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PST 014: Breast Augmentation — Read the Transcript
Hello, Dr Steven Mulholland here at SpaMedica in Toronto, Canada, and welcome to Plastic Surgery Talk and our podcast series. Our podcast today is on one of the most popular and commonly perform aesthetic plastic surgery treatments, breast augmentation. What is breast augmentation? Breast augmentation is the use of an implant, a hollow plastic implant, manmade, with a silicone, solid, vulcanized shell and a cohesive gel, gummy bear silicone gel implant, or saline. And this device, this implant, is placed under the breast tissue. It can be under the gland or under the muscle to increase in a natural and attractive the volume of projection of the breast.
Alternatively, one can increase modestly the volume and the projection of the breast using the patient’s own fat. So two ways to do breast augmentation in the modern era, a natural breast augmentation with a modest increase in volume projection, using the patient’s own fat, harvesting from where you’ve been saving it for a rainy day, purifying it and injecting it into the breast. Or taking a traditional approach and taking a cohesive gel implant through a small incision, placing a lifetime warrantied implant to increase significantly or moderately the volume projection of the breast. Those are your two options. It gives lots of women different ways to increase the volume and shape that they want.
How common is breast augmentation? Well, it has been at the top of the cosmetic plastic surgery hit parade for women for many, many years. So there are hundreds of thousands of breast augments done every year. More than two million Canadian women have breast implants, and so it’s become a very common, a very safe way to achieve the balance and shape and proportion and natural breast waist hip shoulder ratio when Mother Nature, genetics, have not given you that shape or that volume. Or you had that volume and projection, through weight loss or breastfeeding, you’ve lost it.
What are these breast implants made up of? What are the materials actually? What are the structure? Well, if you do natural breast augmentation, which is fat grafting, it’s made up of your own fat. We take your fat cells from where you don’t want it, tummy, hips outer/inner thigh. We spin the fat cells down into purified fashion after removing them through aspiration, and then we inject with a small needle into the breast gland. So natural fat augmentation is made up of fat cells and fat derived stem cells.
What about traditional breast implants? Traditional breast implants have a very solid polymerized shell, similar to the consistency of an IV fluid bag. That solid fluid bag that holds a saline when you get an in, that’s what the shells made of. So very well tolerated, very inert, not reactive at all. The inside of the implant is always been what the controversy has been in the past, and that can be either a saltwater or saline or gel. There was a whole period in the ’90s when there was an analysis of liquid silicone, the liquid silicone gel implants, to see if there was any systemic health risks.
They looked for evidence of breast implants and rheumatoid arthritis, scleroderma, lupus, MS, ALS. And after about 10 years of exhaustive research and analysis, both the FDA, Health Canada, the EU, Health Australia determined there was no health risks between implant materials and systemic human physiology. However, in that 10 years, basic science and innovation engineered a new breed of implant. Not the liquid silicone which could leak and can cause local concerns and pain and discomfort, but semi-solid gel, soft mobile gel, but not liquid, and these came to be known as the gummy bear implants. So these were silicone where it wasn’t liquefied, but it was a semi-solid like a Jello. And the gummy bear implants have come to represent 99% of all breast implants performed in the world, and there’s different consistencies. There’s a sophomore mobile gel that’s not liquid, but it moves with you.
Therefore, you don’t need a shaped implant like a teardrop and a round because when you stand up, a responsive gel responds to your position of space, and Isaac Newton takes the gel and gives you a teardrop shape. When you lie back, the responsive gel becomes round shape. So the modern implant adapts to shape to your position of space making the most natural really brand and model of implant we’ve ever had. You get a lifetime warranty because they don’t leak. Their integrity’s very solid. You can do any kind of lifestyle, and they’ll maintain their structure. If there’s a structural breach or a fracture or a crack, the company warranties a complimentary replacement.
So the structure of your breast augmentation can be either natural fat cells or very highly engineered, very safe life-long lasting silicone, cohesive, non-liquid, gummy bear gel implants. So when I see patients in my office, breast augmentations one of the more common things that I perform, one of the more common operations. I have to sit down with them and decide, does this patient want breast augmentation in the first place? Are they a good candidate for increasing volume of projection? Number two, what do they want to augment with, a saltwater saline implant, which may leak in the next 10 years, but it’s been around a long time, and it’s viewed as more natural? Do they want a cohesive gel gummy bear implant that will last for a lifetime, or do they want natural augmentation with fat? Or a hybrid surgery where we take a smaller gel implant and do over fat grafting for a combination approach?
