OVERVIEW

Having small breasts can be a very difficult problem for some women and can negatively affect their self-esteem and confidence. Breast augmentation addresses this problem directly and has helped countless women get a new found sense of confidence.

Breast augmentation is one of the most popular procedures that plastic surgeons perform because of its ability to quickly and drastically enhance a women’s breast size and shape. Although there are plenty of women who have naturally small breasts, breast augmentation is also suitable for women whose breasts have lost shape due to breast feeding.

DR CONSTANTINE’S PHILOSOPHY
ON BREAST AUGMENTATION

In general, I prefer to perform my breast augmentations through an inframamary incision and place the implant underneath the muscle in what is known as a dual plane. I feel that this provides the most consistent, long lasting, and natural results when compared to other techniques.

CHOOSING THE RIGHT SIZE

Choosing the right size of implant is the most important decision that a patient and I make during a consultation. I believe that a patient’s body tells me what size is appropriate for breast augmentation. During a consultation, I perform a detailed history and physical examination. Part of the examination includes multiple measurements of a patient’s chest, breast, and skin quality and elasticity. Once all of these measurements are taken, I can generally come up with 2-3 different implant sizes that will best suit a patient’s body. The next step is to talk to the patient about expectations and goals. If my proposed sizes align with my patient’s goals, we will proceed with surgery. If a patient asks for breast implants that are too large for her measurements, I will not perform her surgery. I do not believe in putting in whatever implants a patient wants. Placing implants that are too large (or too small) will cause problems in the future and increase reoperation rates, ultimately lead to bad results, and an unhappy patient. My goal is to provide the safest and most natural results for my patients. I do believe that every patient has an optimal “fill” that her breasts can accept, anything more or less will not produce a natural result.

WHICH IS BETTER, SALINE OR SILICONE BREAST IMPLANTS?

This question is brought up frequently during breast augmentation consultations. My answer is simple: there is not one that is better than the other, but there is one that’s better for you. I believe in providing my patients with all the important information about both types of implants, all the pros and cons and advantages and disadvantages. Once a patient has all the information and has all of their questions answered to a point where I feel they truly understand, I allow them to choose for themselves. I will never try to sway a patient towards one or the other; this needs to be your choice. They are being placed in your body and you have to live with them everyday.

SILICONE

Historically, silicone implants were widely used but controversy arose in the 1990s when the media questioned whether a rupture in the silicone implant could cause health problems, most notably autoimmune disorders. The FDA has looked at all available data exhaustively and determined that there was no statistical link between silicone implants and any autoimmune disorders.

Silicone implants have a softer and more natural feel. They tend to hold their shape better and have less rippling at the edges. The new generation silicone implants are made of a more “cohesive” gel which does not leak if there is a tear in the outer shell of the implant. Because of the softer feel and less rippling, silicone implants are ideal for thin patients with smaller breasts.

Silicone implants come “prefilled” and to an already determined volume, therefore they generally require a larger incision to place them into the pocket than saline implants.

The FDA has approved silicone implants for cosmetic use in patients over age 22 years of age. Because silicone implant rupture is harder to detect than with saline implants, the FDA recommends MRI screening for rupture 3 years after the initial placement and every 2 years after that.

SALINE

Saline implants feel less viscous than silicone and some people believe they feel is slightly less natural. Saline implants have a tendency ripple more than silicone. Saline implants have a recommended volume range making them somewhat adjustable. This can be helpful in correcting differences in size between a patients’ breasts to help achieve more symmetry. Saline implants are placed into the breast without fluid and then filled once they are in the pocket; therefore, the incision is smaller with saline implants as compared to silicone. Implant rupture with saline is very easy to detect, as most people notice it within hours to days of rupture, having a “flat tire” appearance. Implant rupture with saline implants is harmless as the saline fluid gets absorbed by the body immediately.

POCKET LOCATION

The breast implant can be placed directly under the breast tissue (subglandular), under the chest muscle (submuscular), or in combination known as a “dual plane.” Dual plane placement gives the advantages of both techniques and minimizes the disadvantages of each.

DUAL PLANE/SUBMUSCULAR BREAST AUGMENTATION

This is my preferred method of performing breast augmentation in the vast majority of cases. Adding more layers of tissue overlying the implant translates to less palpability and visibility of the implant. In thin women, placing the implant under the muscle gives a more natural appearance by hiding the edges of the implant. The muscle maintains most of its attachments to the sternum (breast bone) and rib cage, so most patients do not notice an appreciable decrease in strength. I feel that this technique gives the most natural, consistent, and long lasting results.

Submuscular augmentation is slightly more painful and adds a little more time for the implant to assume its final position. Most women have described the feeling as being very sore as if they had done a vigorous chest work out the day before.

SUBGLANDULAR BREAST AUGMENTATION

Subglandular augmentation places the implant under the breast tissue but over the muscle. This does not provide as much tissue coverage over the implant making the implant easier to see and feel. In thin patients, ripples in the implants are more visible with the subglandular approach.

Subglandular breast augmentation is typically less painful and gives a more immediate postoperative result. Because the implant is directly below the breast tissue, the implant has a more direct effect on the breast shape, making it a useful technique for tuberous or constricted breast deformity. Some have also advocated using this technique in competitive body builders, as putting an implant under such a robust muscle might make it susceptible to implant malposition.

INCISION TYPE

There are four incision locations which are used in breast augmentation. My goal is to choose the incision that permits the best access for precise implant placement while being the least visible.

PERIAREOLAR INCISION

The periareolar incision is placed at the lower and middle part of the areola just inside the pigmented portion of the skin. This incision generally heals very well making it difficult to detect as it is camouflaged by the darker skin surrounding it. In my opinion this incision is useful when the inframammory crease needs to be lowered in patients that have a constricted or tuberous type breast deformity. I also find it useful when the skin of the breast needs to be mild/moderately tightened in conjunction with a periareolar breast lift/mastopexy. There are some disadvantages, however, one of which is that damage to nerves which provide sensation to the nipple is possible. Another being that the incision is placed on the most visible or projecting part of the breast. Because this approach requires dissection through the glandular part of the breast, there can be internal scarring in the breast, which might problematic on screening mammograms later in life. Lastly, and one of the most important considerations is the fact that there is a higher risk of infection with this approach due to dissection through milk ducts surrounding the areola with contain bacteria within them. Placing the implant through a potentially contaminated field might predispose the capsule that later forms around the implant to a “subclinical” infection and may lead to capsular contracture.

UMBILICAL

This approach is somewhat controversial and not widely practiced. I don’t believe in it and do not use this technique.

POST OPERATIVE:

You will feel sore for a few days following your surgery, but I want you to be up moving around even on the day of the surgery. Most of your discomfort and/or pain can be controlled by medication prescribed. Antibiotics are administered as well.

I will place you in a surgical bra after surgery that I want you to wear until I see you back in the office. All sutures placed are on the inside and will absorb with time so there are not sutures to be removed in the office. You will have a dressing in place with a clear plastic tape that you will keep on until your first visit. You may shower the day after your surgery.

THERE IS NO CORRECT ANSWER TO THIS QUESTION SINCE EVERY PATIENT IS DIFFERENT.

Each type of implant has its advantages and disadvantages. This is why Dr Constantine sits down with every patient to explain what the pros and cons of each are, so that an informed decision can be made.