Breast Enhancementhr

Breast augmentation is one of the most common plastic surgery procedures. It refers to the surgical placement of breast implants to enhance breast size. Breast augmentation is performed as out-patient surgery and patients are generally able to return to work within one week. It is necessary however, to refrain from strenuous activity or heavy lifting for one month post-operatively.

Patients considering breast implants generally fall into one of two groups: those wishing to enhance their natural breast size vs. those seeking to restore breast appearance following pregnancies, breastfeeding, or weight loss.

Many patients report always wanting larger breasts since puberty and wish to augment their natural breast development or to address breast asymmetry.

Breast changes following pregnancy and weight fluctuation are the motivation for other patients. When breasts enlarge during pregnancy and weight gain, the skin often stretches beyond its ability to fully contract afterwards. This commonly leads to breast ptosis (referring to a lower position on the chest wall) and loss of breast volume over time, particularly in the upper pole. Many patients wish to achieve a result similar to their breast appearance when breastfeeding. Loss of breast volume in the upper pole is a common reason for patients to seek breast augmentation in addition to increasing cleavage.

Changes in breast appearance following augmentation often translate into improved self-image and self-confidence based on patient reports.

Every procedure is unique given the number of variables that are considered in pre-operative planning.

Desired look

Most importantly, it is important for Dr. Power to understand your aesthetic goals when considering breast augmentation. Many patients wish to achieve natural-looking results, whereas others are interested in a more augmented look. It is helpful to bring photographs to your consultation to demonstrate examples of desired breast size and shape.

Implant selection

Determining the appropriate implant is a critical aspect of pre-operative planning. During consultation, details regarding size and type of implant, placement above or below the chest

muscle, and incision location will be discussed. These factors will be influenced by an individual patient’s surgical goals, chest and body measurements, and preferences.

Implants are selected in terms of fill material – saline vs. silicone –, size, shape, and texture. Both saline and cohesive silicone gel implants are Health Canada and FDA approved. Silicone implants have evolved over time to cohesive gel, which is form stable. This latest generation of silicone implants demonstrates a natural palpability and enhanced safety profile over earlier generations. Cohesive gel implants do not leak or migrate if the implant shell is compromised. Saline implants also have a silicone shell. They are filled with salt water, which is resorbed by the body if rupture occurs. Many patients prefer silicone implants as they feel softer and more natural when examining sizers pre-operatively. Some studies suggest that it may be difficult however to distinguish between the two when placed below the pectoralis muscle. Saline implants are more cost effective. It is often a matter of personal preference for many patients.

Implant size is an important consideration. A given size may vary between patients since it is based on base diameter (influenced by a patient’s chest wall dimensions) and projection. A 300cc implant may appear more prominent, for example, in a small-chested patient as compared to the same implant in a patient with a broader chest. The 300cc implant in the latter case would demonstrate less projection given a larger base diameter. Trying on sizers is an important step during consultation. It is recommended to bring an unpadded bra to wear when trying on implant sizers.

Implants are either round or anatomic (“teardrop”) shape. The outer shell may be smooth or textured. Dr. Power personally prefers smooth round silicone implants. This avoids the risk of a teardrop implant shifting in the implant pocket, which may result in secondary aesthetic deformities. The smooth surface also facilitates implant massage to maintain the pocket dimensions. Textured implants were developed in an attempt to lower the risk of capsular contracture, which is tightening of the scar tissue around the implant over time. Textured implants demonstrate limited mobility however and make implant massage more difficult.

