BREAST ENHANCEMENT (AUGMENTATION MAMMAPLASTY) NEW JERSEY
Introduction To Breast Augmentation
The primary reason that women seek out breast enhancement surgery is when they feel their breasts are too small. Inadequate breast volume may be present right after puberty or may be acquired after pregnancy, breast feeding and significant weight loss. Increasing breast size with implants not only enhances the body proportions of a woman who feels her breasts are too small, but also balances pre-existing differences in breast size. Pregnancy with or without breast-feeding which leads to "deflated" breasts that were previously of adequate size, can be rejuvenated with breast enhancement surgery. Small to moderate weight loss can also result in breast shrinkage corrected by implant insertion, however massive weight loss almost always results in a large degree of sagging that would most likely require a breast lift procedure at the same time as implant insertion.
There are a number of issues regarding breast implants that require discussion and decision making prior to breast augmentation surgery. All breast implants have an outer shell made of silicone elastomer but the filler material can be either sterile salt water or silicone gel. Silicone breast implants are available for breast reconstruction following mastectomy and in cosmetic breast augmentation that meets certain criteria.
Implants can be round, oval or tear drop-shaped and the outer shell can be smooth or have a rough texture. Implants that are not round are always textured so that the implant "sticks" to the surrounding tissue to minimize the chance of the implant turning upside-down or sideways. Round implants will look the same when rotated in any direction and therefore do not necessarily need to have a rough surface. In our practice, straightforward primary breast augmentation surgery is usually performed using round, smooth saline implants, but there are specific occasions when we would choose different shaped and textured implants.
Three incisions are most commonly used for breast augmentation. An incision in the hair bearing region of the armpit does not leave a scar on the breast but the resulting scar may be visible when the arms are raised. The surgical exposure using the axillary approach is more limited and usually requires a lighted camera on a metal rod (endoscope) to be inserted through the incision during the surgery. A periareolar incision follows the curvature of the lower border of the areola, extending from approximately the 4 o’clock to 8 o’clock position. Scarring is usually minimal but there is limited surgical exposure and there may be a higher chance of alteration in nipple sensation. An incision can also be made beneath the breast along the natural crease which offers excellent visualization of the surgical field. The scar is hidden by the lower curvature of the breast. Insertion of implants through an incision at the upper edge of the navel must be performed with an endoscope and is seldom used.
The location of the breast implant is independent of the access incision used. We can place the implant below the breast gland and above the pectoralis muscle (subglandular) or below both the breast gland and the muscle (submuscular) on the chest wall. Implants in the submuscular position are generally better camouflaged especially in patients with small breasts and breast tissue may be better visualized on mammograms when the implant lies behind the muscle. We may place implants on top of the muscle when there you have a small amount of droopiness to your breast.
We most commonly place breast implants in the submuscular position and use incisions along the lower edge of the areola or hidden along the lower breast crease. However, implant placement above the muscle and incisions in the axilla or at the top edge of the navel can be performed when you specifically request it. In all cases, we listen to what you want after we have gone over all the benefits and drawbacks of all of the different options for implant shape, texture, location and insertion sites.
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Breast Implants - Past and Present
The first documented report of breast augmentation surgery dates to the late 19th century, when fatty tissue was transplanted from one area of a woman's body to repair damage caused by the loss of tissue due to removal of a benign breast adenoma. By the early 1900s, breast enlargement was accomplished by injecting liquefied paraffin wax into the breast. The combination of paraffin and olive oil used to create an injectable liquid resulted in the formation of hard masses, so that technique was eventually abandoned. In the 1950s, liquid silicone was injected into women's breasts in Japan to enlarge them, and this method soon found its way to the US. Before silicone gel, implants used for breasts were hand carved from polyurethane blocks. The first silicone gel implants were developed in the 1960s and were smooth, teardrop- shaped bags with Dacron patches on the backs of them to fix the implant to the chest wall.