In general, most patients come already kind of knowing what they want to do. Ninety nine percent of patients are going to choose a lifelong warranty, cohesive gel, modern gummy bear implant. Then my only work with the patient is deciding what’s the best incision, what’s the best pocket, and how much gel? What volume and projection? How do we do that?
We use high tech, 3D computer imaging to try before you buy, to be able to look at what your shape will be like, what your breast, waist, hip ratio will look like with certain sizes of gel implants. You can hit a button and there’s a certain size, and then another button, there’s a bigger size or smaller size. So you get to try on these implants before you decide to do surgery. So the risk of you not liking the volume and projection increase should be pretty close to zero.
So we know we can choose the volume or the size of the implant. Is there a choice for women on shape? The answer is yes and no. In the old days, 10 years ago, we have round implants and tear duct implants. We had a textured surface so the teardrop would stay stable in north-south orientation, but there were problems with textured implants and anatomic teardrop shape devices, and those were a reaction to the textured shell.
And so the whole industry, the last eight, nine years has moved towards a smooth shell, no texture, and responsive gel. And so when you stand, the implant looks teardrop. When you lie down, it looks round, which is by far the most natural behavior of the breast. It changes as your position in space changes relative to gravity. So nowadays round, smooth, cohesive, responsive gel are round when you’re lying down, teardrop when you’re standing up. They have a smooth shell. They’re generally placed under the muscle, and usually through a small incision under the breast because these are fairly large devices that have to be inserted through an incision, not just the shell, like a saline implant. It’s like a baby in reverse. We have to pick out a hidden port through the armpit. It can show up when a patient goes, “Hi,” and raises their arms.
So the axillary approach for a larger gel implant, not a good one. The periareolar incision can cut many of the sensory nerves, and so when you need a bigger incision, it’s not a good solution. And clearly we can’t go through the belly button with a big gel implant, which leaves really the under the breast incision the best place to place the implant. That incision then can be sutured up and high to the ribs so the breast implant hangs over that scar. And even when you’re sitting down or lying down, no one should see it. So small, well-contained incisions under the breast, and the implant can be inserted using something called the Keller funnel, which greatly limits the size of the incision and means the implant doesn’t touch the surface of your skin. So round, smooth, under the muscle, inframammary incision with the incision fix gives the best result for the modern implant patient.
Okay, so these breast implants are warrantied for life. Does that mean that the patient is now stuck with one size implant forever? What if she loses weight? What if she changes shape? What she puts on weight, and her breast gain weight? What if she’s had kids and breastfed, and her breasts shrink? So is there the option for size increase and decrease? Absolutely. Just because you have a lifetime warranty, doesn’t mean that you cannot electively decide to alter the volume. So you might have a nice breast augmentation result, you’re happy for many years, and you lose some weight and you get thinner. Or you’ve had babies, and you’re breastfeeding, and so the breasts [fall 00:09:42]. Well, you can up size at that time. It is a relatively simple procedure, often done under local anesthetic, to inject local anesthesia in the incision in the breast, remove the implant, and replace it with a larger implant. You’ve already stretched out skin almost like a pregnancy, so you can often accommodate a size or two bigger to get that increased volume.
By the same token, you put on weight, you’ve gotten a little older, your breasts are fuller, you want to go down in size. You can remove the implant totally, or you can remove the implant and go to a smaller size if you feel that’s right for you at that time in your life. So size adjustability up or down, definitely possible, and sometimes women do take advantage of that.
So many patients come in for breast augmentation. They’ve read all kinds of things on the Internet about different incisions, different pockets. A lot comes down to a very limited number of options. For example, cohesive gel implants are large, prefabricated, safe, lifelong devices that are ready to insert in reverse. So you’ve got your entire breast volume ready to insert. It’s not like the saltwater saline days where we had a little shell that was rolled up. We could put it through a tiny incision, often down a telescope, and then inflate it. It’s not like that anymore. We have a prefabbed implant ready to go in, and that means you need a sizable incision, often 9 to 10 millimeters for every 100 grams, which means the average size installation is four to five centimeters. That can’t go around the areola. That can’t go in the armpit. It can, but that’s often a very visible scar when you raise your arm, or with a bathing suit on or a tank top, you can see that scar from across the room. Alternatively, the belly button is not a good place. You can’t stuff a big implant through the belly button.