Implant placement

Implants may be placed either above or below the pectoralis major (chest) muscle. Several factors are considered when selecting implant placement, including body habitus and amount of natural breast and soft tissues, aesthetic goals, and level of athleticism. If patients are quite slender and do not have adequate breast tissue to provide coverage for the implant, placement under the pectoralis major muscle (submuscular plane) may be recommended to improve the aesthetic result. If an implant is placed above the muscle in a patient with little natural breast tissue, there may be higher risk of implant visibility, rippling, and dissatisfaction with aesthetic outcome. If patients have adequate breast tissue to provide implant coverage – generally corresponding to 2cm of tissue when pinching the upper pole of the breast – implants may be placed above the muscle. This is referred to as the subglandular (under breast tissue, above muscle) plane. For patients who are quite physically active in upper body activities (for example, rowing, personal training), it is important to know that submuscular implants will shift with contraction of the pectoralis muscle. If wearing form-fitting clothing, you may notice movement of the implants when performing these activities.

Scar placement

Implants may be inserted through different skin incisions. The two most common approaches are inframammary vs. periareolar. Placement through an inframammary incision results in a short scar hidden in the fold below the breast. The periareolar approach leaves a scar at the lower half of the areola-skin junction, which is generally inconspicuous once healed. Some studies have shown lower capsular contracture rates and fewer complications if revision surgery is needed following the inframammary approach. Less commonly implants may be placed through transaxillary (underarm incision) or umbilical (belly button) approaches. These approaches make implant positioning more difficult due to less visibility during surgery. There is also increased risk of bleeding since it is more difficult to carefully control during surgery due to the remote access. Scars in the underarm region may also be more visible when wearing certain clothing (e.g. tank tops, sleeveless dresses) and should be carefully considered before opting for this technique.

BREAST IMPLANT SURGERY FAQS:

What are different types of implants?

  • Implants may be categorized based on filler, shape, and size.
  • All breast implants have a silicone shell as the outer layer.
  • They may be filled with either saline (salt water) or silicone.
  • Some patients prefer silicone implants for a more natural feel vs. saline implants, however some studies have shown no difference when they are placed under the pectoralis major muscle.
  • There are many generations of silicone implants. Current silicone implants are made of cohesive gel, which is form stable. This means there is lower risk of bleeding through the implant shell and if implant failure or rupture occurs, it is contained within the implant pocket.
  • Implant shape may either be round (most commonly) or anatomic (tear-drop shaped).
    • The concern regarding anatomic implants is that they may shift in the pocket, which could lead to secondary aesthetic concerns.

What are different incisions for breast augmentation surgery?

  • Implants may be placed through different skin incisions.
  • The two most common approaches are inframammary vs. periareolar.
    • Placement through an inframammary incision results in a short scar hidden in the fold below the breast.
    • The periareolar approach leaves a scar at the lower half of the areola-skin junction, which is generally inconspicuous once healed.
    • Some studies have shown lower capsular contracture rates and fewer complications if revision surgery is needed following the inframammary approach.
  • Less commonly implants may be placed through transaxillary (underarm incision) or umbilical (belly button) approaches.
    • These approaches make implant positioning more difficult due to less visibility during surgery.
    • There is also increased risk of bleeding since it is more difficult to carefully control during surgery due to the remote access.
    • Scars in the underarm region may also be more visible when wearing certain clothing (e.g. tank tops, sleeveless dresses) and should be carefully considered before opting for this technique.

What are different planes for breast implant placement and how is this determined?

  • Implants may be placed either above or below the pectoralis major (chest) muscle.
  • Several factors are considered when selecting implant placement, including body habitus and amount of natural breast and soft tissues, aesthetic goals, and level of athleticism.
  • If patients are quite slender and do not have adequate breast tissue to provide coverage for the implant, placement under the pectoralis major muscle (submuscular plane) may be recommended to improve the aesthetic result.
    • If an implant is placed above the muscle in a patient with little natural breast tissue, there may be higher risk of implant visibility, rippling, and dissatisfaction with aesthetic outcome.
  • If patients have adequate breast tissue to provide implant coverage – generally corresponding to 2cm of tissue when pinching the upper pole of the breast – implants may be placed above the muscle.
    • This is referred to as the subglandular (under breast tissue, above muscle) plane.
  • For patients who are quite physically active in upper body activities (for example, rowing, personal training), it is important to know that submuscular implants will shift with contraction of the pectoralis muscle.
    • If wearing form-fitting clothing, you may notice movement of the implants when performing these activities.

