Breast Augmentation Dallas
Breast augmentation aims to surgically increase breast size using implants. Although fat can be used, it has many limitations and implants are the predominant method to achieve preditable surgical breast enlargement. Augmentation can be done to enlarge small breasts, fill in breast volume lost after pregnancy and childbirth or correct existing asymmetry.
Although breast augmentation can provide a small amount of lift, women with saggy breasts may need a lift in addition to the implant. Sometimes surgeons place a larger implant to produce an additional lift thereby avoiding a mastopexy (breast lift). Although this strategy works in the short term, it causes significant problems in the long term.
Implants are not considered permanent devices. Although current implants are very durable, rupture can happen requiring change of implants.
Implants have long term complications that are often unrelated to the surgeon or initial surgery. These include capsular contracture, implant rupture and changes in breast tissue secondary to the weight of the implants and from natural aging of the breast over the implant. These changes require surgical intervention that is not insurance covered. A decision to undergo breast augmentation should also take into account these financial implications.
Every woman is built differently and some have breasts that are placed wider apart. Although modern techniques can create the appearance of the breasts being closer with a natural result, anatomical constraints may not allow creation of an ideal cleavage in such persons.
There is no standardization of breast cup sizes; different bra companies vary in their cup sizes. Although it is possible to predict a likely size that be achieved with placement of a certain size implant in a given person, this is only an approximation.
Augmentation can be done using various approaches. They include placing the incision in the fold under the breast, the armpit, the margin of the areola or the belly button. Using these incisions to approach the breast, the surgeon makes a pocket (space) to place the implant. The best predictor of success in augmentation is creation of an ideal pocket. For this reason, most surgeons place the incision in the fold under the breast so that one is close to the breast and can make the pocket accurately. The further away one is, the harder it is to make the pocket accurately. If the pocket is suboptimal, the end results are suboptimal.
Implants can be placed below the muscle (submuscular) or on top of the muscle (subglandular / under the gland but over the muscle). Each have its own advantages and drawbacks.
I prefer to place implants under the muscle for various reasons. The muscle supports the implant with a lower chance of breast tissue thinning and sagging with time. Mammogram interpretation is also easier as the implant is beneath the muscle. Long term scar tissue formation (capsular contracture) is lower; besides, there is lower chance of visible implant ripples. Submuscular placement also prevents an abrupt transition of the implant over the upper part of the breast to give a more natural appearance.
Subglandular implants take less operative time, are less painful and may be ideal in athletic women who need to use the pectoralis muscles. However, they have the drawbacks mentioned above.
Saline or Gel
Gel implants feel more natural and are typically preferred by most women. The older gels resembled thick oil and if the outer membrane holding the gel in place had a tear, the gel would leak into the breast pocket. However, no increase in the incidence of autoimmune disease was ever found even with leaked gel implants. The newer gel is more cohesive and even with a tear in the outer membrane, is not supposed to leak or flow out. Gels also have less rippling and in my opinion are more durable.
Saline implants feel less natural and can ripple more. However advantages include the ability to place them through smaller incisions, the possibility of varying the filling volume during placement (adjustability) and clear indication that the implant has ruptured. When ruptured, the saline is absorbed and the affected side is smaller. It is frequently perceived as the safer alternative. The FDA recommends (not a mandate) screening MRI every few years with gel, but none for saline implants.
Patients go home the same day and can have pain and muscle stiffness for a few days especially if the implant was placed under the muscle. Strenuous activity is restricted for 4 to 6 weeks. Some surgeons prefer support bras and straps after the procedure. I like to let the implants settle down naturally in the first few weeks.
My approach to breast augmentation
The most crucial aspect of breast augmentation is creation of the initial pocket. Often, this is created blindly with blunt dissection in the hope that the implant will eventually stretch it out. I create the pocket under direct vision to exacting dimensions using a lighted retractor. The pocket is made very slightly larger than the implant, such that the implant is snug in the space without being restricted by a tight pocket. If the pocket is too large, the implant can drift outwards or inwards causing a suboptimal result. Creation of an accurate pocket also implies attention to bleeding. Bleeding around the implant has been implicated in capsular contracture.
I prefer to place implants in a submuscular position (although I have performed several subglandular augmentations based on patient request after detailed informed consent) to minimize long term complications.
I do not use ACE wraps or compressive garments after the procedure. Frequently these are used in the hopes that it will decrease the chance of bleeding. With meticulous dissection, there is no need for such maneuvers. Besides, I like the implants to settle down naturally in the first few weeks after surgery without need for any straps to push the implants down.