Breast Augmentation Washington DC
Breast augmentation not only increases the size of the breasts, but can also improve their shape. Some women have naturally smaller breasts which they would like enhanced, while others are looking to regain volume that they have lost after pregnancy and breast feeding or weight loss. While the concept of breast augmentation is straightforward, there are a number of choices which allow us to customize the surgery for each individual.
There are 3 incisions through which a breast implant can be placed. These are:
* Inframammary – in the fold beneath the breast
* Periareolar – around the edge of the areola
* Transaxillary – through the armpit
The choice of which approach is used depends upon the preference of the patient and physician as well as the size and type of implant.
The inframammary incision is placed at or just above the fold beneath the breast. The advantage of this approach is that the pocket where the implant will sit can be developed without cutting through any breast tissue. There is no limitation as to the size or type of implant that can be placed.
The periareolar incision is placed on the edge of the nipple at the junction of the pigmented skin of the areola and the lighter skin of the breast. From this approach, dissection can easily proceed either directly through the breast tissue with minimal interruption of the ducts, or parallel to the skin down to the inframammary fold and under the breast tissue. Any size saline implant can be placed via this incision as they come deflated and are filled once they are in position, but there may be an upper limit on how large of a silicone implant can be used, depending upon the size of the areola. This is the best approach to release a tubular or constricted inferior pole breast deformity.
The transaxillary approach hides the incision in a natural crease in the armpit. To best develop the pocket, endoscopic techniques are utilized. Only saline implants can be placed via this approach, since the incisions are too small for silicone implants. The advantage of this incision is that there are no scars on the breast itself.
There are 2 alternatives for the location of the implant pocket, subglandular (on top of the muscle) and subpectoral (under the pectoralis major muscle). An implant in the subglandular position has the potential for more visible rippling as well as distortion of the natural slope of the breast. Our preference is to place implants in the subpectoral position, where the pressure of the muscle helps to smooth out the implant and minimize rippling. The muscle also drapes over the superior portion of the implant, creating a natural slope in profile. Patients who have previously had implants placed in the subglandular position can have them replaced in the subpectoral position if they are dissatisfied with the visibility of the implants.
In November 2006, the FDA approved silicone implants for breast augmentation in patients over 22 years old. Prior to that, silicone implants were only available to patients getting breast reconstruction, participating in clinical trials, or in other special circumstances. The decision whether to use silicone or saline is a personal one, though there may be situations where one may be a better choice than the other. Typically, if a patient has a small amount of breast tissue, silicone implants will feel more natural and have less visible rippling. If there is already a moderate amount of breast tissue present, then the breasts can be enhanced with either silicone or saline implants. Additional information regarding silicone implants will be provided at the time of consultation.
Breast implants not only come in a variety of sizes, but also different shapes (anatomic vs. round), profiles (moderate vs. moderate plus vs. high), and surfaces (smooth vs. textured). Anatomic implants are shaped like breasts with less volume in the upper half and more in the lower half. They are textured to prevent them from rotating, as this may cause distortion of the breasts, and are only available in saline at this time. Our preference is smooth round implants, as they will slope when the patient is standing and round out when lying down like natural breasts. They also come in different profiles, allowing us to individualize breast augmentation for each patient.
When an implant is placed in either a subglandular or subpectoral position, it compresses the breast tissue, making it appear denser on a mammogram. In the subglandular position, the breast tissue wraps around the implant, making it more difficult to assess the peripheral tissue. In the subpectoral position, there is a distinct layer of muscle separating the breast tissue from the implant. Eklund views are included in breast augmentation patients. These views involve pushing the implant out of the way to better visualize the glandular breast tissue.
The procedure is performed on an outpatient basis with general anesthesia. The patient is first marked in an upright position prior to entering the operating room. If a patient has inverted nipples, this can also be addressed at the time of surgery. Long-acting local anesthesia is also either placed in the implant pocket itself or injected as intercostal nerve blocks to minimize postoperative discomfort. This should last at least 6-8 hours. At the end of the procedure, the patient is placed in a dressing consisting of gauze padding and ace bandages placed circumferentially like a tube top.
Recovery from Breast Augmentation
The most common complaint after breast augmentation surgery is pressure on the chest. This is due to the pectoralis major muscles contracting against the implants in response to being stretched. This will subside as one’s body adjusts to the implants, and muscle relaxants such as Valium offer significant relief to patients in the immediate postoperative period. Sleeping with a folded towel under each shoulder may also help to take tension off the muscles. The patient is seen back in the office a few days after surgery for dressing removal at which time she is placed in a soft bra.
Implant massage exercises are started soon after surgery. The goal is to manipulate the implant around the pocket to keep the pocket larger than the implant itself. This allows the implant to move around more naturally with changes in body position and also minimizes the incidence of capsular contracture. Exercises are performed twice a day on each side.
Patients are instructed to use the right hand to massage the left breast and vice versa. The exercises are performed in 2 directions. First, the hand is held so that the little finger is touching the inframammary fold. The patient is then instructed to turn the palm toward the body to push the implant in an upward direction, hold it in that position for a few seconds, and then release. This should be a rocking motion, not a lift. This is then repeated with the other breast. The second exercise is to push the implants toward the center of the chest, hold for a few seconds, and then release.
Breast Augmentation Risks and complications
Risks and complications are uncommon, but may occur. They include, but are not limited to: infection, bleeding, scars, sensory changes of the overlying skin and nipple (increased, decreased, lost), capsular contracture, implant deflation, persistent asymmetry, and need for revision in the future.
Capsular contracture is our primary concern after breast augmentation. The capsule is the scar tissue which normally forms around the implants. If this scar tissue tightens around the implants, it may cause distortion and/or discomfort. This may be treated initially with more aggressive massage exercises. Accolate, a medication typically used for asthma, may also be added, as it can lessen capsular contracture in some patients. If these measures are unsuccessful, surgery is needed to remove the scar tissue and reopen the pocket. Implant massage exercises are then restarted a few days later to maintain the larger pocket and prevent recurrence.