Breast Augmentation Information Breast Implants

Implant shape
Round implants are not affected by rotation and cost less than teardrop implants. They do not require a textured surface. There are no disadvantages to round implants. This is the most common implant employed .

Teardrop implants were developed to provide a more natural look. They cost more than round implants and require a textured surface to prevent rotation. In the event that the implants rotate, it creates a distorted breast shape.

A recent study determined that a round implant takes on the same shape as the teardrop implant when standing. The study also concluded that when lying down, the round implant is more natural in appearance than the teardrop implant because it retains the teardrop shape and the round implant does not.

Implant surface
Textured implants have an increased risk of rippling but a decreased risk of displacement. They also cost more (about $100). A recent study showed that textured implants have a higher deflation rate and are firmer than smooth implants.

Smooth implants have a lower risk of rippling, are less firm than textured implants. Any rotation of the implant will not affect the appearance. Smooth implants are used in 90% of operations.

Implant size and volume
Implants that are less than 350 ml have a lower risk of displacement, but may not provide the desired size.

Implants that are more than 400 ml have a higher risk of displacement, but may provide the desired size.

Choosing your desired size can be a difficult decision. You'll want to decide your cup size and that will determine how large your implant will be. A 400 ml implant placed on a woman with an A cup will produce a C cup. The same implant placed on a woman with a B cup will produce a D cup. Bring pictures of your desired size (take a look at a lingerie catalog or swimsuit pictures) to your consultation. Take the time to decide what you'll be happy with so you don't feel the need to undergo a second surgery. You can also ask your surgeon for implant sizers to try on different implant sizes.

Be sure your surgeon plans to overfill the implants. This technique decreases the risk of deflation, rippling, and sloshing. There are no disadvantages to overfilling. Implants are meant to be overfilled, and the implant manufacturers recommend surgeons to overfill them.

Implant placement
Implant position refers to whether the breast implant is placed above or below the pectoralis muscle. See Illustration below.

Subpectoral or submuscular implants: Placement under the pectoralis muscle is the approach most commonly used. It has a lower risk of capsular contracture, interferes less with a mammogram, and a better cosmetic result in women with small breasts and a worse cosmetic result in athletic women. It is associated with a lengthier recovery and more pain and swelling than placement above the muscle. This approach requires general anesthetic.

Subglandular implants: Implants that are placed above the pectoralis muscle and below the breast tissue. This has a greater risk of capsular contraction, interferes more with a mammogram, and a worse cosmetic result in women with small breasts. It has a better cosmetic result in athletic women (body builders may want to consider a male pectoral implant as it can look more natural). It is associated with a shorter recovery and less pain and swelling than placement below the muscle. This approach can be performed with intravenous sedation and local anesthetic.

Incision site
Inframammary incision: The incision is made on the lower portion of the breast, in the crease where the breast meets the chest, so that any scar will still be hidden. This incision allows your surgeon the best visibility during surgery. Most commonly done.

Periareolar incision: The second most common incision is made in the areola. The incision is usually a small semi-circle. The scar is camouflaged by the nipple. However, if there are any imperfections in the scar, it will be highly visible. This type of incision has an increased risk for diminished nipple sensation.

Axillary incision: The incision is made in the armpit, and may require the use of an endoscope. The scar is well-hidden, but provides poor visibility for the surgeon.

Umbilical incision: The incision is made in the belly button. It usually requires the use of an endoscope, and it is very difficult to place the implants below the muscle utilizing this method.

After Surgery

On the day of surgery you will feel sleepy and may feel pain or be nauseated. Your chest may feel tight and uncomfortable. Your arms and back may also be sore. Pain medication will be prescribed to minimize your discomfort.

After surgery your breasts will be very firm, high, and swollen. After about a month, the swelling will be gone and they will be lower, smaller and softer. It may take up to a year for the implants to settle into a permanent position.

Recovery Tips:

Keep ice packs applied to your chest on the day of your surgery.
Sleep in an upright position. Do not sleep on your stomach for the first two weeks after surgery.
To avoid unnecessary swelling or bleeding, do not bend over, strain, exercise or do any other activities that could increase pressure in your chest during the first week.
If you have smooth implants, massage them daily to keep them softer, avoid capsular contracture and keep them in proper position. Do not massage in the first 24 hours and do not massage textured implants.

Your doctor knows your particular case best, these are only general guidelines.