Silicone can be processed into three forms: a fluid, a gel and a solid rubber-like compound known as elastomer. All implants have a shell made of solid silicone shell that can be smooth or textured. These are either filled with saline or silicone gel. Other fillers such as peanut oil, soybean oil, liquid silicone and others have been tried and have failed. Concerns about the use of silicone gel-filled breast implants began to surface in the US and Canada in the 1980s, and then spread to Europe in the 1990s. In 1992, spurred by concerns that silicone gel leaking into the body might harm the immune system, the FDA declared a moratorium on silicone gel use in the US. Breast implants have been studied more intensely over the past 2 decades than any other medical device or material and no link between breast implants and connective-tissue disease (CTD) or breast cancer has been found.
The chief advantage of silicone is that it feels very natural, more like a human breast. It has a fleshy consistency and "squeeze-ability" like real tissue. When silicone gel implants rupture the gel leaks into the surrounding pocket. Usually it is contained within the scar capsule that surrounds the implant. Sometimes however it can migrate out of the capsule and into the breast tissue causing small areas of scar tissue we call granulomas. The effects of a ruptured silicone implant are localized to the breast and have not been systemic. When saline implants rupture the volume of the breast diminishes slowly over several days or even in the course of a few weeks. The body absorbs the saltwater fluid like drinking a glass of water and is harmless. Gel implant ruptures however may be silent and no change in the appearance or feel of the breast is notable. It is for this reason that recommendations will be made for long-term follow-up in patients with gel implants to undergo diagnostic testing such as MRI every five to ten years in order to assess the integrity of the gel implant. Patients choosing silicone gel implants must be fully aware of this and weigh the benefits and risks.
The newest model silicone gel implants are made of a thicker more cohesive gel material designed to minimize migration of the silicone that has been associated with conventional gels. The implants popular in the 1970's had thinner more liquid-like gel material that were more prone to rupture and migration then the products available today. In fact, a totally cohesive gel implant whereby no gel migration occurs is being developed and is under investigation even today. With this implant even if the outside shell breaks down the gel will not bleed out over time because the molecules stick tightly together. It is firmer then conventional gel, but may strike the best balance between implant feel and safety.
"Although we are very satisfied with the results we can achieve with saline-filled implants, we are pleased that silicone gel breast implants may soon be available in the United States again so that women can have a choice."
In July 2005, the FDA issued an "approval letter" with conditions to Mentor Corporation regarding its silicone breast implants. The approval letter stipulates a number of conditions that Mentor must satisfy in order to receive FDA approval to market and sell silicone breast implants in the United States.
How We Do It
We usually perform breast augmentation under general anesthesia but it could be done under local anesthesia with intravenous sedation. It is usually too time consuming and impractical to inject local anesthetic over the entire chest wall. First, we make an incision, lift the breast tissue and/or the muscle to create a space or pocket beneath the breast. Then the implant is ready to be placed in the pocket.
The most common approaches for insertion of implants include the lower part of the areola, beneath the curve of the breast and through the armpit. Implants are also infrequently placed through incisions along the navel. The implants can be positioned beneath your breast gland and on top of the chest wall muscle or can be placed beneath the muscle depending on the quality of soft tissue that exists. Placement considerations include the anatomy of your breasts, whether you are interested in breast feeding, and your personal preference. Thin women with only a small amount of breast tissue get a better result when the implant is placed beneath the muscle to camouflage the edges of the implant and achieve a more natural look. We prefer under the muscle placement in the great majority of our patients.
What To Expect Afterwards
Your stitch lines will be covered with gauze and then you will wear a soft surgical bra for protection and support that has no underwire and opens in the front. After five to seven days, the gauze dressing will be removed and we recommend that you wear the surgical bra or an elastic type of sports bra continuously for several weeks. Initially your breasts may appear firm, swollen and to be sitting high on your chest. As the swelling resolves and gravity comes into play, the implants will sink down slightly and assume a lower, more natural appearing position. You will be told to minimize arm movements and to bend from the knees only as needed. You may be able to resume work within a week or two after surgery, but aerobic activity involving running, jumping or bouncing should be avoided for three to four weeks. We use absorbable stitches which should dissolve in two to four weeks.
What Are the Risks
Breast implants are not associated with the development of breast cancer and do not impair breast cancer detection. There has also never been a definitive association with breast implants and autoimmune or collagen vascular disorders.
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