I am so excited to continue our conversations about breast surgery with a focus on breast implants. I want to share with you the essentials of what I share with my patients to prepare them for surgery.
There is an inherent language barrier in plastic surgery between the surgeon and patient when discussing breast size. Women usually think about breast volume in terms of cup size (which does vary from one lingerie company to another), and surgeons are trained to think in cc’s. I have found the best way to communicate about breast size is through pictures. In the office I measure the width of the breasts, this number sets a range of implant sizes that will “fit” on the chest. This is a rule of anatomy that is important to follow no matter what the size goal is. I then give my patients homework. I have my patients find a before photo of a woman who has similar breasts to her own and an after photo with a result they like. Using the breast width measurement and the “wish” photos I guide my patient in a choosing an implant that will achieve their goals. Talking cc’s with your friends that have had breast implants can be fun, but unless you have the exact same frame and breast mound it is likely to be a misleading comparison. It is so important to know that a 350cc implant on one woman can be a subtle B-appearing breast, and on another woman can be a very obviously augmented D-appearing breast. Choosing your breast implant size should be a conversation between you and your doctor.
The term “profile” refers to the projection of the implant off of your chest. Low profile implants are exactly as they sound, less projecting, and more discrete. Low profile implants are a great option for either a woman that wants a discrete augmentation, or a woman that already has significant breast tissue but wants to improve her overall breast shape. High profile implants project more and can give a fuller, more augmented appearance. This explanation is a bit oversimplified and there are nuances to choosing the right profile. The practical application of this concept for me is very simple and strategic. Implant profiles allow me to fine-tune the implant size for a given breast width measurement. What does this mean? It means I can play with the profile to get you bigger or smaller depending on your goals.
Breast implants are either placed underneath the breast gland, or underneath the muscle. Most of my breast augmentations are performed under the muscle- either completely under the muscle or dual-plane with the inferior portion of the implant resting below the muscle edge. I do have patients with special circumstances that require a sub-glandular augmentation for the best results.
There are several significant benefits of sub-muscular breast implant placement including:
- The risk for capsular contracture is less - with capsular contracture the scar tissue that forms around an implant is much thicker and tighter than normal creating a firm and sometimes painful breast.
- The implant itself is less visible under thin skin/tissue.
- Mammograms tend to be easier to perform because the muscle helps exclude the implant from the imaging platform.
The main drawbacks to sub-muscular breast implants include:
- The initial pain of stretching the muscle to accommodate an implant.
- “Animation deformity” - a movement of the pec muscle and implant during focused pec exercises that can cause breast shape distortion.
There are three main incisions used for breast implant placement including infra-mammary, peri-areolar, and trans-axillary. If you are my patient and do not have a lift planned with your surgery then I use an infra-mammary breast incision because it has the best risk profile compared to others. A fourth incision that never became standard practice is trans-umbilical. I never thought I would see one in my career, but I actually have revised a breast augmentation that was originally done through an umbilical incision.
- Inframammary - this is about a 4cm incision in the lower breast crease. this scar hides nicely in most women and is not seen in most clothing or positions. There is less risk associated with this incision because of the direct access to the planned implant pocket without having to dissect through breast tissue (which can lead to infection and/or capsular contracture in some cases).
- Periareolar - this is a semi-circular incision at the border of your areola and breast. I do not often use this incision for several reasons but importantly it requires dissection through breast tissue to the planned pocket and increases risk for complications because of this.
- Axillary - this is a niche procedure and my advice is if you want this approach find a surgeon that does a lot of them routinely (I have a great recommendation if you need that). Why do I not routinely perform this? The access is further away from the breast and breast pocket and in my hands there are more opportunities for complications like implant malposition, infection, and an obvious scar. The scar is visible in the axilla and I think this is less than ideal compared to the breast fold.
Implant Fill: Saline versus Silicone
Both types of implants have a silicone shell, the difference is that one is filled with saline, and the other with silicone gel.
Saline filled implants have one main advantage - if they rupture it is often obvious because of immediate deflation and the saline is absorbed and processed by your body. The cost of the device is cheaper compared to silicone gel (less technology/less cost). The main disadvantages are a hard less-natural feel and appearance, visible rippling, shorter lifespan than silicone gel implants. There are some women who feel very strongly that they do not want silicone gel implants and elect to have saline placed.
Silicone gel filled implants look better, feel better (soft and less rigid), have less rippling, and last longer than saline implants. This is the implant I would put in my mom or sister. Not all silicone implants are created equal though, technology has really changed over the years and the silicone implants on the market today are improved in so many ways from the ones placed 20 years ago. A disadvantage of silicone gel implants is that ruptures are harder to detect.
The FDA recommends an US or MRI five to six years after the implants are placed and every two to three years thereafter to monitor for asymptomatic silent rupture. I offer breast ultrasound surveillance of implants in my practice. I think this is the most practical and efficient exam. MRI’s are costly and a much bigger ordeal than a simple breast ultrasound.
The implants that I use in my practice have an average rupture risk rate of 1% per year. If you do have a rupture then I recommend either a breast implant exchange or removal.
Breastfeeding After Breast Implants
Many women with breast implants have successfully breastfed their children. A woman with implants has the same average success rates with breast feeding as a woman without breast implants.