So over the years, with the advent and popularity of these cohesive gel implants, unless it’s a very small gel implant where sometimes the armpits are a good option, for the average size woman, 350, 400, and 450 grams, we use the under the breast or inframammary incision.
We create a fold, lift the scar up, hide it under the new breast implant that rides over it. And that’s how we get access to the pocket, under the breast, inframammary, well hidden, self-contained, and sutured to the rib incision. So we’ve got our incision, inframammary, well hidden under the breast, concealed. What about the pocket? Some women are still okay candidates for under the gland or subglandular approach. That’s less painful, there’s no muscle dissection, but you have to have a healthy amount of gland to cover the implant or you get that sort of Posh Spice, round bubble breast look that women just don’t like. And so to get the coverage, we often go under the gland in the early part of the pocket, and then dive under the muscle, almost like a tuque over the ears and hat on a cold day, to cover the top part of the implant. So under the muscle, the pectoralis major muscle, to cover the upper pole and under the gland in the lower pole.
It’s called a dual plane, and that’s the most common breast pocket I create under the gland, up to about the areola, and then under the muscle so you don’t get that Posh Spice bubble breast. The other pocket concern women have is there’s not enough mobilization or creation in the inner part of the pocket, so end up with that sort of Tori Spelling, two implants, one here and one there and three hands in between with a very wide intramammary space. Women really don’t like that. So you don’t want your implant so close together you have a uni-boob. You want a cleavage one or two fingers. So we make sure we select just the right baseline for both sides that when they’re implanted leaves a nice one or two finger cleavage. So the pocket, the pocket dissection and pocket selection is very important.
I spend time with patients on that, just like the incision placement, and the actual device or implant, size, and volume that the patient wants to choose. With those set of discussions and the computer imaging, 3D vector simulation, most patients are extremely happy because they got to try before they buy. They get to sample before the implant, and the end up with a shape and a form and an appearance that they have a say in, that they had some contribution in creating.
So how is it that patients can actually select the size of implant? How to choose the volume. There’s a number of tactics and strategies. There’s some old-school techniques where we will take, let’s say, the gel implant itself that we let the patient hold and look at. And they can put that in their bra, almost like a breast implant breast pad, and they can see what kind of volume projection they get.
However, that grossly overestimates the amount of projection because it’s on top of the skin. Once the implant of that size is under the gland or under the muscle, you don’t get the same projection. And so some of these old techniques, a have baggy full of rice, baggy full of water, a breast implant all stuffed into the bra doesn’t give the woman a true sense of projection and overestimates what they’re going to get. And so not surprising, when you look on the Internet from women who have had techniques of estimation of size that involve putting a sizer and abroad and under a T-shirt, they usually ended up going, “Wow, I wish I had gone bigger. I was a bit worried because this size that I got to sample before maybe look too busty. So I went a little smaller, and now that I’m finally under the muscle, under the gland and I’m getting my projection, I wish I’d done more.” And up to 20% of women will say, “I’m glad I did it, but I wish I’d gone bigger.”
In order to try and get around that problem, about eight years ago, I started incorporating at SpaMedica a high tech 3D computer imaging system where we can take a photo of a patient and in different positions, three-quarter, lying on the back, rotating, looking up, looking down. You can hit a button and get a certain size implant. Three hundred grams, hit another button. Four hundred grams, hit another button, 450, 500, 550. You can look at your shape and form very accurately. This is a very good estimation of what you can achieve in advance of the surgery.
And so now using the VECTRA 3D, it’s virtually impossible to come out of that operating room in recovery without ending up with an implant that you’re pretty happy with because you get a say on the volume of projection based on 3D computer imaging. So it’s really helped women close in on the volume of projection that they most desire and we have very, very few patients nowadays who say, “I really love my breast augment, but I wish I had gone bigger.”
Now they say, “I just really love my best augment.” Okay. You’ve done your 3D imaging. You’ve signed up for your best augment surgery. You’ve decided you want a cohesive gel, gummy bear implant. You’ve done your VECTOR 3D imaging. You know the volume of projection you’re going to like. You know the scar. You know where the incision is going to be, probably inframammary, and it’s going to be probably under the pocket of the muscle. What’s the recovery like?
Plain and simple, breast augmentation is uncomfortable. It hurts. How much? Well, because of the muscle dissection, it’s kind of like you ran through the house, and you hit your thigh the coffee table, and you have a Charlie horse. And now you’ve got a charlie horse here and here. It feels like heavy pressure, like a muscle ache, like when you breathe in it’s tight and uncomfortable like you have a horse standing on your chest. That lasts for two or three days.
