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CHAPTER 8 - BREAST RESHAPING
Women commonly seek consultation for breast reshaping surgery with stories of spending an enormous amount of money on padded bras, push-up bras, water bras, "chicken filet" inserts, and self-adhering bra cups. Women often complain about limitations in their clothing choices when they feel their breasts are too small, too saggy or too large. Breast augmentation, lift and reduction will give you greater freedom with fashion and will usually give your self-image a boost as well. It is always better when you have breast reshaping procedures for yourself rather than to make your spouse or significant other happy.
For the purpose of illustration, let’s say that breast tissue is represented by a baseball and the surrounding skin envelope is represented by a sock. A breast augmentation means the baseball is exchanged for a softball and the sock remains the same size, resulting in a larger breast. In breast reduction, the baseball is converted to a tennis ball or golf ball while at the same time a smaller sock is created. The end result is a smaller, uplifted breast. A breast lift involves designing a smaller sock for the existing baseball which means that the same sized-breasts assume a higher position on the chest wall.
All types of cosmetic or reconstructive breast surgery involve possible inability to breast feed after the surgery, depending on the extent and type of surgery. There may also be temporary or permanent sensory changes ranging from decreased sensation to hypersensitivity. Pre-existing breast asymmetry is common and may also be possible following any type of breast surgery. Patients who are over the age of 35 and are undergoing surgery to reshape the breasts in some way, should have a mammogram prior to surgery (if is has not been done in the past year) to rule out existing abnormalities and to be used as a baseline for future comparison.
Breast Enhancement (Augmentation Mammaplasty)
The main reason that women want breast enhancement surgery is a feeling that their breasts are too small. They may have always had inadequate breast volume or they may develop small breasts after pregnancy, breast feeding and significant weight loss.
Increasing your breast size with implants not only improves your body proportions when you feel your breasts are too small, but can also balance pre-existing differences in your breast size. Implants can rejuvenate breasts that have "deflated" after pregnancy with or without breast-feeding. Breast augmentation is able to correct breast shrinkage from small to moderate weight loss, however massive weight loss almost always results in a large degree of loose skin and sagging that is best treated with a breast lift procedure in addition to implant insertion.
There are a number of issues about breast implants that require discussion and decision making prior to breast augmentation surgery.
- Filler material
- Implant shape
- Surface texture
- Access incisions for implants
- Location above or below the muscle
- Implant size
All breast implants have an outer shell made of a type of solid silicone but the filler material can be either sterile salt water or silicone gel. Silicone gel-filled breast implants are available only for women having breast reconstruction following mastectomy and in women having cosmetic breast augmentation that meets certain criteria.
Breast 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, we use round, smooth saline implants for women having straightforward breast augmentation surgery but there are specific occasions when we might choose different shaped and textured implants.
Three incisions are most commonly used for breast implant placement during breast augmentation: in the armpit (transaxillary), along the areola (periareolar) and under the breast (inframammary). An incision in the hair bearing region of your armpit does not leave a scar on your breast but the resulting scar may be visible when you raise your arms. The surgeon’s visualization using the axillary approach is more limited and usually requires a lighted camera on a metal rod (endoscope) that is inserted through the incision during the surgery.
A periareolar incision follows the curvature of the lower border of your areola, extending from approximately the 4 o’clock to 8 o’clock position. The scar is usually minimal but there is limited visualization by the surgeon and there may be a higher chance of altering your nipple sensation.
An inframammary incision beneath your breast along the natural crease gives excellent visualization of the surgical area and the scar is hidden by the lower curvature of your breast. Putting implants in through an incision at the upper edge of your navel (transumbilical) must be performed with an endoscope and is seldom used.
The location of the breast implant relative to the chest wall muscle is independent of the access incision we use. 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 women with small breasts and breast tissue is better visualized on mammograms when the implant lies behind the muscle. We may place implants on top of the muscle when 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, insertion sites and location.
The exact implant size is determined on the day of surgery once the implant has been filled with fluid, but we estimate of the size of the implant you would like beforehand by taking measurements of your breasts and by having you put implant sizers in a surgical bra while looking in the mirror.
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