Frequently Asked Questions about Breast Enlargement, AKA Breast Augmentation

• What is the minimum age to have breast augmentation?
  
• What does it mean under or above the muscle?
  
• Which is better? Above the muscle or below?
  
• What are the major differences between under the muscle vs over the muscle?
  
• Is it possible for the implant to be completely under the muscle?
  
• What is capsular contracture?
  
• What is the likelihood that I will get capsular contracture?
  
• How can I prevent capsular contracture?
  
• What are textured implants?
  
• Who should get textured implants?
  
• What are the most common complications of breast augmentation?
  
• Is it likely that I will need more surgeries on my implanted breast in the future?
  
• How will my breasts look if I decide to have the implants removed?
  
• What size implant is best for me?
  
• Which incision is best?
  
• What shape implant is best for me?
  
• Will breast augmentation affect my ability to breast feed?
  
• How will my implanted breasts look over time? Will they sag?
  
• How will my implanted breasts look after pregnancy or breast feeding?
  
• What are my options if I am dissatisfied with my breast augmentation?
  
• When deciding on a plastic surgeon, what is important to know?
  
• How long is recovery after breast augmentation?
  
• Will breast implants cause stretch marks?
  
• When can I wear an under wire bra again after breast enlargement?
  
• Will I lose sensation in my nipples?

What is the minimum age to have breast augmentation?

Eighteen is the minimum age that I recommend for breast augmentation. This is my policy and the policy of the American Society of Plastic Surgeons. The reasons are: 1) Teens and their parents may not fully realize the risks associated with implants. 2) A teen's body often has not yet fully developed.
3) A teen may not be psychologically ready to handle the outcome or potential complications. Click the link for more information from the American Society of Plastic Surgery.

What does it mean under or above the muscle?

Deep to the breast tissue is the pectoralis major muscle. Breast implants can be placed either on top of this muscle or underneath it. See pictures below.

Which is better? Above the muscle or below?

The answer is not completely straight forward. The majority of the time placement under the muscle is better. This is especially true with saline implants. The muscle acts as a buffer and makes the implants feel much more natural.

What are the major differences between under the muscle vs over the muscle?

Advantages of placement under the muscle.

1. Lower risk of rippling. Once again, if you have large implants the inferior and lateral portion of the implant is not under the muscle and, therefore, is more likely to have rippling regardless of placement.

2. Lower risk of capsular contracture. It is thought that the constant flexing of the muscle acts like a massage to the capsule and, therefore, keeps it softer.

3. There is less of an "implant look" at the superior aspect of the breast. The muscle softens the upper pole of the implant. This causes the implant to have more of a sloped look and less of a rounded, implant look.

4. Mammograms are slightly more accurate. Because the breast tissue is separated from the implant by the muscle the breast tissue is easier to see on mammography.

Advantages of above the muscle.

1. In women with well developed pectoralis major muscles such as body builders, it is possible that the muscle will move the implant with shoulder movement. This can be very annoying. In body builders I recommend silicone implants over the muscle.

2. Technically easier for the surgeon.

3. Less painful. Since the muscle is not stretched there is less of postoperative pain. After 3 or 4 days there is no difference.

Is it possible for the implant to be completely under the muscle?

The short answer is "No." Over the years I have developed a technique where I place the lateral aspect of the implant under the Serratus Anterior muscle. This effectively covers the part of the implant that is most likely to show rippling via the conventional "under the muscle" technique.By placing it under both the pectoralis major and serratus anterior almost all of the implant is covered by muscle.

Of note, a small percentage of women has a poorly developed serratus anterior muscle making total muscle coverage impossible. In this situation the implant is still covered by the pectoralis major muscle. With large implants, the inferior part of the implant remains uncovered.

What is capsular contracture?

When any foreign body is placed under tissue the human body defends itself by walling it off. This involves forming a capsule around the foreign body. The same is true for breast implants. All women form capsules around breast implants. The problem is, some people form very thick and hard capsules. In rare cases, this can distort the implant and even make it painful. It can occur months or even years after the implants have been placed.

