Plastic surgeons are often called upon to create a solution for breast deformities. Initially, the main concern was to reconstruct a breast after mastectomy resulting from cancer or a birth abnormality. From this experience grew an understanding of breast surgery in general: techniques were developed to improve the appearance of small or sagging breasts which were in all other respects completely normal.
Before we go there, the first question you must ask yourself is “Why do I want to have breast implants?” Most of the women I see with a complaint about breast size have absolutely normal breasts. Even if my patient complains of “small breasts”, when I measure their height, weight and chest size, more often than not her breasts are of an adequate size, “within normal limits” in med-speak.
So, it is important to ask yourself why you are unhappy with your breasts. Did a significant other say something to you about it? Did you overhear someone say something that made you feel inadequate? Maybe you want to wear some type of clothing style that does not suit your present size and shape? Is it worth having an operation to make your breasts larger because of clothing?
I am not particularly in favour of breast augmentation because I know that some women will develop complications and problems. Accordingly, this has made me cautious about this procedure. However, I realize that for some women at least, this operation can be liberating. Often, women returning for a check up are so grateful that I can’t really even understand their happiness, excitement or joy. Maybe that is not surprising, since I am a man (and therefore can’t be expected to understand everything about women).
Now that you have decided for your own personal reasons you want larger breasts, let me give you an example of a person I saw just recently, but who is quite similar to many patients I’ve seen desiring this type of surgery:
She arrived at the clinic with her husband. She is a fit twenty-something professional who is involved in sports, has a business career, an active social life and is married but with no children (yet). She is 5′ 6″ tall, weighs about 130 lbs and wears a 34 B cup bra which is heavily padded. She also has purchased a water bra and a bra that accepts small inserts to enhance the size of her breasts.
Examining her breasts reveals tight normal skin with no significant droop nor stretch marks. There is a sufficient amount of tissue in the upper part of the breast. The nipples are at a slightly different height on her chest, but she had not noticed that before. The breasts are slightly asymmetric (one breast is slightly larger than the other). The fold under the breast is also at a slightly different height. The breasts are otherwise completely normal and have an aesthetically pleasing shape.
She wants larger breasts because she just does. She does not have any pressure from her husband. In fact, quite the opposite, he does not really want her to go ahead with it because he loves her the way she is. He has decided he will support her decision, however. She wants large breasts, because if ‘she is going to do it, she wants it to be worth it’. I explain to her that it is important that the implant be completely covered with her natural breast tissue and fat, regardless of the type of implant. I explain that size 10 feet will never fit into size 5 shoes, and vice versa.
Breast implants are used to enhance the appearance of a breast that has lost volume, such as after pregnancy. There are many ways to insert breast implants. Almost always, I use an incision just under the breast, along the fold or around the areola (the edge of the colored skin around the nipple).
Consider the following: all implants will eventually break or need to be replaced. These incisions provide the best access to the entire breast. There is little point in inserting the implant through the armpit, since this incision simply is not used for revision or repair of the breast. Putting the implants in through the belly button was a dumb idea and almost no one still uses this method.
Typically, preferred placement of saline implants is below the muscles of the chest, since this affords an added layer of camouflage for the implant and will help hide any rippling of the implant. The patients shown here with implants have had them placed under the chest muscles.
Short answer: sub-muscular for saline, sub-mammary for gels. First of all, breast implants look best when inserted just under the breast tissue, since this is, after all, where your natural breast tissue is normally found. For cohesive gel implants, the logical location of the implant is above the muscle since cohesive gel implants feel very much like (firm) normal breast tissue.
Saline implants placed just under the breasts tend to have some serious problems. Implants that have only skin to cover them will appear artificially round with a crescent shaped curve at the outer edge. Implants positioned just under the breast tissue will also usually plainly show the edges of the implant (similar to the edge of a scallop shell, hence the term “scalloping”). Because of this, saline implants are almost always used under the muscle.