Who is a suitable candidate for breast augmentation?

  • A suitable candidate for breast augmentation is otherwise healthy, ideally a non-smoker or able to stop smoking at least one month before and after surgery, with realistic goals and expectations.
  • Many patients express interest in breast augmentation to address longstanding concerns about their breast size and to enhance self-image.
  • It is recommended to delay surgery if experiencing any significant life stresses or changes. This poses higher risk of dissatisfaction following breast augmentation.

What are common concerns of patients considering breast augmentation?

  • Many patients considering breast implant surgery express dissatisfaction with breast size after adolescent development.
  • Others are interested in augmentation to address breast changes that resulted following pregnancy, breastfeeding, or significant weight loss.
    • Depending on clinical examination, other types of breast surgery (for example, breast lift or breast lift plus implants) may be more appropriate to achieve aesthetic goals within this group of patients.
    • This will be discussed in detail during consultation with Dr. Power based on your specific aesthetic concerns and presentation.

What to expect during consultation for breast augmentation?

  • During consultation, a detailed history will be performed. This will focus on your aesthetic concerns and surgical goals.
  • It is also important to know about your past medical history, pregnancy history, whether you have breastfed or wish to breastfeed in the future, and whether there is any personal or family history of breast disease or cancer.
  • A detailed physical examination will also performed to assess breast and thorax measurements, which will help to determine appropriate implant measurements.
  • Dr. Power will also inquire regarding weight history and lifestyle. If significant weight gain or loss is experienced after surgery, breast appearance may also change.

How is implant size selected?

  • Implant size determination is one of the most important considerations.
  • Dr. Power will ask about your goals and desired look following augmentation.
  • Cup sizes vary widely between bra manufacturers and are not standardized measurements.
  • You will have a range of sizers to try on pre-operatively. This is not an exact science however, since the implant fits differently when inserted surgically vs. within your bra on top of your natural breast tissue.
  • Dr. Power will also discuss the rice test, which is another tool that may guide size selection.
    • At home you may fill a cut-off nylon stocking with rice to the desired size when placed in your bra.
    • Avoid tying the nylon too tightly so that the rice moves freely and molds easier.
    • You may then bring the rice to your clinical appointment. It will be measured and a corresponding implant size discussed.
  • Dr. Power will ensure that there are no surgical concerns regarding desired implant size. For example, the desired size may be considered too large based on clinical examination and potentially too tight for the implant pocket. This could increase the risk of healing complications or suboptimal aesthetic result.

What to expect the day of breast augmentation surgery?

  • You should begin fasting (no food or drink) at midnight prior to surgery.
  • If you take any prescription medications, please discuss with Dr. Power whether they should be taken on the morning of surgery with limited sips of water.
  • Someone must accompany you on the day of surgery to drive you home afterwards once discharged.
  • You will be advised regarding the time to present at the private OR facilities at 199 Avenue Road
  • You will be assigned a locker for personal belongings when you check in for surgery.
  • Routine vitals will be checked and you will meet the anesthesiologist who will be performing your general anesthetic and OR nurses.
  • Dr. Power will see you before surgery to perform surgical markings, answer any remaining questions, and review post-operative instructions.
  • Once you are taken to the operating room, a checklist will be performed based on standardized operating room guidelines to confirm patient and surgery details and you will be put to sleep shortly thereafter.

What to expect after breast augmentation surgery?

  • You will wake up from surgery in the recovery room.
  • Pain medication is administered during surgery and will be supplemented in the recovery room if any discomfort is experienced.
  • Dr. Power will have provided a prescription for post-operative pain medication prior to surgery. It is recommended to fill the prescription in advance to avoid needing to stop at the pharmacy on the way home.
  • You will be discharged an hour or two after surgery once drinking well and medically fit.
  • Please arrange to have someone stay with you for 24 hours after the general anesthetic to ensure personal safety.
  • You may require prescription pain medication for a few days following surgery and may then transition to Tylenol plain or extra-strength as needed.
  • You may resume showering the day after surgery.
  • A detailed instruction sheet will be provided outlining appropriate incision care and activity restrictions.
  • It is important to wear a sports bra full-time (even when sleeping) for one month following surgery.