Capsular contracture can occur on one or both sides.

What is the likelihood that I will get a capsular contracture?

The chance of getting a capsular contracture that causes distortion is less than 4%. Saline implants are less likely to cause capsular contracture than silicone. Similarly, placement under the muscle is less likely to cause it than placement over the muscle. Finally, textured implants are less likely to harden than smooth implants. Theoretically, the best scenario to prevent capsular contracture is textured, saline implants placed under the muscle.

How can I prevent capsular contracture?

The most effective way to prevent capsular contracture is to perform daily massage of the implant. Massage is known to soften scar tissue. If you feel your breasts begin to become firm I recommend taking vitamin E daily. In addition, I recommend taking Accolate twice a day for six months. Accolate is an asthma medication that blocks the production of leukotrienes which are known to contribute to inflammation and scar formation.

What are textured implants?

In the 1970's capsular contracture was a much bigger problem than it is today. It was found that by adding texture to the shell of the implant the capsule that formed around the implant was much thinner and softer. It was found that the texture caused tissue ingrowth which broke up the collagen that formed around the shell. Textured implants still have a slightly lower rate of capsular contracture today but the advantage is not as significant because the smooth shells have been improved dramatically.

Who should get textured implants?

There are two types of women who can benefit from textured implants.

1. Women who have developed capsular contracture with smooth or silicone implants and need to do everything they can to prevent it from recurring. They should have their previous implants removed, the capsule removed and textured saline implants placed under the muscle. This is the best chance of preventing recurrence of capsular contracture.

2. Women who desire anatomic implants a.k.a. tear drop implants. If anatomic implants turn within their pockets they will not be positioned correctly because they are not round. When round implants turn it does not matter because round implants are in proper orientation no matter how they rotate. This is not true for anatomic implants. When they turn they are no longer oriented properly. This can be a big problem. Textured implants are less likely to rotate.

What are the most common complications of breast augmentation?

The most common complication of breast augmentation is patient dissatisfaction with breast size. More commonly, the implants are too small and the patient exchanges them for larger ones. Therefore, it is important that you feel comfortable during your consultation that your plastic surgeon and patient coordinator have meticulously gone over this with you. This requires bra sizing either with trial implants or, my favorite, bra sizers. This is important and can not be over emphasized.

The second most common complication of saline breast implants is wrinkling. This is especially true with big saline implants over the muscle. Even under the muscle the lateral aspect of the implant is close to the skin and prone to wrinkling. I feel that if you plan to get a large implant it should be placed under both the serratus anterior and pectoralis major muscle. This, however, is not a common practice.

Silicone implants are much less likely to ripple.

Other complications include:

3. Loss of nipple sensation <10%.

This tends to improve over several months.

4. Asymmetry 7%.

Once again bigger implants are more likely to be asymmetric because it is necessary to lower the infra-mammary fold. This make the procedure more complicated and increases the chance that both folds will not be lowered the same amount.

5. Intense nipple sensation 5%.

This tends to go away in several months. It is not uncommon for the nipples to be constantly erect.

6. Capsular contracture 4%.

This has a whole FAQ devoted to it. If it happens it can be a bad problem that may not go away unless the implant is removed or re-operated on.

7. Infection 2%.

Is it likely that I will need more surgeries on my implanted breast in the future?

You must understand that a breast implant is not designed to last a life time. It is likely at some point you will have your implants changed. This may be because you wish to change size or you need a lift. Remember, the number one reason for reoperation is dissatisfaction with implant size. It is critical that you feel that your plastic surgeon and patient coordinator know what you want. Other reasons include deflation or implant shifting. Many women in my office have had their implants for over 20 years and have not had a problem. If there is no problem, I tell them there is no reason to exchange them.

How will my breasts look if I decide to have the implants removed?

This depends on how big of an implant you have and the quality of your skin. If you have good quality skin, i.e. no stretch marks, and your implant is less than 400 cc's it is likely that your skin will recoil well and return close to where you were before the implants. If you are over 40 years of age or have stretch marks it is unlikely that your skin has the ability to recoil. This may result in loose skin or dimpling.

