Breast Enhancement

The women who most commonly request breast enhancement are those who have had children and their breasts have lost volume or women who have never had significant breast development.  Other reasons for losing volume of breast tissue is weight loss or the onset of menopause.  If there is significant sagging or the breasts have an unusual shape they may be better corrected with an implant and a lift.  A breast implant is surgically placed beneath the breast tissue or chest wall muscle.  Breast enhancement can improve self-confidence, help clothes fit better, and make bodies more proportionate.

There are a lot of benefits to breast enhancement, but there are also risks and future costs to consider before you decide to have surgery.  Implants are mechanical devices and will not last forever.  Just like an artificial hip, knee, or heart valve, they eventually wear out.  You likely will need surgery again on your breasts at some point in the future, either to remove or replace the implants.  The implants used for augmentation are saline filled in a silicone plastic envelope or silicone gel in a silicone plastic envelope.

When an implant fails, it will deflate or leak.  When a saline implant leaks, it will deflate over a few days or weeks.  Your body absorbs the fluid, which is intravenous saline.  The breast will look smaller on that side.  It is not a medical emergency, but is somewhat easier to fix if not too much time passes before it is replaced.

You may not be able to tell by physical exam or even mammography that a silicone implant has leaked.  A special MRI may be necessary to detect a leak.  This MRI is 80% accurate in detecting silent leaks.  The newer cohesive gel silicone is stickier and does not ooze out like the old silicone gel.  Older silicone implants leaked out significantly when their shell was disrupted.  Much of the older implants have oozed silicone gel into the breast implant pocket through the intact silicone shell.  The silicone that leaks out of the implant is usually kept in place by the encapsulation your body has built around it.  It is not a medical emergency when the silicone has leaked out of the evenlope.  It is something to remove and repair at your convenience.  The only cause for concern is that if there should be a large enough injury to your breast tissue that disrupts your body's encapsulating scar, the silicone gel may be forced into your soft tissue.  This might cause a granuloma, or scar that could be painful and cause a lump in your breast and would need to be removed.

The silicone filled breast implant has an advantage over the saline filled breast implant in its texture and appearance.  If the original breast is small and the implant is large, or the tissue covering the implant is very thin the silicone may give a better appearance and more natural feel.  Sometimes the saline filled breast implant will have a visible edge with rippling.  Even a silicone implant can have some rippling if the tissue is very thin, though it will be much less visible.  If you are going from a very small breast to a large breast, are very thin, or are placing the implant on top of the muscle with very little breast tissue or fat covering it, then silicone may be a good choice if the texture and lack of rippling is important to you.  For example, a competitive body builder or fitness contestant may do better will a silicone implant over the muscle.  However, if you are increasing the size a modest amount or if you have a moderate amount of breast or soft tissue to cover it then a saline implant may work very well.

The silicone implant information collected over the past fifteen years and presented to the FDA revealed no increased incidence of immune disorders with silicone implants (i.e. rheumatoid arthritis, scleroderma, lupus, etc.).  However, a silicone filled implant does have a higher immediate cost and a higher future cost over a saline filled implant.  To place a silicone implant, the incision, and therefore the scar, has to be longer than that for a saline filled implant.  This is because the silicone implants are pre-filled and bigger initially, so they must go in through a bigger incision.  The implant itself costs about twice as much as a saline implant.  In the future, to evaluate whether the silicone implant has leaked or not, an MRI may be necessary, and will likely not be covered by your insurance carrier if it is related to a cosmetic breast implant.  If the implant has leaked, then silicone will be outside of the implant, coating the scar around the implant, or perhaps even leaked beyond the scar into your breast tissue.  To remove the silicone you will also need to remove this silicone coated scar.  This capsulectomy or scar removal costs about twice as much as it would cost to remove a saline implant and takes longer.

Another consideration is that your mammogram will be slightly affected by the implant.  Both silicone and saline filled breast implants will block a portion of your breast from being evaluated by a mammogram.  Extra views will be necessary to make a more complete examination of your breast.  The mammogram is less affected by placing the implant under the muscle rather than over the muscle.  I prefer to place the implant under the muscle if possible, but there are times that the appearance of the breast is much more natural looking if the implant is placed above the muscle.  This is the case if there is mild to moderate sagging of the breast tissue.

A breast lift may be necessary for a very droopy breast, especially if you want your implant under the muscle.  This mastopexy, or lift, involves scars directly on your breast and around your nipple that may be quite visible.  These scars will be permanent.  To get the best shape possible a significant lift may be necessary.  Unfortunately, there is no way to take a very saggy breast and lift it without scarring.  There is a compromise with shape of the breast and the amount of scarring.

One of the possible complications of breast implants is that your body may form a tight scar or capsular contracture around them.  A tight scar can change the appearance of your breasts.  This is true for either silicone or saline filled implants.  It may be necessary to re-operate to release the scar and make the breast soft again, and unfortunately it is possible that even after a surgical release the tight scar could recur.  Occasionally the use of an asthma drug, Singulair or Accolate, has helped to soften a hard implant scar, but it is not predictable.  It is considered by the FDA as an "off label" use of the drug, but may be worth trying to avoid surgery.

One recent method being advertised and promoted that I do not feel is a safe way to enhance your breasts is injection of substances into your breasts.  The FDA has not approved of the use of any soft tissue fillers in your breasts, and yet it is being done by some people (most often not even physicians, or physicians not licensed in the U.S.).  Some of these substances are non-medical grade silicone injected freely into the breast tissue; some are unknown drugs/fillers of questionable origin.  The long term sequelae of these injections are not known, but if these (often non-sterile) substances should cause an infection, it could be disastrous, sometimes requiring a mastectomy to remove all the contaminating substance.

Some people are promoting injection of your own fat tissue into your breasts.  I do not feel that this is a safe technique of enhancing your breasts yet.  Fat grafting is not predictable.  It takes a huge graft to make a breast significantly bigger, and the larger the graft the more likely you will have problems.  Fat grafting the breast with a large volume of fat tends to cause the formation of cysts of oil, areas of necrosis, scarring and calcifications.  These will render a breast exam for breast cancer useless as it will cause lumps and firm areas within the breast tissue.  It will also likely render your mammogram unreadable with the calcifications and cysts.  That is a steep price to pay with the incidence of breast cancer approaching one in eight women.  Also, a few injections that I have seen have had an undesirable shape and abnormal texture of the breasts.  There is some work being done on these issues in order to find a way to enlarge the breast with your own fat, but it is currently experimental and I do not recommend it at this time.

There are many things to consider if you want breast enhancement.  It is important to discuss the operation and other details with your surgeon.  Your surgeon should be chosen with care.  A surgeon who is board certified by the American Board of Plastic Surgery has had a least five years of intensive post-graduate training.  The training includes academic instruction and rigorous supervised hands on surgical training.  The training involves not only the placement of the implants and lifts, but also teaches the skills to address and avoid the possible complications.  There are many people performing cosmetic procedures with little or no formal training.  It is in your best interest to check on the experience and qualifications of the physician you choose to perform your surgical procedure.  A surgical suite in a physician's office can allow for more privacy and decrease costs.  If you have your surgery done in a surgical center, make sure that it is certified by the American Association for the Accreditation of Ambulatory Surgical Facilities, or other nationally recognized certifying agencies.  The certification assures the availability of specific emergency drugs, monitors, and safety equipment as well as established procedures in the event of a medical emergency.  Breast augmentation can enhance your body and make you more confident, but it is surgery.  Understand what it can do and what to expect in the future.