Please visit our Photo Gallery Page to see examples of Breast Augmentation
BREAST AUGMENTATION GENERAL INFORMATION
State of the art breast augmentation placed below the muscle provides a much softer, natural result with a higher satisfaction rate than any prior breast augmentation technique. Quite a number of options are available to patients, including both gel and saline implants. A number of breast lift techniques can complement these procedures. This makes breast augmentation surgery as individual as each patient.
Indications: Smaller than desired breasts, asymmetry of the breasts, desire for more cleavage. In some cases desire for correction of a small amount of sag. In some cases to assist a breast lift procedure in shaping.
Intended Results: Larger, more shapely breasts. An enhanced self image.
Procedure Description: The procedure is done most commonly under general anesthesia. Through an incision around the lower edge of the areola or beneath the breast, a saline or gel implant is inserted beneath the underlying muscle. This procedure is done on an outpatient basis.
Recuperation and Healing: The patient goes home with the breasts wrapped with a support bandage. On the second or third day after surgery, the patient can shower. Initial discomfort is controlled with oral medication. Sutures go away on their own; light activity can be resumed as tolerated. Aerobic activity can be started in three weeks. You can return to a desk job in as little as 5 days.
Other Options: In some cases of breast sag, a Breast Lift (mastopexy) is done along with breast augmentation for the best shape. Inverted nipples can be corrected at the same time.
IMPLANT CHOICES
Now years after their return to availability, gel implants are clearly better than ever. They feel very natural and their rupture rate is considerably decreased. Furthermore, the gel is thicker and with "cohesion", leakage long term appears to be less of a concern than in the past.
Saline implants will remain a preferred choice for many patients. They have decades of experience now with very high patient satisfaction.
Saline and gel implants each come in a variety of profiles, each with their own advantages. With so many options it has never been more important to have a careful thorough consultation with an experienced plastic surgeon. These improved options better facilitate optimal choices since women vary greatly in height, chest width, breast size, amount of sag and goals.
OBTAINING A SOFT NATURAL RESULT
Because the scar at the infra-areolar position is so minimal, attention and decision-making should more appropriately be directed toward obtaining a soft, natural result. Saline and gel implants have been a quantum leap forward in this quest. Beyond the type of implant, the method of surgery is extremely important. With today's most advanced techniques, the operating surgeon is implementing multiple precautionary measures to avoid "capsular contracture" or hardening of the breast. These measures can be referred to as "no-touch" techniques. They include touching the implant with fresh, clean gloves and immediately coating the surface of the implant with antibiotics. I tend to change to fresh, clean gloves multiple times throughout the course of surgery. Over the years, these measures have proven extremely valuable in successfully accomplishing the soft natural result you desire.
BREAST SAG AND IMPLANTS
Descent of all or part of the breast tissue down the chest is a normal part of aging in many women. It may be related to pregnancy, weight gain, or just inherited poor elasticity of the skin. For the latter reason, it can even be seen in teenagers. Certain shapes or mal-developement of the breast can lead to sag very early in life. An example is a "constricted breast"- a breast that is so narrow that it can't support its weight on the chest wall, so sag develops early.
 Types of Breast Sag |
One of the primary gauges of sag is the relationship between the nipple and the fold beneath the breast (inframammary fold/IMF). Breast sag is progressively worse as the nipple to IMF relationship falls from above the fold, at the fold and to below the fold. Sag is at its worst when the nipple is not only well below the fold, but is also the lowest part of the breast. There is another type of sag in which the nipple really doesn't fall but stays above the fold, and the entire breast and IMF move downward like a paint drop on a wall. We have to consider this type of sag in our decision-making.
If a woman wants correction of her sag but not larger breasts, she should get a breast lift alone and not breast implants. All breast lift procedures though result in some pattern of scar on the breast as a trade-off. If a woman is willing to have larger breasts, then she may have more options in correcting the sag. Sometimes, if the sag is not severe, breast implants alone significantly improve the sag. This can be quite an advantage, because the scar from placement of breast implants is quite minimal compared to breast lift scars.