What size implant is best for me?

There are several ways to determine implant size. One way is for the surgeon to place different sizers during the operation. The other way is to do bra sizing during your consultation. I believe that it is critical to determine implant size prior to going into the operation. I do not believe in having the surgeon put trial sizers on during the operation because on the surgery table the breasts do not look like they normally do. Furthermore, this technique does not take into account how the breasts adapt over time. Finally, this method relies on the surgeon deciding on what is best for the patient. In my opinion, it is important to try on trial bras during your consultation, form fit it and then look at yourself in the mirror. Not all plastic surgeons do this, therefore, you can improvise by filling zip-lock bags with appropriate amount of e.g. rise and place them in your bra to get an idea. As you can imagine, this is not as accurate.

It is very helpful to bring in a picture of someone with a similar body type to you who has breasts that you would like. This helps immensely to demonstrate size, shape, and implant position. Do not be embarrassed! Remember, dissatisfaction with implant size is the number one reason why implanted women have to exchange their implants.

There is a number of factors influencing the size you will choose. And it should be always you who chooses the implant size. You might take into consideration opinions of your spouses, friends, etc. but you will be the one who carries them ultimately. This is why it is very important that you feel comfortable with the size you choose. Our patient coordinator will help you figure the size and match it with your body size, look for proportion and symmetry.

Which incision is best?

The three common incisions are 1) Infra-mammary (in the breast fold)
2) Peri-areolar (under the nipple where the dark skin meets the lighter skin)
3) Trans-axillary (armpit)

Each incision has its pros and cons.

All 3 incisions can provide excellent results. The incision along the margin of the areola allows for very accurate implant placement. The scar becomes almost imperceptible within 2 months in most women. The incision within the fold at the bottom of the breast is the best choice when future breast feeding is absolutely necessary or when a secondary surgery is expected. The scar can be more noticeable than the other two incisions depending on how well you heal. This approach may be necessary if you decide on large silicone implants that can not be inserted via the other two incision sites. The axillary incision is best when the patient absolutely does not want an incision on the breast. The tradeoff is that implant positioning is not as easily adjusted from this distant site. This topic is discussed more in "Dr. Cruise's Philosophy."

A fourth option for the incision is through the naval. Some plastic surgeons use this incision but the results when compared to the standard incisions are not as predictable. This is because it is impossible to visualize the pocket where the implant will be placed. For this reason Dr. Cruise, and most plastic surgeons, no longer perform breast augmentation via this approach. This is not to say that this incision cannot produce good results. It is just that the results are less predictable and Dr. Cruise only performs procedures with predictable results.

What shape implant is best for me?

Most plastic surgeons use round, saline implants. Round has become the favorite because there is no way for it to become mal positioned because of rotation. If tear drop shaped implants rotate they may need to be surgically repositioned. The fact is, when you are standing round implants assume a tear drop shape anyway because gravity naturally causes the saline to descend. This makes the implant bigger at the bottom of the breast and smaller near the top.

Will breast augmentation affect my ability to breast feed?

It is unlikely that breast augmentation will affect your ability to breast feed. With the peri-areolar incision there is a small chance ( <5% ) that the ducts could be injured during implantation. The likelihood that both breasts would be affected is less than 1%. Therefore, if breast feeding is critical than an infra-mammary or trans axillary incision may be best for you.

Current studies do not implicate any problems associated with silicone implants and breast feeding. Having said that, I have seen inflammatory reactions within lymph nodes from extremely small amounts of silicone bleeding out of the implants and collecting in the lymph nodes. So far, this has not been identified as a problem. Read more information than you could possibly want on this topic at:www.lalecheleague.org/cbi/bibimplant.html

How will my implanted breasts look over time? Will they sag?

Breast implants are much more resistant to sag than your own breast tissue. If you have little nature breast tissue you will probably never have to worry about sag. If you have a significant amount of breast tissue than this tissue will sag with age just like it would if the implant were not there. If the sag becomes severe you may notice a separation of the implant which stays in place from the nature breast tissue. This is called a "Double Bubble."

