Breast Augmentation Information Resource for Southern California including Orange County, Los Angeles, Newport Beach, San Diego, and Beverly Hills.
Breast Enlargement
- Overview of Breast Augmentation
- Incision for Breast Augmentation
- Breast Enlargement and Mammograms
- Benefits of Breast Enlargement
- Are you a good candidate for Breast Implants?
- Dr. Cruise's philosophy regarding Breast Enlargement
- Possible complications of Breast Augmentation
- Silicone vs. Saline Breast Implants
Frequently Asked Questions
What is the minimum age to have breast augmentation?
What does under or above the muscle mean?
Which is better, above the muscle or below?
What are the major differences between under the muscle and 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 breasts 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 breastfeeding?
What are my options if I am dissatisfied with my breast augmentation?
What is it important to know when deciding on a plastic surgeon?
How long is recovery after breast augmentation?
Will breast implants cause stretch marks?
When can I wear an underwire bra again after breast enlargement?
Will I lose sensation in my nipples?
What is a tubular breast?
What happens if my implants deflate?
What is the minimum age to have breast augmentation?
Eighteen is the minimum age recommend for breast augmentation. This is my policy and the policy of the American Society of Plastic Surgeons. This very sound recommendation is based on the following.
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 under or above the muscle mean?
Deep in 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.
 Implant above muscle |
 Implant below muscle |
When the implant is placed on top of the muscle, it is closer to the skin and therefore may be more easily felt and appear more rounded superiorly in patients with little breast tissue. If a patient is a B cup or greater, implant visibility is not a problem. Therefore, the implant can be placed either under or above the muscle with excellent aesthetic results. Implant placement below the muscle, however, has a slightly lower risk of capsular contracture.
Implant above muscle. This type of positioning
causes the upper pole of the implant to be
more palpable and more visible.
It should be noted that when an implant is placed under the muscle, the bottom and lateral parts of the implant are not completely covered by the muscle.
Depiction of how lateral/inferior 1/3
of
implant is not covered by muscle even
if placed submuscularly.
The amount of uncovered implant increases considerably when larger implants are placed. This is why rippling may occur along the lateral and inferior aspect of the breast, especially with larger implants.
Notice that as the implant becomes larger,
less is covered by the pectoralis major muscle.
Which is better? Above the muscle or below?
The answer is not completely straightforward. It depends on the amount of natural breast tissue and the amount of breast sag, if any, that the patient has. Outlined below are four possibilities:
1. Patient with little breast tissue and no sag.
In these patients, implant placement above the muscle would likely create an "implant look." The superior part of the breast would be unnaturally round. In addition, because there is little natural breast tissue to cover the implant, rippling would be more likely to occur. For these reasons, implant placement below the muscle is usually the best choice.
2. Patients with moderate amount of breast tissue and no breast sag.
These patients have a choice. If they desire a large implant, then placement below the muscle is probably best. If they choose a moderate to small size implant, placement either above or below the muscle is acceptable. One caveat, in athletes or bodybuilders who need full use of their pectoralis major muscle, placement above the muscle may be a better choice as the muscle is not altered.
3. Patients with small amount of breast tissue and breast sag.
In these patients, it is usually best to put the implant under the muscle and perform a breast lift. If silicone implants are used, above muscle placement is also acceptable as silicone has a more natural appearance and is less likely to show rippling.
4. Patients with moderate or large amounts of breast tissue and also breast sag.
These patients are best served when the implant is placed above the muscle in conjunction with a breast lift. This allows the natural breast tissue and the implant to integrate into one. This provides a more natural appearance and lessens the chance of "double bubble."
What are the major differences between under the muscle and 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 are not under the muscle and, therefore, are more likely to have rippling regardless of placement. If you have a moderate amount of natural tissue, then rippling is unlikely 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. Less of an "implant look" at the superior aspect of the breast when the patient has little natural breast tissue.
The muscle softens the upper pole of the implant. This causes the implant to have a more sloped look and a less rounded implant look. When a patient is a B cup or larger, this becomes less relevant.
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. Recommended for 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 is undesirable and annoying.
2. Allows for more natural appearance in patients who have a significant amount of natural breast tissue.
The implant and the breast tissue are not separated and are allowed to become one.
3. Allows for a more natural appearance in patients with breast sag.
In these patients, the placement of the implant below the muscle will separate the breast tissue from the implant and may create a "double bubble" appearance. The implant is held higher on the chest wall by the muscle and the natural breast tissue sags lower, thus creating an unnatural separation.