If breast implants alone do not correct enough of the sag, there still may be advantages to implants. Often by filling out the breast, the scar pattern of the breast lift can be considerably shorter. Also, breast implants accomplish what breast lifts can't: filling out the upper chest. If we decide on a breast lift with breast implants, the two procedures are most commonly done at the same time but may be performed sequentially. My goal is to always get the best possible result with the least amount of scar. With some borderline cases, we may choose to proceed with breast implants and allow them to settle for six months and let the skin adapt. Later a smaller type of lift or possibly no lift at all will be necessary.
 Types of Lifts |
Let's discuss a little more about the scar patterns. In the illustration above, pink shows the final scar position. The crosshatched skin is removed. In "2" the crosshatched skin is not shown since it is mostly on the undersurface of the breast. The length and placement again are determined by the type and amount of sag. Raising the nipple alone is done with a supra-areolar lift as in "1," also know as crescent mastopexy, however, this does not help breast shape. If we want to accomplish more than just raising the nipple, then it is necessary to tighten the skin below the nipple. Only with scars below the nipple can we begin to actually shape the breast or sculpt it.
Magnificent shaping can be accomplished with the full lift pattern as in "2." With implants placed at the same time, the horizontal limb of scar can often be shortened considerably. This pattern makes sense if you stand in front of a mirror and pinch the skin beneath the breast. That action raises and cradles the breast tissue upward. This shaping action brings out the true artistic abilities of a plastic surgeon. I place the patient in an almost sitting position in the operating room and progressively sculpt the breast by sequentially tightening in multiple directions. With quite significant sag, patients gladly accept the scar lines as a tradeoff for such great improvement in shape. Many breast lifts are not permanent but the amount of sag that returns is often so small that most women do not seek another procedure years later. For photographic examples of breast augmentation with lift please refer to the Breast Lift section of the Hubbard Plastic Surgery web site.
BREAST AUGMENTATION AND POSSIBLE LOSS OF NIPPLE SENSATION
Even in the early days of breast augmentation in the 1960s, it was recognized that a small portion of women will find some decrease in nipple sensation following surgery. Many changes have occurred in breast implants and breast augmentation techniques since those days. A variety of incision choices are available now. It was hopeful that new techniques would eliminate the possibility of nipple numbness following surgery. For example, for a time it was thought that possibly the incision under the arm would avoid nipple numbness because the incision was far from the nipple area. Unfortunately, the rate of nipple numbness has turned out to be the same or even possibly higher with the armpit approach also known as the axillary approach according to a recent study by Dr. Howard Tobin. In early weeks after surgery, a very large portion of his patients had nipple numbness and after time, although many had their sensation return, the incidence still remained higher than the usual 10 to 15% described for other approaches. His findings are consistent with the publications of Dr. Tebbetts of Dallas, an international authority on the armpit approach to breast augmentation. Dr. Tebbetts' extensive experience with this approach began in the 1980's and his publications in 1984 and 1988 (Plastic and Reconstructive Surgery) mentioned there may be less nipple numbness. With experience and review of his results though he found that the armpit approach had just as high rate of nipple numbness (July 2001 Clinics of Plastic Surgery). As there are a number of other disadvantages to the armpit approach, Dr. Tebbetts now prefers very short breast incisions around the areola or beneath the breast.
The higher incidence of nipple numbness with the armpit approach actually makes sense from an anatomical standpoint. Nipple numbness has absolutely nothing to do with where the incision is made. It is related to the actual implant pocket extending out on the side of the chest where the nerves come from. That is where the nerves can get stretched. There actually may be an advantage to the incision beneath the nipple or in the fold beneath the breast since with those approaches the surgeon can often feel the sensory nerves and avoid their disruption. With the armpit or axillary approach, it is not possible to feel these nerves and thus there may be a higher likelihood of injury.
BREAST IMPLANTS AND CANCER
Excellent natural results must always go hand-in-hand with excellent safety. One primary safety issue concerns breast cancer. The American Cancer Society sites a one in eight or 12.5% incidence of breast cancer in women in the United States by the age of 85. What impact do breast implants have in this setting? Is the incidence of cancer higher? Do the implants result in later detection of breast cancer with an effect on survival?