Risks and Complications

Possible risks and complications: (not an exhaustive list)
Anesthesia reaction, Asymmetry, Bleeding, Breast droop, Capsular Contracture (hardening of scar tissue around implant), Deflation (approximately 7%), Displacement, Hematoma (pooling of clotted blood; risk is 3-4%), Implant leak, Infection (risk is less than 1%; always involves removal of implant), Interference with mammography, Keloid (heavy scar), Nerve Damage, Nipple numbness, Permanent numbness (risk is 15%), Reactions to medications, Rippling, Rupture of the implant (often due to injury), Seroma (pooling of watery blood), Skin irregularities, Sloshing, Slow healing, Swelling, Symmastia (breasts merge into one mass),Visible sca r

Silicone Implants
In the early 1990's it was reported that silicone breast implants were responsible for connective tissue diseases in some women. After a comprehensive evaluation of the evidence for the Association of Silicon Breast Implants with human health conditions, the Institute of Medicine concluded in June that there is "no definitive evidence linking breast implants to cancer, neurological diseases, neurological problems or other systemic diseases." However, silicone implants are still not available to the general public in the United States. They are still widely used in Europe and may be available again in the US.

Silicone gel-filled breast implants are available for select cases: women seeking breast reconstruction or revision of an existing breast implant, women who have had breast cancer surgery, a severe injury to the breast, a birth defect that affects the breast, or a medical condition causing a severe breast abnormality.

For more information, go to http://www.fda.gov/cdrh/breastimplants

Capsular Contracture
Capsular contracture is one of the most common complications associated with breast augmentation. It occurs when the scar tissue hardens around the implant. It may be more common following infection, hematoma, and seroma. Capsular Contracture is much less common and less severe with saline implants than with silicone implants.

There are four grades of capsular contracture - Baker Grades I through IV.

The Baker grading is as follows:
Grade I - the breast is normally soft and looks natural
Grade II - the breast is a little firm but looks normal
Grade III - the breast is firm and looks abnormal (visible distortion)
Grade IV - the breast is hard, painful, and looks abnormal (greater distortion)

Grade I and Grade II require no treatment. Grade III is treated by reopening the incision and releasing the capsule. Grade IV requires repositioning the implant and may require implant removal. Capsular contracture may recur after additional surgery.

According to the FDA, in a clinical study of saline-filled breast implants conducted by Mentor, 9% of 1264 women with implants experienced Grades III and IV capsular contracture after 3 years of the study. In a similar study by McGhan, the rate was also 9% (of 901 patients). The rate of contracture in reconstructive patients is higher.

Another FDA study indicated that 17.5 % of 749 women had at least one surgical procedure over an average of 7.8 years because of capsular contracture.(1) This study included women who had implants for cosmetic and reconstruction purposes, most of whom had silicone gel-filled breast implants.

Dr. Jorges Planas, a plastic surgeon in Barcelona, Spain, conducted two studies on women with capsular contracture (a group of 52 women and a group of 24) and found an 83.8% improvement at 1-year follow-up following external ultrasonic treatment. On average, positive, long term results were achieved in less than 8 sessions. Ultrasound can also be used as a preventative method. You may want to discuss this treatment with your surgeon.

Source: Planas J, Cervelli V, Planas G. Five years experience on ultrasonic treatment of breast contractures. Aesth Plast Surg 2001;25:89-93.

Hematoma/Seroma
Hematoma is a collection of blood inside a body cavity, and seroma is a collection of watery blood around the implant or around the incision. Postoperatively, they may contribute to infection and/or capsular contracture. If a hematoma occurs, it is usually soon after surgery; it can also occur after an injury to the breast. While the body absorbs small hematomas and seromas, large ones will require the placement of surgical drains for proper healing. A small scar can result from surgical draining.

Implant displacement
Implants can move out of position at anytime after surgery. If they move only a little, it may not be noticeable. If they move a lot, you may need surgery to put them into position. This is very uncommon except in women who have very large implants. The larger the implant, the greater the chance that it will displace.

Infection
Infection is very uncommon. The risk is about 1% but if it occurs the implants will have to be removed. If infection does occur, it is usually within six weeks of surgery.

Necrosis
Necrosis is the dead tissue around the implant. This may prevent wound healing and require surgical correction and/or implant removal. Permanent scar and/or deformity may occur following necrosis. Factors associated with increased necrosis include infection, use of steroids in the surgical pocket, smoking, chemotherapy/radiation, and excessive heat or cold therapy.

Galactorrhea
Sometimes after breast implant surgery, you may begin producing breast milk. This is more likely if you have previously lactated. The milk production often stops spontaneously or medication may be given to suppress milk production. In other cases, removal of the implant(s) may be needed.

Mammography
Saline and silicone implants affect a mammogram reading. Implants placed below the muscle permit a clearer reading. When implants are below the muscle, 90% of breast tissue is visible. When implants are above the muscle, 75% of breast tissue is visible.

Regardless of where placed, implants do not interfere with self-exams. They do not interfere with MRI scans or ultrasounds, which are alternatives to a mammogram. No studies have shown a connection between implants and breast cancer (See http://www.plasticsurgery.org/mediactr/evidence.htm). However, ineffective mammography could result in a higher risk of undetected breast cancer from other causes. If you have a history of breast cancer in your family, breast augmentation may not be an option.