Because there is little room under the pectoralis muscle for a breast implant, implants placed under the muscle temporarily sit higher than a breast normally would. Over time, however, they will move to a lower position and appear more natural. In some patients, saline implants will not give as natural a result as cohesive gel implants. Gel implants are less likely to show rippling or irregularities, feel less ‘sloshy’ and more natural than saline implants.
Capsule formation (hardening) is less likely to occur when a smooth surface implant is placed under the muscle (less hard capsule formation under the muscle) or when a textured implant is used above the muscle. Rippling or unnatural crinkling is more likely when saline implants are placed just under the breast tissue (less rippling and crinkling under the muscle).
I believe the best placement for smooth walled saline implants is below the muscles of the chest. Textured implants have a lower risk of capsule formation above the chest. Cohesive gel implants are shaped and also textured. This type of implant is placed above the muscle for the best effect.
Placement of the implants below the muscle is more painful in the short term and the implants will flatten with forceful muscle action of the chest, such as during weight lifting (bench-press). You may have noticed women who have had implants whose breasts flatten with intense muscle movement. This makes the breasts look unnatural. On the contrary, implants placed above the muscle do not show this problem. For weight lifters, I usually recommend cohesive gel implants, since these will function more realistically than saline implants placed below the pectoralis muscle.
Sometimes, patients ask for large implants. This is not a good idea, for several reasons:
First, large implants will cause stretching of your natural breast skin so that if you ever decide to remove the implants, your breasts will sag more than if you had never had implants (you may need a breast lift that you otherwise would not have needed). If you need proof of this, just look at your tummy skin if you have had children. The womb pushing out against the tummy for nine months results in a permanent bit of excess skin that was not there previously. Remember that skin will always grow to cover whatever is under it. No matter how big and heavy some people get, they never run out of skin, do they?
Second, just as your bra strap can cause pressure atrophy (shrinkage) of the fat under the skin of the shoulder straps of your bra (causing a noticeable shoulder strap groove), a large heavy implant can cause the same changes to the tissues inside your breast. This means that if you change your mind about the implants in the future, your natural breast tissue will have shrunk somewhat because of the weight of the large implants. In other words, your breasts will be smaller than they would have been if you never had implants.
Lastly, implant rippling is much more common if the implant is large, the amount of natural breast tissue is small, the skin is thin and there is little fatty tissue or muscle to hide the implant. How visible the implant is externally will depend on the the thickness and quality of the skin that is covering it. If you start with a really thick-walled balloon and blow it up to a large size, the wall will become quite thin due to being stretched out. If you have a smallish breast, and put in watermelon-sized implants, don’t be surprised if you can see the manufacturer’s logo through the skin.
Remember that sizing a breast implant is an important aspect of your consultation. Consider these two patients:
Patient A: 5′ tall, weighs 80 lbs and measures 28″ around her chest
Patient B: 5′ 11″ tall, weighs 160 lbs and measures 38″ around her chest.
Clearly, the second patient will likely be able to “wear” larger breast implants than the first. Placing implants that are appropriate to a larger woman on a smaller woman is not only inappropriate, it causes a DEFORMITY and responsible surgeons would never do this!
Unfortunately, everything in surgery is about weighing the risks versus the benefits, the give versus the take and the pros versus the cons. A personal consultation with me, Dr. DeLorenzi, will give you the kind of details you need to make the right choice.
Read everything you can, speak to your friends, ask around and DON’T RUSH. Look up resources on the internet and visit your local library. There is plenty of information available.
Invest in a couple of consultations; prepare your questions before you go. Ask yourself the following after each consultation: Did you like the Doctor? Did you feel you were “being sold” an operation or did you feel you were getting a personalized consultation? Were you given some insights that had not occurred to you previously?
A good consultation should leave you with a good understanding of the issues such as: Am I a good candidate for surgery? If I am a candidate for breast augmentation, what type of implant should I consider and where should it be placed? Did the doctor really help me to understand the risks and complications, the expected results and the required aftercare of surgery in my case?
Breast implant surgery is usually done under general anesthesia and recovery is approximately 7 days.
–Prepared by Dr. Claudio DeLorenzi of The DeLorenzi Clinic.