In the past, breast implants have most commonly been filled with silicone. In 1992, the FDA restricted the use of silicone implants to breast reconstruction, such as after mastectomy. Although the scientific evidence supports the safety of silicone breast implants, the FDA allows only saline implants to be used for cosmetic breast augmentation. Saline breast implants are filled with salt water (IV fluid) which is safe and completely compatible with the body.



The evolution of the surgery for breast enlargement has created a number of choices which allows women to achieve the results that are most consistent with their own personal wishes and desires. Dr. Nein offers all his patients choices in breast augmentation.

Choices

The woman wishing to have a breast augmentation has a number of options and choices open to her. This gives her the best opportunity to achieve the appearance and result that she wants. These choices include implant style, placement, and size as well as incision location. Just as there are many different sizes and shapes of women, so are there a number of choices that can give each woman the best possible result.

Submuscular vs. Subglandular

One of the primary choices in breast augmentation is whether to have the implants placed "under" or "over" the muscle (submuscular or subglandular). This muscle is the pectoralis major muscle which lies over the rib cage and underneath the breast. It is the chest muscle that is commonly developed in weight lifters.

Traditionally, when the majority of implants were silicone, implants were most often placed underneath the breast gland and on top of the muscle. With the more common use of saline filled implants, it was noticed in women who were thinner or who had relatively little breast tissue to cover the implants, that there was a tendency to develop "rippling" or a waviness in the skin overlying the implant.

This is especially true with the use of the "textured" or rough surfaced implants. In an effort to decrease the incidence of rippling and the potential for capsular contracture, there has been a move to place implants in the space beneath the pectoralis major muscle. Submuscular placement increases the padding overlying the implant offering more coverage and camouflage to the shape of the implant. Using this technique, rippling has become a rare problem.

Incision Choice

There are three incisions commonly used to place the implant. Either an inframammary crease incision (in the natural fold where the breast contacts the lower chest), a periareolar incision (around the areola where the skin of the nipple changes to the lighter breast skin), or an axillary incision (in the armpit). The decision as to which incision to have rests entirely with you. There are certain differences, however, of which you should be aware.

The inframammary crease incision made by Dr. Nein is 4 cm long (about 11/2 inches). It has the advantage of being in a natural skin fold where it is well camouflaged and is generally covered by the natural curvature of the lower breast. It will probably always be covered by any clothing - even the smallest of bikini tops. This incision is close to the pocket where the implant will be placed. The distance to dissect is short and it is possible to very accurately create the size and shape of the pocket for the implant and to carefully control the position of the implant within that pocket.

A periareolar incision can also be used to place the breast implant. The dissection is carried through the gland, down to the chest wall. A sub-glandular pocket is created for the implant. If the woman wishes to have the implant underneath muscle, the muscle is elevated and moved out of the way to place the implant.

The third option is an axillary incision. This incision is placed in the armpit and dissection is carried out either above the muscle or below the muscle bluntly to create a pocket for placement of the implant. Because the incision is at a remote distance from where the implant will be placed, it can at times be a little more difficult to get very accurate control of the exact position of the implant, especially with anatomical implants.

Implant Choice

Traditionally, implants were all round. Viewed from the front, they are circular and in profile they appear to be half moon shaped. Over the last few years there has been a significant increase in the use of the so-called anatomical implants. These anatomical implants are slightly taller than they are wide and are fuller in the bottom - having a slightly more natural shape to them.

When using the round implants, the breast has a slightly more circular appearance to it whereas the anatomical implants give the breasts a more natural look. There tends to be a smoother transition from the upper chest wall to the top of the breast and not quite so much of a "step-off" as is commonly seen using round implants.

Choice of Implant Size

The final consideration is size of the implant. Implants come in a wide variety of sizes and it is possible for any woman to comfortably carry a variety of sizes on her chest. The objective during the examination is to determine which implant will give the desired appearance. As you can imagine, any given implant in a very small framed woman will achieve an entirely different result than the same implant in a larger and heavier woman with different shaped breasts.

Identical implant, different women with different breasts equals different results. The key, therefore, is to choose an implant that will give you the look that you desire. In order to accomplish this, we use a number of techniques. One of which is to take specific measurements of the size and shape of your breasts. This information, combined with the dimensions of the implants, and your desire for size and shape will help us determine which implant will most closely give you that look.

Bigger is not necessarily better. In choosing a very large implant it is important to be aware that as the volume of the implant goes up so do its dimensions, which includes the implant width. If you choose an implant that is excessively large, the edge of the implant may extend around beyond the breast and potentially even under the arm pit. This would be undesirable. Also, as the implants become excessively large, the potential for rippling and other long term adverse cosmetic consequences increases.

A very attractive look is a slight bulging on the silhouette of the lateral portion of the breast outside the chest wall and then down to the waist and hips to give that classic "hour glass" figure.

Complications

With any procedure, no matter how complicated or how simple, there are always certain risks of complications. As a general rule, breast augmentation is an extremely safe procedure preformed as an outpatient. You will have some breast soreness for a few days, however, that can readily be controlled by pain medication and most women do extremely well. After the recovery is complete there is no restriction on activities. One can go scuba diving, sky diving or any activities that you wish.

As a general rule, breast augmentation is an extremely safe procedure preformed as an outpatient.

Leakage

Like any other mechanical device, a breast implant is subject to mechanic failure. The fluid that the implant is filled with is IV saline; if it should leak, it is harmlessly absorbed by the body. All of the implants that Dr. Nein uses come with a lifetime warranty. Dr. Nein only uses implants made by either McGhan or Mentor.

Loss of Nipple Sensation

Perhaps the most serious consequence or potential problem associated with breast augmentation is the potential for loss of nipple sensation. The nerve to the nipple comes from between the fourth and fifth rib, travels through the side of the breast to the nipple itself. In the course of creating the pocket to place the implant, the nerve can be injured. If the nerve is damaged or cut, one can have permanent loss of nipple sensation. Fortunately, this is an extremely uncommon complication. In fact, it rarely happens.

Infection

There is an extremely small risk of infection during the immediate postoperative period. If a woman develops an infection around the implant, it is necessary to remove the implant. She must be on antibiotics and no sooner than six weeks later can the implant be replaced. This is a potentially correctable, reversible situation; but it is expensive by the time one pays for a second trip to the operating room and for a third implant. The good news is that this too is an extremely rare occurrence. In fact, it is so uncommon that for most plastic surgeons it may only occur only once or twice in their practice careers.

Hematoma

In the early postoperative period one can develop some bleeding around the implant which can cause a blood pocket to form next to the implant. If this happens, it may require a return trip to the operating room to have this washed out. In our experience in this practice, this has never happened.

Women who desire cosmetic surgery are encouraged to seek out plastic surgeons who are experienced in the various techniques available and who are certified by the American Board of Plastic Surgery.