4. Is less painful.
Since the muscle is not stretched, there is less postoperative pain.
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.
Implant under both pectoralis major and
serratus anterior muscles. Not all women
have a well-developed serratus
anterior
but, if present, it provides additional
coverage.
It is notable that 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, including a breast implant, is placed under tissue, the human body defends itself by encapsulation; that, is the body forms a capsule around the foreign body. All women form capsules around breast implants. A problem arises in those rare cases when the capsule is thick and hard, causing distortion of the implant and sometimes pain. This problem can occur months or even years after the implants have been placed and 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 1970s, 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. Also, the texture caused tissue growth which broke up the collagen that formed around the shell. Textured implants still have a slightly lower rate of capsular contracture, but the advantage is not as significant because the dramatic improvement of today's smooth shells.
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.
The previous implants and surrounding capsules should be removed and replaced by textured saline implants placed under the muscle. This is the best way to prevent recurrence of capsular contracture.
2. Women who desire anatomic implants, also known as tear drop implants.
When round implants turn, they are always in proper orientation no matter how they rotate. If anatomic implants turn within their pockets, they will not be positioned correctly because of their tear drop shape. Textured implants reduce the likelihood of rotation in anatomic implants.
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| Anatomic Implant (Tear Drop Implant). If anatomic implants rotate, the resulting misplacement may need to be surgically corrected. Adding texture to the anatomic implant helps reduce the chances that it will rotate. | Round Implant. Rotation does not affect this implant. This is the main reason why most plastic surgeons prefer round implants. |
What are the most common complications of breast augmentation?
1. The most common complication of breast augmentation is patient dissatisfaction with breast size. Most often, the patient believes that the implants are too small and she exchanges them for larger ones. It is important therefore that during your consultation you and I and your patient coordinator thoroughly discuss the size of your breast implants. This requires bra sizing either with trial implants or, as I prefer, bra sizers. I cannot overemphasize the importance of this step.
2. The second most common complication of saline breast implants is rippling. This is especially true with large, over the muscle, saline implants. Even in under the muscle implants, the lateral aspect of the implant is close to the skin and prone to rippling. Although it is not a common practice, I believe that a large implant should be placed under both the serratus anterior and pectoralis major muscle. There is less likelihood of rippling when silicone implants are used.
Implant under both pectoralis major and
serratus anterior muscles. Not all women
have a well-developed serratus
anterior
but, if present, it provides additional
coverage.
Other complications include:
3. Loss of nipple sensation <10%.
This tends to improve over several months.
4. Asymmetry 7%.
Once again, larger implants are more likely to be asymmetric because it is necessary to lower the inframammary fold. This makes 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 complication is described more fully in an earlier FAQ. Treatment may require re-operation or removal of the implant.
7. Infection 2%.
Is it likely that I will need more surgeries on my implanted breast in the future?
Many women in my office have had their implants for over 20 years without a problem, and I advise them that there is no need for replacement. Still, a breast implant is not designed to last a lifetime and you most likely will have your implants replaced for any number of reasons. You may wish to change size, you may need a lift, there may be deflation or implant shifting. Since the number one reason for re-operation is dissatisfaction with implant size, it is critical that you clearly express your decision about size to me and to your patient coordinator at your pre surgery consultation.
How will my breasts look if I decide to have the implants removed?
This depends on the size of your implants 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, your skin probably will recoil well and your breasts will look much like they did 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 is for the surgeon to place different sizers during the operation. I do not favor this technique for several reasons: on the surgery table the breasts do not appear as they do when you are upright, it does not take into account how the breasts adapt over time, and it relies on the surgeon to decide what is best for the patient.
The other is to determine implant size before the operation, and this is the technique I favor. During the consultation, you can try on a trial bra, form fit it, and then look at yourself in the mirror. You can try this at home by filling zip-lock bags with appropriate amounts of rice and placing them in your bra, but, as you can imagine, this is not as accurate.
It is also helpful for you to bring to your consultation a picture of someone with a body type similar to yours whose breast size, shape, and implant position demonstrate what you want from your surgery. Do not be embarrassed! Remember, the goal is to avoid dissatisfaction with implant size, which is the number one reason why women have to exchange their implants.
Our patient coordinator will help you determine the appropriate size for your body and advise you on proportion and symmetry. Ultimately, however, the size of your implants should always be your choice. There are a number of factors that might influence your choice, including the opinions of your spouse and friends, but you must be comfortable with the implant size you choose.