So if you’ve had kids, childbirth pain, 9 out of 10. Tummy tuck pain, 8 out of 10. Submuscular breast augmentation, about a 6 or 7 out of 10. It’s not nearly as painful as childbirth, but it’s uncomfortable for two to three days. So you need a good pain medication, often some sort of narcotic pain medication for two or three days. And then you can transition because the muscle pain goes down. It feels externally uncomfortable chest pain. It’s not like internal pain. Nevertheless, it can be significant, and it requires two to three days of recovery. By the third day, you’re often on a non-narcotic antiinflammatory like a Toradol, which is Ketorolac or Celebrex or Naprosyn and maybe some acetaminophen. So two to three days of pain, and it falls down and decreases to a tolerable level, where by the third or fourth day you’re often doing some massage exercises.
So for the first three days, we have patients touch the top of their head, move their shoulders, avoid any kind of massage exercise of the breast. After the third or fourth day, we start to do massage exercises to help the patient soften and de-engorge the gland and the breast itself. Usually over about three, four weeks, the implant softens and drops into the pocket, looks less upper pole fullness and much more natural. By 12 weeks or three months, patients are very happy, the incisions heal, and they’re back swimming in an ocean or a pool or in the lake, and feeling like these are now their breasts.
Other activities, specifically, most patients say, “When can I get back to the gym?” Two answers to that. Light gym activities like a stair climber, elliptical, some light yoga, some leg toning exercises, on average three weeks.
I want patients walking briskly the next day. So walking and keeping active and ambulating first week and second week. By the end of the third week, stair climber, elliptical aerobic activities that are not too aggressive. By six weeks, full on jogging, pec major flies, bench press, pushups, working your pec major, working your deltoid and your latissimus, and jogging and high impact aerobic activity.
Intimacy, again, I’ll divide that into low impact intimacy, high impact. Low impact intimacy without a lot of pressure on the chest or movement, two or three weeks. High impact intimacy, lots of pressure on the chest and the chest wall, more like six weeks. Once you’re out six weeks, there’s absolutely no restriction. You can do whatever you want. If you were doing full contact karate, you’re going back to a full contact karate. If you’re doing kickboxing, kickboxing. Golf, tennis, racket sports, high impact aerobic activity, jogging, swimming, no restriction of activity once you’re done.
Sleeping, a lot of women ask about sleeping. It feels odd to sleep on your tummy. So if you’re tummy sleeper, the breasts act like to kind of roller balls. You’re lying on them, and it feels odd. It takes some months to get used to that. Most front sleepers become side sleepers, and some side sleepers become back sleepers, but there’s no restriction in sleeping activity. Remember, these cohesive gel, gummy bear implants are warrantied for life. So there’s no modest to even strenuous exercise activity that should compromise how they remain and how intact they are. So you’re safe to do whatever you want. You just have to graduate into these activities with reason, and wait about six weeks to you will engage in full cardio and combat style athleticism. A lot of women ask about the scar and other sort of pigment issues on the breast.
In general, the scars going to go through a phase of healing. So it takes four to six weeks to get solidly healed, and then about six to nine months to remodel and soften. Most breast scars will go white overtime or light, depending on the skin color of the patient. And in general at SpaMedica, we assist in a complimentary fashion the resolution of that under the breast, breast augment scar. So we’ll inject things to make it smoother. We use topical silicone gel to leach out some of the discoloration and flatten the scar. We use lasers like IPL impulse light to take the color out of the scar. And with some babysitting, like lasers, topical gel, and injections, we can usually end up with a flat light star on all patients that’s a nicely placed.
So scar management is a very important part of post-augmentation discussion, and there’s other little irritations that can happen. Sometimes the veins on the chest will stand out more, and they take some time to go away. Sometimes they don’t, and the bigger veins on the chest can be injected or treated with the laser. Sometimes the areola distends and expands, and you then lose the definition of the aerial or border. And sometimes we need tattoo removal lasers or pigmentation to sharpen that border.
Very little in the way of intervention is required but when needed we modify the star, the appearance of the veins on the breast, and sometimes the areola. Women will often ask, “Can I breastfeed after, let’s say I have another child” or “I’m very young and I want to have children one day, what’s the probability I can breastfeed. Am I still able to?” Because the perception out there, the urban myth is that with implants you can’t breastfeed. That couldn’t be more wrong. The vast majority of breast-augmented women can breastfeed. 85% plus of breast-augment women can successfully breastfeed.
