Jason R. Hess MD FACS
4060 Fourth Ave. #120
San Diego, Ca 92103

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Breast Augmentation

Breast Augmentation


Breast Augmentation, technically known as augmentation mammaplasty, is a procedure that enhances a woman's breasts for reasons including improvements in size, shape, and symmetry.  Advances in breast implants and the surgical techniques have made breast augmentation a common and safe procedure for women of all ages.  


Women seek breast augmentation for a variety of reasons.  Many are simply hoping restore breast size and shape to youthful or pre-pregnancy proportions.  Others hope to improve self esteem and femininity.  Regardless of the reason for augmentation, there are many factors to consider.  While full, firm breasts are generally considered the aesthetic ideal, bigger is not always better.  Women who have lost breast volume due to weight loss or child bearing may consider an implant to fill loose skin and to modestly lift the breasts.  Others who have large saggy breasts may choose a mastopexy, or breast lift, rather than an augmentation.  Women who have lost volume and skin elasticity may choose an augmentation mastopexy (implants and breast lift).


Symmetry and shape are extremely important components of breast aesthetics.  The majority of women have some degree of natural breast asymmetry.    This may range from very subtle to severe differences in size or shape.  Occasionally, women are born without a nipple (athelia) or an entire breast (amastia).  Abnormalities such as Poland's Syndrome and tuberous breast deformity have a dramatic developmental impact on breast shape and size.  Breast augmentation is an excellent means of restoring the physical shape and self confidence in women afflicted with these conditions.  


Breast Augmentation Candidates


Women of all ages seek to improve breast appearance via breast augmentation.  The best candidates for surgery include women who are in otherwise good physical health and are well informed regarding breast augmentation.  Women should await cessation of lactation following pregnancy prior to undergoing surgery.  Also, women with active breast cancer or infection are not candidates for surgery.  However, breast reconstruction is commonly performed on women who have undergone lumpectomy, mastectomy or other treatment for breast cancer.  Women over 40 should generally receive a baseline mammogram prior to breast surgery.   Women with breast pain (mastalgia or mastodynia) should seek treatment or an underlying cause of pain prior to surgery. 


Breast Augmentation Surgery


While breast augmentation may be performed under local anesthesia and sedation, the most common approach is to perform surgery under general anesthesia.  The breast and muscle are highly innervated, and surgery is most tolerable while a patient is completely asleep.  Patients may choose saline or silicone implants.  Each type of implant has positive and negative characteristics.  Silicone implants are very soft and feel natural, but are more expensive than saline implants.  Rupture is rare, but is more difficult to detect than that of saline implants.  


Saline implants are slightly more firm and tend to ripple more than silicone implants.  However, saline implants can be placed through a smaller incision than silicone implants.   


Implants may be placed under the pectoralis muscle (subpectoral) or under the breast alone (subglandular plane); This choice is made by the patient and surgeon depending upon individual anatomy and patient preference.   Most plastic surgeons agree that placing the implants behind the pectoral muscle reduces the potential for capsular contracture (hard breasts).  Implants placed in the submuscular plane however, may be slightly more painful and the recovery takes a few days longer than a subglandular augmentation.   The vast majority of patients and modern plastic surgeons choose a subpectoral approach.  


The incision placement is determined by an individual's anatomy, breast shape, and personal preference.  


There are essentially four approaches for implant placement.  


Inframammary Incision


The inframammary incision is placed near the crease under the breasts, slightly above where the breasts meet the chest wall.  A small transverse incision is used to create a subpectoral pocket where the implant will be placed.  When properly placed, the surgical scar will be hidden in the fold beneath the breast.


Periareolar Incision


The periareolar incision (nipple incision) is placed between your areola and breast skin.  The incision is marked at the outer diameter of the areola.  The goal is to place the incision in transition area between the darker pigmented areolar skin and the surrounding breast skin where it can be hidden.  After healing, this incision should be camouflaged or nearly invisible.  


Transaxillary Incision


The transaxillary incision is created in a natural armpit crease.   This procedure is most optimally performed with an endoscope or surgical camera.  This instrument facilitates accurate implant placement and minimizes bleeding.   A tunnel is created in the armpit and a pocket is created behind the breast where the implant will be placed.  


Transumbilical incision


The trunsumbilical or TUBA incision facilitates placement of saline breast implants throught the navel.  This is an incision is rarely used due a high risk of implant malposition.  Dr. Hess does not perform this procedure, and it is rarely performed by board certified plastic surgeons because the alternative procedures (inframammary, transaxillary, and periareolar incisions) offer substantial benefits with fewer risks of complications. 


What to Expect


Breasts are often relatively numb in the period immediately following surgery.  However, discomfort becomes apparent when local anesthesia dissipates from the breasts.  This pain is easily controlled with prescription medication.  Breasts are often swollen and the implants are often slightly higher than desired in the first several days following surgery.  Swelling gradually subsides and implants settle into their optimal position a few weeks after surgery.  Incisions are initially apparent, but their visibility subsides in the weeks following surgery.