Which incision is best?
The three common incisions are:
1. Inframammary (in the breast fold)
2. Peri-areolar (under the nipple where the dark skin meets the lighter skin)
3. Transaxillary (armpit)
The best incision for you is the one that your plastic surgeon performs most often and feels most comfortable with. I have found that the Peri-areolar incision leaves the least visible scar and provides the most accurate implant placement. For these reasons, I prefer this incision and routinely use it. I cannot overemphasize how important it is that the surgeon follows his or her usual surgical routine. If he or she normally does not use the incision you prefer for your breast augmentation, the wisest course is to go to another plastic surgeon who does.
Each type of incision has its pros and cons. All 3 can provide excellent results.
The incision along the margin of the areola allows for very accurate implant placement. In most women, the scar becomes almost imperceptible within 2 months. The incision within the fold at the bottom of the breast can provide equally excellent results, but the scar can be more noticeable than with the other two incisions, depending on how well you heal. This approach may be necessary if you decide on large silicone implants that cannot be inserted through the other two incision sites. The axillary incision can also provide a great result, but the implant positioning is not as easily adjusted from this distant site. This topic is discussed more in "Dr. Cruise's Philosophy."
A fourth option, still used by some plastic surgeons, is an incision through the navel. Most plastic surgeons no longer perform breast augmentation using this approach. An incision through the navel makes it extremely difficult to place the implant with predictable results. Since I always opt for predicable results, I avoid this option.
What shape implant is best for me?
Most plastic surgeons use round, saline implants. Round implants are favored because they cannot move out of position if rotation should occur. If tear drop shaped implants rotate, they may need to be surgically repositioned. Moreover, round implants actually assume a tear drop shape when you are standing because gravity causes the saline to descend, making the implant bigger at the bottom of the breast and smaller near the top.
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| Anatomic Implant (Tear Drop Implant). If anatomic implants rotate, they may need to be surgically corrected. Adding texture to the anatomic implant helps reduce the chances of rotation. | Round Implant. Rotation does not affect this implant. This is the main reason why most plastic surgeons prefer round implants. |
Will breast augmentation affect my ability to breast feed?
It is unlikely that breast augmentation will affect your ability to breast feed. Current studies show no problems associated with silicone implants and breastfeeding. Nevertheless, 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.
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 breastfeeding is a critical factor, an inframammary or transaxillary incision may be best for you.
There is ample additional information 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 natural breast tissue, you will probably never have to worry about sag. If you have a significant amount of breast tissue, the breasts will sag with age just as they would if the implant were not there. If the sag becomes severe while the implant stays in place, you may notice a separation of the implant from the natural breast tissue. This is called a "Double Bubble."
"Double Bubble" |
| If over time the nature breast tissue sags while the implant stays in place, there may be a separation of the two creating 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 breastfeeding, some changes will likely occur. 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 options to pursue. You should discuss them with your plastic surgeon prior to augmentation.
When deciding on a plastic surgeon, what is important to know?
1. What other patients say about the plastic surgeon.
If someone you know and trust reports a good result and an overall good experience from a particular plastic surgeon, this plastic surgeon should be seriously considered.
2. How many breast augmentations the plastic surgeon performs in a month.
My recommendation is that the surgeon should perform at least 4 a month. You can ask the patient coordinator to show you the surgeon's schedule for the last month to verify that he or she has had this amount of experience.
3. How comfortable you feel with the plastic surgeon and the office in general. This importance of this factor cannot be overemphasized. You must be able to trust that the surgeon and his team are dedicated to providing a safe procedure and a satisfactory outcome. Does the surgeon answer your questions? Does the patient coordinator genuinely help you through the process?
4. How comfortable you are with the way implant size is determined prior to surgery.
Remember, the number one reason for re operation after breast augmentation is to change implant size. Proper interviewing by the surgeon and proper bra sizing by the patient coordinator can markedly increase the likelihood that you will be satisfied with the results of your surgery. You should be able to leave your pre-surgery consultation fully confident that enough time, thought, and care went into the determination of the best size for you. If not, you should look elsewhere.
5. Whether the surgeon can show you examples of surgeries he has performed.
Can the surgeon provide examples of his or her work such as Before and After pictures of patients?
6. If he or she is board certified.
Be careful to make sure that he or she is 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, you can expect the most discomfort for the first 48 to 72 hours. After that, the muscle adapts and the discomfort level drops off quickly. In larger implants this takes 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, then you will need to take at least 3 weeks off work.