Double bubble can corrected by a breast lift.

How will my implanted breasts look after pregnancy or breast feeding?

This is variable. If you are young and have good quality skin, i.e. no stretch marks, it is likely that your breast will return to your pre-pregnancy state. If you have poor quality skin and/or your natural breast tissue enlarges greatly during pregnancy or breast feeding than some changes will likely result. This usually results in one nipple being slightly lower than the other and/or some degree of sag.

It should be mentioned that these changes would have occurred without the implant. If anything, the immobile volume provided by the implant provides some degree of protection against sag.

What are my options if I am dissatisfied with my breast augmentation?

There are many different scenarios that fall within this category. At the very least, you should discuss this with your plastic surgeon prior to augmentation.

When deciding on a plastic surgeon, what is important to know?

1) Word of month. If you know someone with a good result and a overall good experience than this plastic surgeon should be seriously considered.

2) It is important to know how many breast augmentations does the plastic surgeon perform in a month. My recommendation is that the surgeon should do at least 4 a month. This shows that he or she has the recent experience necessary. This can be verified by asking the patient coordinator to show you the surgeon's schedule for the last month.

3) How comfortable do you feel with the plastic surgeon and the office in general. This can not be emphasized enough.You must be able to place a great deal of trust in their hands. Does the surgeon answer your questions? Does the patient coordinator genuinely help you through the process?

4) How comfortable are you with implant sizing. Remember the number one reason for re operation after breast augmentation is for change of implant size. While dissatisfaction with implant size can not be eliminated it can be markedly reduced. This requires proper interviewing by the surgeon and proper bra sizing by the patient coordinator. You should be able to leave your consultation with confidence that the time was taken to determine what size is best for you. If you do not feel this than you should look elsewhere.

5) Ask to see before and after pictures performed by the surgeon and not by some other surgeon. This makes sense. The surgeon should be able to provide examples of his or her work.

6) Is he or she board certified? Be careful to make sure he or she is board certified by the American Board of Plastic Surgery and not some other board.

How long is recovery after breast augmentation?

There is less discomfort if the implant is placed above the muscle. If the implant is placed under the muscle then you can expect the most discomfort for the first 48-72 hours. After this time period, the muscle adapts and the discomfort level drops off quickly. Bigger implants take slightly longer. You will not be able to actively move your shoulders for the first 3 weeks. If you have a sedentary job it is possible to return to work after 5 days as long as you do not move your arms too much. In general, you should expect to take a week off work.

If your job requires significant lifting than you will need to take at least 3 weeks off work.

Will breast implants cause stretch marks?

Usually they do not. If, however, you go with large implants and have poor quality skin then it is possible that you will. Stretch marks are small scars within the dermis caused when the dermis is no longer capable of stretching. Massaging with Vitamin E twice a day may help to reduce the chances of developing stretch marks.

When can I wear an under wire bra again after breast enlargement?

Most plastic surgeons require that you wait at least 6-8 weeks after breast augmentation to begin wearing an under wire bra. This is because the strong support provided by the wire can alter the positioning and/or prevent the "dropping" of the implant into proper position. The reality is you probably will not need an under wire bra because the implants provide more than enough upward support on their own. You will notice that comfortable under wire bras are much harder to buy with implants because the implants are less moldable than your nature breast tissue.

Will I lose sensation in my nipples?

There is a small chance, i.e. < 3%, that you will lose sensation in your nipples. This is more likely with large silicone placed through a peri-areolar incision, The reason for this is that silicone implants are pre-filled. Saline implants, on the other hand, are placed in the pocket first and then inflated. This allows saline implants to be placed through a smaller incision with less trauma. If you are worried about nipple sensitivity and want to have silicone implants 450 cc's or larger than the infra-mammary incision may be best for you. Another consideration is the size of your areola. If you have very small areola it is harder to place silicone implants through the peri-areolar incision.

Often after breast augmentation, women experience hyper-sensitivity. The nipples may become erect which can be uncomfortable. This goes away within a month or two.