Breast Implant Safety Matters
Breast Implant Shell: Textured versus Smooth + BIA-ALCL
The outer shell of implants can either be smooth silicone or textured (think micro cobblestones). In the US most surgeons currently use smooth implants in order to avoid problems associated with textured implants. There is an association between a specific type of textured implant (that is no longer on the market) and BIA-ALCL. This does not mean that the textured implant caused the cancer, but because of the association found in extensive research - we consider these devices no longer safe to use. Why would texture be associated with this condition? The leading theory (not proven) is that the texturing creates an environment that harbors more biofilm and potentially more natural immune response to that burden of biofilm and over time can become an abnormal proliferation of immune cells. Breast Implant Associated Lymphoma (BIA-ALCL) is not breast cancer - it is a type of non-Hodgkin's lymphoma (cancer of the immune system). The number of cases worldwide is < 1,500 and there have been 59 reported deaths. BIA-ALCL is a slow-growing, non-aggressive form of cancer and if diagnosed early is treated with a breast implant + capsule removal. In rare cases of late presentation the disease can spread systemically.
For these reasons I do not offer textured implants in my practice. I am confident in the safety profile of smooth implants and practically speaking your risk for BIA-ALCL is VERY low (potentially even zero) because there are not any known cases that can be attributed to a smooth implant.
Breast Implant Illness
Social media has brought a new wave of attention to breast implant safety, especially in regards to “Breast Implant Illness”. What the general public does not often realize is that the FDA spent much of the 1990s-2006 formally investigating the safety of breast implants. The bottom line is that the FDA found no real association between breast implants and systemic illness and approved them for general use in 2006.
The Aesthetic Society recently commissioned a research working group to perform an updated response to the new wave of social media fueled concern. Again, there are no known associations with systemic illness and breast implants - but the specific findings of the research was fascinating. I’ll save that for another newsletter because there are a lot of details that I would love to share.
Breast Implant Lifespan
The risk that your implant will rupture is around 1% per year and this is additive, so the older your implant, the greater the risk. Do you need to have your implants replaced at 10 years? Only if you have a problem with your implant - like rupture. In general silicone gel implants will last greater than 10 years - I am currently on year 15 with mine and haver zero intention of replacing them until after I have children in case I need a lift. Most reputable plastic surgeons will tell you, if there isn’t a problem, you do not need to replace them.
Breast Implant Surgical Experience
Breast augmentations are performed under general anesthesia to create a controlled environment focused on patient safety. My operating room is a state-certified surgery center contained within our office, this makes the whole experience so convenient. Your consultation, surgery, and post-op visits are all in the same place with the same staff.
The duration of the surgery is about 1-2 hours depending on the nuances of the patient needs and goals. I take many precautions in the operating room to minimize risk for bleeding and infection (the two main risks associated with breast augmentations). The breast implant pocket is dissected carefully with cautery in order to prevent and minimize bleeding - this also helps with swelling. I wash the breast implant pocket with antibiotics + betadine solution, use nipple shields, change my gloves before handling the implant, and take many other precautions in the operating room in order to minimize risk. There are many carefully planned details during the breast augmentation that all contribute to a relatively low risk procedure.
The experience of pain after a breast augmentation is usually due to the muscle being stretched. I have found that women tolerate this differently. Some women feel fantastic as soon as the anesthesia is out of their system and I have to beg them to restrict their activity. Other women struggle a bit more with the muscle tightness and require several days of pain medication before the pec muscle gives up and they are comfortable enough to move freely.
After a breast augmentation you must wear your post-operative compressive bra at all times for 6-8 weeks. At your first clinic visit I will graduate you to a bra of your choosing if it meets the requirements. Some women need to wear a breast band over the top of the breasts after surgery to help encourage the implants to drop into a natural position.
Exercise After Breast Implants
You will be able to resume light cardio activity at 2 weeks, and from 6-8 weeks slowly progress from light weight-bearing to your pre-operative workout routine. If your implants are under the muscle then there is no real role for focused chest-exercises in your lifetime. Shoulders/back/arms should be unaffected and you should not have any restrictions after 8 weeks of healing. If you are a body builder then I will evaluate you to assess if you have enough breast tissue to perform a safe breast augmentation above the muscle.
Special Medications After Breast Implants
In my practice I routinely recommend Vitamin E oral supplements after breast surgery. This supplement has been studied in patients with fibrocystic breast changes and is known to help with breast pain/tenderness. My mentors in breast surgery are big believers in this supplement and so I adopted this practice early on.
Montelukast aka Singulair
Montelukast reduces airway inflammation and is prescribed for allergies and asthma. Why does this have any relevance in breast surgery? There is good evidence to support off-label use of this drug helps prevent/treat early capsular contracture. It makes sense that if capsular contracture is just a very robust scar formed from inflammation, then an anti-inflammatory medication could help keep the breast capsule soft. I prescribe 90 days of montelukast after every breast augmentation. This is another practice I adopted from my mentors in aesthetic breast surgery. At the end of the day, if an ethical breast surgeon with 20+ years of experience believes in the validity of a medicine or method, then that is the sort of data I believe in. Because of this I recommend that all of my breast augmentation patients take 90 days of montelukast. If the patient has a strong history of depression/anxiety I counsel them that there is a warning associated with the medication that there is a possible association with abrupt worsening of mental health and I offer to let the patient decline use or self-monitor for changes in mental health status.
Contemplating any aesthetic surgery can be daunting. Women often put family needs above their own and will feel guilty investing family resources in their own breast surgery. I’ve seen this conflict of guilt in many of my patients so if you feel this way, you are not alone, but there is no better investment than your own confidence. It may seem trivial and vain to others, but as a woman who has had breast surgery, I know that it can change your life in a very meaningful way.
Here’s to choosing how we age, on our own terms!
Dr. Lindsey Tavakolian, MD
This Week at Highland Park Plastic Surgery Center
I sat down with my good friend Misty and talked about breast implants from the perspective of patient and plastic surgeon. Misty had a breast augmentation 8 years ago and came to my office with questions about implant management and future surgical options. We wanted to make this conversation accessible for women who have these common questions. Listen as we talk about breast implant surgery, navigating “breast implant illness”, when to replace implants, and how to approach family-planning and breast surgery.