Will breast implants cause stretch marks?
Stretch marks are small scars within the dermis caused when the dermis is no longer capable of stretching. Usually implants will not cause stretch marks. If, however, you choose large implants and have poor quality skin, it is possible that you will have stretch marks. Massaging with Vitamin E twice a day may help to reduce the chances of developing stretch marks.
When can I wear an underwire bra again after breast enlargement?
Most plastic surgeons require that you wait at least 6 to 8 weeks after breast augmentation to begin wearing an underwire bra. The strong support provided by the wire can alter the positioning and/or prevent the "dropping" of the implant into proper position. In fact, you probably will not need an underwire bra because the implants provide more than enough upward support on their own. You will find that it is more difficult after implantation to buy comfortable underwire bras because the implants are less moldable than your natural breast tissue.
Will I lose sensation in my nipples?
There is a small chance, < 3%, that you will lose sensation in your nipples. This is more likely to occur with large silicone implants placed through a Peri-areolar incision, because silicone implants are pre-filled. Saline implants, on the other hand, are placed in the pocket and then inflated. This allows 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 or larger, then the inframammary incision may be best for you. Another consideration is the size of your areola. If it is very small, it is harder to place silicone implants through the Peri-areolar incision.
Often after breast augmentation, women experience hypersensitivity and sometimes nipples become continuously erect. These conditions, while uncomfortable, usually go away within a month or two.
What is tubular breast or tuberous breast malformation?
Tubular breasts are also called constricted breasts. Tubular breasts have many variations, the most common ones include:
- high and tight folds
- very narrow base
- protruding nipples
- herniation of the breast tissue through the areola
- abnormally broad areolas
Silicone may be the best option for correction of constricted breasts, especially in patients with very little breast tissue. Many times augmentation alone corrects tubular breasts. If there is a significant amount of ptosis (sagging or prolapsing), or the areolas are very large, a Benelli or anchor lift may be necessary to correct the malformation.
It takes longer for tubular breasts to achieve the roundness and fullness of average breasts. With time, however, the implants create a round shape.
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| Tubular breasts before augmentation. | 3 months after breast augmentation with 450cc silicone breast implants, through areola incision, above the muscle. Notice the tension on the skin on the lower portion of the breasts. |
6 months after the surgery the breasts are shaped like the implants. The bottom of the breasts are no longer tense as at 3 months. |
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| Notice the narrow base, protruding nipples and high and tight base. | Notice the constriction below the nipple. | Now the nipple is no longer protruding and the base of the breast is naturally round. |
What happens if my implants deflate?
In case of saline implant deflation - there is nothing to worry about. The fluid that is in the saline implant is salt water, totally harmless to your body. It is strongly recommended to exchange that deflated implant within a month to avoid further complications. Your implants come with the warranty below:
ConfidencePlus™ Limited Warranty for Natrelle Implants
• Automatic Enrollment.
• Silicone filled and saline filled breast implants covered.
• Lifetime product replacement in case of deflation.
• 10 years of guaranteed financial assistance. Receive up to $1,200 of out-of pocket expenses for surgical fees, operating room and anesthesia expenses not covered by insurance.
For extra $100 you may purchase an extended warranty, which gives you double the benefit: two implants and up to $2400 of financial assistance.
ConfidencePlus™ Platinum Limited Warranty for Natrelle Implants
• Low enrollment fee of $100.
• Silicone filled and saline filled breast implants covered.
• Lifetime product replacement in case of deflation.
• 10 years of guaranteed financial assistance. Receive up to $2,400 of out-of pocket expenses for surgical fees, operating room and anesthesia expenses not covered by insurance.
If you have silicone implants, it is harder to say whether they are leaking or not, since the gel usually stays within your breast capsule. Seldom, it would leak out of the capsule. There is no evidence whether it is harmful or not. The way to find out if there is a leakage is usually through ultrasound or MRI. At this time your implants will automatically come with the extended warranty.
ConfidencePlus™ Platinum Limited Warranty for Natrelle Implants
• Low enrollment fee of $100 - Waived at this time.
• Silicone filled and saline filled breast implants covered.
• Lifetime product replacement in case of deflation.
• 10 years of guaranteed financial assistance. Receive up to $2,400 of out-of pocket expenses for surgical fees, operating room and anesthesia expenses not covered by insurance.
Breast Augmentation Information Resource for Orange County, Newport Beach, Los Angeles, San Diego, Beverly Hills, and Southern California