BREAST

1. Overview

A breast augmentation is a cosmetic surgical procedure that involves the use of breast implants (composed of either saline or silicone) to enhance the size and shape of an individual’s breasts or to restore breast volume that has been lost as a result of weight reduction or pregnancy. By increasing the fullness and projection of your breasts, a breast augmentation will also give you a more balanced figure.

A breast augmentation will not correct severely drooping (ptotic) breasts. If you would like your breasts to look fuller and also lifted because of sagging, you may require a breast lift (mastopexy) in addition to a breast augmentation procedure. This can either be performed at the same time as your breast augmentation or as a separate procedure. Dr. Lee will take the time to explain all the options and help guide you in making your decision.

2. THE IDEAL CANDIDATE

In general, ideal candidates for breast augmentation are healthy females with realistic expectations who:

• Are bothered by the fact that their breasts are too small
• Are bothered by the fact that your breasts have lost their shape and volume after pregnancy, weight loss, or with aging
• Are bothered by the fact that the upper portion of your breast appears “empty”
• Are bothered by the fact that your breasts are asymmetric
• Are bothered by the fact that one or both of your breasts either failed to normally develop during adolescence or has an elongated narrow shape.

3.1.1. Filling Material: Silicone VS Gel Implants

3.1.3. SALINE IMPLANTS

• FDA and Health Canada approved for several years
• Consists of silicone shell filled with saline at the time of surgery
• Allows for smaller incision than silicone gel implants as the empty silicone shell is first inserted through the incision and then filled with saline once inside
• Their volume can be adjusted during surgery and thus allow to correct for asymmetry intraoperatively.
• Disadvantages of saline implants in comparison to silicone implants include a less natural feel and a higher risk of rippling/wrinkling
• In the event of a leak or rupture, saline gets absorbed by the body without causing any harm, but does result in collapse of the implant

3.2. IMPLANT SIZE

• Measured based on volume (in cubic centimeters or cc’s) and do not correspond traditional bra cup sizes
• Larger implant = higher number of cc’s

3.3. IMPLANT SHAPE: ROUND VS. ANATOMICAL

3.3.1. ROUND SHAPED IMPLANTS

• To fill out existing breast tissue by adding volume to the upper pole of the breasts
• Ideal for patients who have lost fullness in the upper pole with gravity (i.e. upper pole of breast flattens)

3.3.2. ANATOMICAL (“TEARDROP”) SHAPED IMPLANTS

• To fill out existing breast tissue with a subtle increase in volume at the upper pole and a greater increase in the lower pole
• Help shape the breast when there is little native breast tissue present

4. ANESTHESIA

• A breast augmentation is usually performed under general anesthesia. Though less common, the procedure can also be performed under local anesthesia with intravenous sedation.

4.1. INCISIONS

• Incisions are made in inconspicuous areas of the breast or axilla (armpit) to minimize visible scarring.
• The location of your incisions will vary according to the type of breast implant, degree of enlargement desired, your particular anatomy, and patient-surgeon preference. Dr. Lee will discuss which incision he believes will be the most appropriate for your desired outcomes.

Incision options include:

• Inframammary incision (most common): In the predicted location of the new breast fold
• Periareolar incision: Around the lower border of the areola (dark-colored skin around the nipple)
• Transaxillary incision: In the armpit

4.2. CREATION OF THE IMPLANT POCKET

4.2.1. SUBMUSCULAR

The implant is either completely (total submuscular or subpectoral pocket) or partially (partial submuscular or partial subpectoral pocket) covered by the chest wall muscles (i.e. pectoralis major muscle).

Advantages:

• Reduced implant visibility in the upper pole of the breast
• Lower risk of capsular contracture (undesirable hardening of the capsule that forms around your breast implant)
• Lower risk of implant bottoming out (unfavourable downward movement of your breast implant)
• Decreased visibility of implant rippling/wrinkling (i.e. the natural folds of the implant shell)
• Easier interpretation of future mammograms (in comparison to a sub-glandular placed implant)

Disadvantages:

• More post-operative discomfort (as a result of muscle needing to be released from the chest wall)
• Breast and implant movement with exertion of chest muscles (animation deformity)
• More time for breasts to assume their final position and shape

4.2.2. SUBGLANDULAR

• The implant is placed above the pectoralis major muscle and covered by the overlying breast gland

Advantages:

• Less post-operative discomfort
• Quicker post-operative recovery
• Less time for breasts to assume their final position and shape

Disadvantages:

• Increased implant visibility/rippling
• Higher risk of capsular contracture
• Higher risk of implant bottoming out
• More difficult interpretation of future mammograms

4.2.3. DUAL-PLANE

The upper portion of the implant is covered by the pectoralis major muscle while the breast gland is released (separated) from the chest wall muscles, and used cover the lower portion of the implant.