What is the anticipated recovery after breast implants?

  • Patients returning to office-based work or academic programs are usually able to return within a few days to one week after surgery.
  • Once no longer taking prescription pain medication and comfortable performing upper body movements, you may resume driving.
  • To lower risk of bleeding, it is recommended to avoid strenuous activity, heavy lifting, and exercise for one month after breast augmentation.
    • Although the risk of bleeding decreases as more time passes after breast augmentation, avoiding activities that increase your blood pressure and heart rate is important during this time period.
  • There will be swelling following breast implant surgery. Although final results will not be apparent until one year post-operatively, the majority of swelling will settle within the first few months.

What are potential complications of breast augmentation?

  • Early complications of breast augmentation include bleeding, bruising, hematoma formation (collection of blood or ongoing bleeding into the implant pocket), and infection.
  • There is also risk of altered nipple sensation, delayed wound healing, hypertrophic (thickened) scarring, and potential need for revision surgery.
  • Aesthetic complications include rippling, implant distortion, malposition, and capsular contracture.
    • Capsular contracture refers to scar tissue that develops around the implant since it is a foreign body.
    • It ranges from a mild capsule that does not cause any distortion of the implant or pain to an implant that is fixed, painful, and high on the chest wall.
    • Revision surgery may be required to address moderate to severe capsular contracture.
  • Device failure may also occur, ranging from an asymptomatic silicone leak noted only on imaging (“silent rupture”) to a deflated saline implant which is fully decompressed and flattened.
    • Implant failure may be related to ongoing friction at an implant fold or potentially valve failure on a saline implant.
  • There is no “lifespan” of a breast implant. If a patient remains pleased with the aesthetic appearance and does not report any symptoms, it may be observed over time. Revision surgery is not required unless complications or concerns arise.

Are there any risks associated with larger breast implants?

  • Larger implants generally lead to more ptosis (lowered position on the chest wall) over time than smaller ones.
  • They may also lead to greater thinning of your natural breast tissue over time.
  • Some studies have found lower capsular contracture rates for implants 350cc or less.

Is there a link between breast implants and lymphoma?

  • This has been a hot topic over the last few years.
  • There does appear to be a very rare association between breast implants and an uncommon type of lymphoma – anaplastic large cell lymphoma (ALCL)
  • Fortunately the risk is extremely low and the particular type of lymphoma is treatable.
    • Some reports have shown less than 100 cases worldwide.
    • It may occur in approximately 1-3 per million breast augmentations performed.
  • Implant-related ALCL has been documented following cosmetic breast augmentation as well as breast cancer reconstructions.
  • It is important for any patient who develops late swelling or pain of one breast a year or more after breast augmentation to discuss the very low but potential risk of ALCL with your surgeon.

Is there increased risk of developing autoimmune disease from silicone breast implants?

  • Fortunately not, although this was a major concern many years ago and remains a frequently asked question.

How many follow ups are required after breast implant surgery?

  • Patients generally return for routine follow up visits one day after surgery to rule out any bleeding, then at one week, three months, and one year post-operatively.
  • Patients are welcome to schedule additional follow up at any time if concerns arise.

Do breast implants affect screening for breast cancer?