Fortunately, we have decades of experience with breast implants and there are now good answers to these questions. Several studies show the risk of breast cancer is actually decreased in women with breast implants. Since it is unlikely there is any true protective effect of implants, we can at least say the incidence of cancer is not increased by the presence of implants.
As to possible interference of implants in the early detection of breast cancer, we have good news from quite a number of studies. A very nice review of these studies was recently published in the Journal of Plastic and Reconstructive Surgery in May 2001. Studies going back to the early 1960s on the effect of implants and cancer detection were reviewed. The conclusion of this study is as follows; "Women with implants should be reassured by the consistency of scientific studies which have uniformly determined that, compared with women without implants, they are not at increased risk for cancer, are not diagnosed with later stage breast malignancies, are not at increased risk for breast cancer recurrence, and do not have a decreased length of survival."
BREAST AUGMENTATION IN ATHLETES
For over ten years I have been a strong advocate of implant placement beneath the pectoralis muscle. Occasionally, I am asked if this location is still optimal for athletes. I continue to feel strongly that it is. Body builders, runners and other such athletes surely want to enjoy the same benefits of subpectoral placement: (1) better shape, (2) more padding and much less likelihood of rippling, (3) much less likelihood of capsule contracture (hardening of the breast), and (4) better quality, more informative mammograms. Weight lifters will find that during muscle contracture, the breast will change shape. Having said that and having performed this surgery on many such patients, I have yet to have one tell me of any reluctance to return to her old gym and exercise with weights. What about strength of the muscle? I have not seen any evidence that the muscle is weaker after surgery. Now with sophisticated muscle testing, some fairly slight weakness has been detected in some patients. Presently I know there are professional athletes such as tennis players choosing to have their implants placed beneath the muscle. Subpectoral placement then continues to be an easy decision in my opinion. Why would anyone choose to forego these benefits?
CHEST SHAPE AND IMPLANTS
During my patient evaluations, I pay particular attention to chest shape. Quite a number of factors about the contour of the chest can affect the results of breast augmentation. It is very common to see ribs that are more prominent on one side of the chest. This may or may not be related to scoliosis. Regardless, after breast implants, the breast on the side of the rib prominence may appear larger. Therefore, I place a little less saline on that side depending on the degree of asymmetry. This is very similar to the usual practice of placing less saline on the side of a larger breast to help correct asymmetry. Another anatomic chests factor that varies greatly is overall chest shape. Is the breast bone more or less prominent or about the same level as the ribs on both sides? Some women's chest are very keel-shaped, meaning the breast bone protrudes forward. In this situation it is very difficult to get the breast implants as close together. Actually, unless a woman has such a very keel-shaped chest or a wide breast bone, plastic surgeons do have considerable control over how far the breast implants are apart. We actually make the pocket or space in which the implants are placed. Opinions among surgeons vary greatly. It is my opinion that most women do not want their implants to fall far to the side. With displacement to the side, cleavage is lost both standing and lying. Therefore, by limiting the space to the outside of the implant, I can better accomplish the highly desirable fullness towards the center of the chest. Of course, there are pros and cons to everything in life. Many women have nipples that are far to the side of the chest. With implants ideally positioned for cleavage, the nipples may not be perfectly contoured over the implants that are more to the middle of the chest. I have found though, that most women gladly accept this trade-off. Because an individual's personal preference is so important, these types of issues are discussed prior to surgery.
REVISION BREAST SURGERY
Dr. Hubbard is often asked to perform revision breast surgery from patients who have had their surgery elsewhere. One common type of revision surgery is repositioning breast implants whether they are gel or saline. See Gallery 3 for an example of a patient who had her surgery in another state and clearly the implant pockets are too low. This type of revision surgery is called a capsulorraphy and to correct this problem, the lower pocket is closed off with sutures. A very soft result is maintained. Other common types of breast revision surgeries Dr. Hubbard does include lowering implants, correction of capsule contracture (hardening), changing breast implant size or type and performing a variety of breast lift procedures or revision of breast lift procedures with implants already in place.
Please visit our Photo Gallery Page to see examples of Breast Augmentation or click on the following links for information on other procedures.
 Before Breast Augmentation |
 After Breast Augmentation |
 Before Breast Augmentation |
 After Breast Augmentation |
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