Rippling
Rippling looks like indentations or waviness on the surface of the breast. It is the saline moving inside the implants. In most cases it occurs during movement. According to a 1994 survey (commissioned by implant manufacturers) 12% of women who were dissatisfied with their implants were dissatisfied because of rippling. Rippling is less likely to occur with implants that have a smooth surface. It is more common in implants that are placed above the muscle, especially in women with little or no breast tissue. Rippling can be a result of underfilling the implant.

Sagging
Sagging is less likely in implants placed above the muscle. Because the implant is likely to be higher on the chest than the breast tissue, you may have separate tissue hanging from the firmer implant. Your surgeon may recommend a mastopexy (breast lift) in addition to the augmentation.

Sensation Loss/Change
After surgery, you may have temporary or permanent numbness. There is also possibility of diminished sensation or increased sensitivity. The risk of having permanently numb nipples is roughly 15%.

Implants placed above the muscle may have a greater risk for this as the surgery may interfere with breast tissue near the skin. You can also expect sensation change if your incision is in the aerola. If the surgeon injures the nerves which lead to the nipple area it can lead to temporary or permanent numbness. All incisions have a risk of diminished sensation.

Rupture or Leak
Rupture of Saline Implants
If a saline implant breaks, it will deflate and the salt water will be absorbed by the body. Alert your physician right away as the implants will have to be replaced. Some implants deflate or rupture in the first few months after being implanted and some deflate after several years. You should also be aware that the breast implant may wear out over time and deflate. Additional surgery is needed to remove deflated implants.

In a study conducted by Mentor, 3% of 1264 patients had deflation after 3 years. In a similar study by McGhan, the deflation rate was 5%of 901 women after 3 years. Another study indicates that 10.1% of women followed for an average of 6 years had at least one implant deflated.(2)

Rupture of Silicone-Gel Implants
When silicone gel implants rupture, women may notice decreased breast size, hard knots, uneven appearance of the breasts, pain or tenderness, tingling, swelling, numbness, burning, or changes in sensation. According to the FDA, 69% of 344 women had at least one ruptured breast implant. Factors that were associated with rupture included increasing age of the implant, the implant manufacturer, and submuscular rather than subglandular location of the implant. A summary of the findings of this study is also available at the FDA's website at http://www.fda.gov/cdrh/breastimplants/studies/biinterview.pdf

For silicone gel and saline-filled implants, some causes of rupture or deflation include:

damage by surgical instruments during surgery
underfilling of saline (only) implant
capsular contracture
trauma, injury, or intense physical manipulation
excessive compression during mammographic imaging
placement through the belly button
normal aging of the implant

Deflation is less likely to occur if the implants are over filled. If the implants are not over filled they will fold when you move and may eventually rupture and deflate.

The Department of Surgery at Fairfield Hospital in Cleveland, OH, recorded the spontaneous deflation rates in 305 saline solution-filled breast implants:

Deflation rates compared to fill volumes

Fill volume	Number of implants	Number of deflations	Rate
Within recommended volume amount	305	22	7.21%
Filled to original implant size	84	10	11.9%
Greater than recommended volume	21	0	0.00%
Less than recommended volume	19	3	15.80%
Totals	345	25	-

According to this data, overfilling greatly reduces the risk of deflation.
Source: Raj J, Wojtanowski MH, Spontaneous Deflation in Saline Solution-filled Breast Implants. Aesth Surg J. January/February 1999;19:24-26

Additional Surgeries
Additional surgery may be needed to replace or remove the implants due to problems such as deflation, capsular contracture, infection, shifting, and calcium deposits. Women who do not have their implants replaced may have cosmetically undesirable dimpling, puckering of the breast following removal of the implant, or other unsatisfactory cosmetic outcomes.

In a study of saline-filled breast implants conducted by Mentor, 13% of 1264 patients needed additional surgery after 3 years. In a similar study by McGhan, 21% of 901 patients needed additional surgery after 3 years.(2)

A study by Gabriel et al. of both saline and silicone-filled implants concluded that 24% of women with breast implants experience adverse events resulting in surgery during the first 5 years after surgery.(1) According to this study, about 1 in 3 women getting breast implants for reconstruction may need a second surgery within five years, and about 1 in 8 women getting breast implants for augmentation may need a second surgery within five years. These additional surgeries may result in the loss of breast tissue.

(1) Gabriel SE, Woods JE, O'Fallon WM, Beard CM, Kurland LT, Melton LJ. Complications leading to surgery after breast implantation. New Engl J Med 1997; 336:679-682.
(2) Gutowski KA, Mesna GT, Cunningham BL. Saline-filled Breast Implants: A Plastic Surgery Educational Foundation Multicenter Outcomes Study. Plastic Reconstructive Surgery. 1997 (100): 1019-27.

Satisfaction Rates

A recent study conducted at the University of Minnesota in consultation with the Food and Drug Administration (FDA) did a 10 year follow-up with 450 women who had undergone breast augmentation. Almost 96% of women with saline-filled breast implants stated they would make the same choice again. 93% were satisfied or very satisfied with their breast implants and 71% rated their breast implants as soft and natural.