Advantages:

• Combines the advantages of both subglandular and submuscular implant placement
• Reduced implant visibility/rippling
• Lower risk of capsular contracture
• Reduced animation deformity

4.3. INSERTION OF BREAST IMPLANTS

If silicone implants have been chosen preoperatively:

i) Intraoperative assessment with implant sizers

• Implant sizers are identical in terms of their shape, base diameter, and volume of your desired implant
• Once the implant pocket has been created on both sides, implant sizers are inserted, and your surgical wounds are temporarily closed.
• The operating table is adjusted to bring you into a seated position so that Dr. Lee can properly assess the appearance and symmetry of your
• breasts with your desired implants in place. If necessary, minor adjustments are made to ensure that an optimal outcome is achieved

ii) Exchange of implant sizer for permanent silicone breast implants

If saline breast implants have been chosen preoperatively:

i) The empty silicone shell of your saline implants are inserted into the newly created implant pocket

ii) The implants are then filled with a saline solution (via their attached fill-tube), until the volume (size) chosen preoperatively is attained

iii) Intraoperative assessment with saline implants in place

• Surgical wounds are temporarily closed and the operating table is adjusted to bring you into a seated position so that Dr. Lee can properly assess the appearance and symmetry of your breasts with your implants in place
• If necessary, minor adjustments are made (i.e. to the volume of your implants or to the implant pocket) to ensure that an optimal outcome is achieved

iv) Removal of implant fill-tube

• Once satisfied with the volume of implant, the fill-tube is removed

4.4. CLOSURE OF IMPLANT POCKET

4.5. SKIN CLOSURE WITH ABSORBABLE SUTURES

5. PREOPERATIVE CONSULTATION

During your consultation, Dr. Lee will thoroughly explain the procedure and all your options, and help you choose which procedure is right for you. He will perform a thorough medical evaluation during your preoperative consultation to ensure that you are medically fit for surgery. He will also revise your medication list, as certain medications may need to be temporarily stopped before your surgery.

Since smoking is known to be associated with poor/delayed wound healing, wound dehiscence, wound infections, and increased scarring postoperatively, smokers will be asked to stop smoking 4 weeks prior to surgery, and for at least 2 weeks postoperatively.

Patients will also be scheduled for routine pre-operative blood testing and an electrocardiogram before surgery. Dr. Lee may make additional recommendations based on the results of your tests.

6. RECOVERY

The operation is performed on an outpatient basis. Most patients are permitted to go home a few hours after surgery.

You will have a dry dressing over your incisions, as well as a support bra to minimize post-operative swelling and to support your breasts as they heal.

Before leaving, you will be given specific instructions on how to care for your breasts and surgical wounds during your recovery. It is imperative to continue following these recommendations in order to minimize the appearance of your scars and to optimize your final result. You will be prescribed medications to help with pain management post-operatively, as well as an oral antibiotic to reduce the risk of infection. Pain and stiffness in the chest for the first 2-5 days is expected and completely normal. You will likely experience some bruising and swelling of your breasts; however, this usually resolves in 2-3 weeks. Patients are instructed to sleep on their backs and avoid vigorous physical activity for 6 weeks.

Your dressings will be changed during your first post-operative follow-up with Dr. Lee. We ask that patients not lift upon their breasts in order to look at their scars or to lift their arms above your shoulders, as this will create tension across your wounds and increases the risk of your wounds breaking down. Patients should continue wearing their surgical bras (at all times) until Dr. Lee advises you to start wearing a sports bra.

Recovery times after breast augmentation vary and depend on a number of factors (i.e. location of the implant pocket, implant size, the extent of chest wall muscle dissection, etc.). Most patients are able to return to work and resume normal activities within 2-3 weeks. Although the results of your breast surgery will be immediately apparent, it may take up to 6-12 months for you to completely heal and achieve your final look.

7. RISKS AND COMPLICATIONS

As with any surgery, there are risks associated with breast augmentation. Smoking, diabetes, peripheral artery disease (poor circulation), as well as heart, lung, or liver disease may increase your risk of perioperative and/or post-operative complications.

Risks and complications include:

• Risks associated with anesthesia
• Bleeding (hematoma)
• Infection
• Changes in nipple or breast sensation
• Scarring
• Fluid accumulation (seroma)
• Poor wound healing
• Persistent postoperative pain
• Implant malposition
• Capsular contracture
• Implant leakage or rupture
• Breast asymmetry and/or deformities
• Visible implant rippling
• Skin discoloration and/or prolonged swelling
• Deep vein thrombosis
• Cardiac and pulmonary complications
• Possible need for revision surgery
• Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), for further information please refer to the most up to date FDA recommendations

Dr. Lee will thoroughly discuss these risks (and possibly others) with you and answer any questions you might have prior to obtaining your consent for surgery.

8. Post-operative scarring

Scars form as the body’s natural response heal tissues. As with any scar, the extent of post-surgical scarring depends on a number of modifiable factors (i.e. avoidance of UV light exposure, tension-free wound closure, appropriate wound care, etc.) and non-modifiable factors (i.e. patient age, comorbidities, skin type, genetics, etc.). While it is not possible to perform scar-free surgery, Dr. Lee makes every effort to minimize the appearance of your post-surgical scars through careful pre-operative planning, the use of meticulous surgical technique, and by ensuring appropriate wound care and follow-up postoperatively.

It is not unusual for scars to appear red and be slightly raised/firm for the first 4-6 weeks following surgery. Scars will flatten and become paler over time and can take up to 12 months before achieving their final appearance.