the implant shell, which with repeated movement such as breathing, increases risk of eventual breakdown at the crease point and implant deflation (with saline implants). Implant movement exercises (massage) may be recommended to keep your implant pocket open and larger than the implant itself, which can aid in reducing the incidence of capsular contracture, and maintain a soft, natural look. Other surgeons prefer a tight bra or elastic bandage after breast enlargement surgery, likely to compress the breast area and surgical pocket in an effort to reduce bleeding, bruising, and resultant capsular contracture from this cause. We believe careful surgery is preferable to a tight bra, bandage, and certainly a drainage tube!
The other side of the coin is excessive softness, thinness, or laxity of the overlying tissue, allowing saline implants to have wrinkles or ripples that can be felt, and sometimes seen. Optimal fill (as discussed previously) and placement below the muscle can help to reduce, but will not always completely eliminate, this concern with saline implants. If bothersome rippling does occur, Dr. Tholen or Dr. Gervais can discuss the options available to improve or correct this problem; switching to silicone gel implants solves this issue (or improves it significantly) in most patients. Avoidance (or significantly reduced risk) of rippling that can be seen or felt can be generally achieved by the use of silicone gel implants in the first place.
Recovery and Results
After an hour or so in the recovery room, you will be discharged to the care of another adult who needs to stay with you for the evening. You will need someone to bring you to your first post-operative recheck, since you should not drive a car for the first two days after breast enlargement surgery, or while taking pain medication.
You should avoid exercising, lifting, or strenuous activity for a full two weeks following surgery, to limit the possibility of bleeding. If you have bleeding, reoperation is necessary to remove the blood, cauterize or suture the source, and re-close the incision. Most patients prefer to reduce activities rather than risk reoperation and the higher rate of capsular contracture that may result if this occurs. You can bathe (shower), get dressed, do your hair and makeup, and carry out normal everyday activities--as long as you avoid anything that might increase your blood pressure or cause your pulse to elevate. This generally means no exercise or other strenuous activity for the first two weeks. Jogging, horseback riding, weightlifting (bench press, military press, curls, etc.), yoga, or any activities that bounce the breasts or stretch the chest muscles should be avoided for a full month.
Although limitation of strenuous activity requirements are simple, straightforward, and in your best interest, a few patients each year feel they can bypass this rule, think they are doing so well that this doesn't apply to them, or decide that they "got away with (an inappropriate activity) once, so it must be OK," and end up in the operating room again. This is usually avoidable, but bleeding can still occur despite everyone's (patient and surgeon) best effort. If this is the case, timely reoperation can remove the blood (usually only a few ounces), control the bleeding source, and avoid or limit any untoward effect on the final result. If you have significant swelling on one or both sides post-operatively, notify your surgeon.
Infection is extremely rare in this operation. It can occur, however, and you must take the prescribed antibiotics until gone to reduce this risk as much as humanly possible. If an implant becomes infected, it must be removed (usually with the other implant, infected or not) and will need to be left out for several weeks to as long as a year, to allow all bacteria to be destroyed by antibiotic therapy and your own antibodies, as well as to allow scar tissue to soften enough to permit replacement of the implants.
You can also reduce the risk of infection by showering rather than bathing, and you should absolutely stay out of the lake, Jacuzzi, pool, hot tub, or sauna for three weeks after surgery. Close contact with animals or household pets should be limited as well during this time. Taking your antibiotics as prescribed does not eliminate the need to follow these recommendations!
You will also receive prescriptions for muscle relaxants, pain medication, and anti-inflammatory before you leave our Clinic; take these as advised to reduce nausea, vomiting, and the resultant increase of blood pressure that might start bleeding.
Keep fluid intake up and walk, move around, and flex your calf muscles to reduce the risk of blood clots. This is important to reduce the risk of heart attack, stroke, pulmonary embolism or sudden death. Do not take aspirin, ibuprofen, Aleve™, etc. during the two weeks after surgery. Resume other medications as advised by your doctor. Return to work based on the activity levels required at your job, and resume exercise or strenuous activity gradually, no sooner than the two weeks discussed above. Jogging, horseback riding, weightlifting, or vigorous sexual activity should be avoided for four weeks to decrease the risk of bleeding, reoperation, and/or capsular contracture. Your bleeding risk is actually highest 10 to 26 days AFTER surgery, as pain and soreness resolve, and activities naturally increase.
Following these recommendations will make the likelihood of a successful outcome as high as possible, and the risk of complications low.Your final appearance will take some time to be achieved, as your muscle, breast tissue, and skin must heal, stretch, soften, and settle over time. Some patients look fabulous days after surgery; most take somewhat longer! Most patients are sent home with a Velcro bandeau placed on the upper part of the breasts. This will be worn at night, and in most cases, patients will be asked to remain braless during the day. This will allow your breast implants to drop into the proper position over time. The amount of time necessary is different for each patient. Do not judge your recovery by the yardstick of a friend's or relative's experience; every patient is unique, and every recovery and result is also unique. Your surgeon will guide you as time goes by and advise you on how to enhance your result. We offer our patients a lifetime of no-charge rechecks and will keep you apprised of the best advice we are capable of giving.
Most patients look good in clothing within days after surgery; unclothed, a soft, natural appearance will take longer to develop. Final softening, settling, and the return of sensation can take several months to as long as a year or so. During this time, or at least as long as your scars are pink, you must avoid tanning booths or any source of ultraviolet exposure in order to reduce the chance of permanently darkening the scars. Vitamin E oil or ointment massage of the scars after three week's time can help to soften and fade them; you should not begin this prior to three weeks after surgery in order to avoid the risk of prematurely softening and stretching the scars. If you have a tendency to form thick or heavy scars, your surgeon may instruct you in the use of scar pads or other scar-treatment remedies as other ways of helping to reduce this concern.
All in all, breast enlargement is a straightforward procedure with a very high satisfaction rate. This information and these recommendations are not intended to be complete or all-inclusive. Post-operative rechecks are designed to monitor your progress and address any specific concerns or questions. Following the guidelines above will help you to achieve the best result that we are capable of obtaining for you.
Copyright 2008 Dr. Richard Tholen and Dr. Douglas Gervais
Contact Minneapolis Plastic Surgery, LTD. in Minnesota for Your Breast Enlargement with Implants Consultation
Please feel free to contact our practice for a consultation at our Minneapolis, Minnesota office regarding breast enlargement with implants. You may also contact us to receive answers to your surgery questions at any time. Our phone number is 763-545-0443.
To view this, you need to install the Flash Player 9. Please go to here and download it.
Those interested in visiting our Minneapolis, Minnesota office for breast enlargement with implants may learn more about the procedure by contacting our office.
* indicates a required field
Minneapolis Plastic Surgery, LTD.
4825 Olson Memorial Highway (Hwy 55) Suite 200
Minneapolis, Minnesota 55422
Phone: (763) 545-0443
Fax: (763) 545-2784