  • Studies have interestingly found lower incidence of breast cancer in patients with breast implants.
    • Augmented patients generally have less natural breast tissue than non-augmented patients, which may partially explain this finding.
    • Some theories have questioned a protective effect of silicone.
  • Studies have not found any delay in breast cancer detection following breast implant surgery.
  • It may actually be easier to palpate any abnormalities on self-breast examination, since there is a firm implant backing to press against.
  • Research has shown that patients with breast implants often detect breast tumors at a smaller size than patients without implants.
    • This may be attributed to frequent self-examinations when massaging the breast implants.
  • Special mammogram views are required following breast augmentation. It is important to find a breast screening center that is accustomed to imaging patients with breast implants to ensure the breast tissue is appropriately visualized.
    • Given that breast augmentation is the most commonly performed cosmetic surgery, these centers are becoming increasingly widespread.

Do breast implants have to be replaced every 10 years?

  • This is a common myth regarding breast augmentation. Breast implants may remain in place as long as there are no medical or aesthetic concerns. Routine replacement is not indicated

Can I breastfeed after breast augmentation?

  • Changes in nipple sensation following breast augmentation may affect breastfeeding for some women. Patients who undergo breast augmentation often have less native breast tissue than non-augmented patients. The good news is that the majority of women are able to breastfeed after breast augmentation surgery. There may be lower risk of interfering with breastfeeding when an inframammary approach is used (when the implant is placed through an incision in the fold below the breast).

Can breast implants change nipple sensitivity?

  • There is risk of increased or decreased nipple sensation following breast augmentation. The majority of cases resolve over time, however some studies quote up to 15% risk of permanent sensation changes. The risk may be lower with smaller implant sizes and when placed below the pectoralis muscle through an incision in the inframammary fold.

Should I avoid breast implants if I’m an athlete involved in contact sports?

  • Playing contact sports is not a contraindication for breast augmentation and does not increase risk of implant rupture. Contact sports may be resumed once you have healed well following breast augmentation. You may generally resume exercise and routine sports after one month following breast implant surgery.

Am I too skinny or athletic for breast implants?

  • Slender patients with limited breast tissue may still undergo breast augmentation. Implants are generally placed below the pectoralis muscle to lower risk of aesthetic complications (for example, implant visibility, rippling, and palpability) and to give a more natural result. The pectoralis muscle provides extra coverage for the implant, which gives a more natural result. It is important to discuss your aesthetic goals when selecting implant size. Athletic patients may also be candidates for breast augmentation. Many athletic patients often have limited breast tissue in the upper pole. Submuscular implants may also be recommended based on clinical presentation. It is important to consider that submuscular implants will shift with pectoralis muscle contraction. If you are quite active in upper body work-outs or rowing, for example, you will note shifting of the implants with pectoralis contraction, which may be apparent through tight clothing.

Can breast implants rupture and cause silicone poisoning?

  • Fortunately not. Silicone breast implants have evolved over time. Early generations demonstrated thin shells with low viscosity silicone. These implants were prone to rupture and leakage. The latest generation of silicone implants are made of cohesive gel. The silicone does not bleed through the implant shell or migrate if rupture occurs. If the implant shell is compromised, it is generally an incidental finding noted on imaging (ultrasound or MRI). The silicone will not travel throughout the body.

Are fat injections an alternative to breast implants?

  • Fat grafting is an option for breast augmentation, however does not achieve equivalent results to breast implants. The procedure involves suctioning fat from regions of excess fatty tissue (most commonly the abdomen) and then carefully preparing the fat for re-injection into the breasts. Once the injected fat has reestablished a new blood supply, the tissue may feel quite natural however the size and shape do not match results achieved from breast implants. There are risks of fat grafting in the breasts, including regions of fat necrosis (which are firm areas where the fat has not established an adequate blood supply) and limitations on size. There was initial concern whether injected fat may interfere with detection of breast cancer or cause microcalcifications, leading to false positives on breast imaging. Others questioned whether injected fat stem cells may induce breast cancer. Studies thus far have demonstrated that fat injections appear safe for both reconstructive and cosmetic cases. It may be useful in smaller volume for contouring, for example, to mask implant visibility or rippling in select cases.

Breast augmentation continues to increase in popularity and has shown high satisfaction rates in appropriately selected patients.

Please contact us to schedule your consultation.