Just think about why. We’re not disrupting the gland. We’re sliding under the gland, then under the muscle. We leave the entire gland, the areola, and the nipple and the ducts alone. There’s not cutting through the areola or the nipple. That was more of an older approach, the periareolar incision approach. There was definitely a reduction of breastfeeding when we use the nipple and areola’s access. Now that we go under the breast with cohesive gel implants, 85% to 90% of all augmented women could successfully breastfeed if they needed to.
So breast augmentation surgery is a very, very common procedure. With a common procedure, when you want to discuss with your surgeon, what are the risks? I know the benefits, I can see that on the imaging. I get my projection volume. I look good in a cocktail dress, an evening gown, a tank top without a bra, a skimpy bikini without pads or underwire. Those are the advantages. That’s the benefit. That’s why you’re doing it. What are the disadvantages or the risks you have to accept? Remember, risks are probabilities. There’s no certainty you’re gonna get that complication, so you need to know what is the percent of patients that are going to surgery that actually get the complication.
Fortunately, they’re extremely rare. The most common ones are number one, if you don’t select the right surgeon that uses computer imaging, there’s a high probability your complication has nothing to do with the surgery, that your dissatisfaction in the volume selected. So complication number one, dissatisfaction ’cause you under-augmented. You should’ve gone a bit bigger.
Say you managed that, you’ve healed. Everything is going well. Complication number two, which is common, would be in the range of 2% of patients, experience a immunological reaction to one of the implants. The body says, “No, no, no. This is not my owner. I don’t like it.” And it starts to harden around it, forming a hard, encapsulated implant, hence called a ‘breast capsule’ or ‘capsular contraction’. One hard ball-like, unnatural, painful implant, and once bouncing, soft, and natural.
So that capsular contraction rate is 2%. It’s easily fixed. We go through the same incision, take the old implant out, remove the scar tissue, and put a new implant in. The assumption being that there’s no immune recognition signal on the shell, and your body just gives up. And that’s true. 95% of the time, with that little procedure, which sounds like it wouldn’t work. Why wouldn’t the body react again? It’s the same kind of implant. Well, it just doesn’t. 95% of the time, the body says, “That’s it”, forgets about it, and it ends up bouncy and soft, just like the other side. So capsular contracture, 2% risk.
About 1% of the time, the opposite happens. The implant doesn’t get too hard, but over the years, it starts to stretch out the pocket. The pocket gets bigger and bigger. Not in this direction, ’cause the incision’s sutured right to the rib. But it can migrate more to the outside, and the implant, when you lie down one night, falls into your armpit. It’s really dissected, and opened up the pocket. In that case, we need to go back, take the implant out through the same incision, stitch up the inside of the pocket, make it smaller, sort of an internal breast lift, if you will, and support that implant. And that works very nicely. That’s 1% of the time and easily fixed.
Scarring can occur. That’s adverse. That’s less than 1% of the time. We can easily manage all scars. Then implant failure. It can fracture in a car accident, while skiing. And that’s why you have a lifetime warranty on the integrity of the device in case that happens. So the complications are Rare. Vast majority of the patients are super happy they did it, which is why it’s the most common female operation that we do.
Women often have to plan busy lives around breast augment surgery. They’ve got little kids. They may or may not have a significant other. They need childcare during the procedure day. So many women ask, “Do I have to stay overnight?” Most Canadian plastic surgeons, just like me and my American counterparts, we own our own surgery centers licensed by the state or the provincial government, and one of the safest places to have surgery. So yes, you have a general anesthesia with an anesthesiologist. Some physicians do more of a twilight sedation. Most, when going under the muscle, will have a general anesthesia. The operation in experienced hands is less than an hour. You generally don’t have to stay overnight. So you can plan, let’s say some ancillary childcare at home. But you’re kind of just had surgery that day, so I wouldn’t be in the line of fire of a primary caregiver for two or three days, ’cause you’re gonna have discomfort. So, maybe mom sweeps in, or you have a nanny, or your sister comes to help.
But you can go home after. You don’t have to stay overnight. The recovery is fairly quick. A lot of women with sedentary jobs, they can go back to in three days. I recommend five to seven, but sometimes time is money. And women don’t wanna miss work, so they go back to work on the morning of the third day, and they’re at the typewriter at their sedentary job at their office. If you have a more active position, where you gotta carry parts around or you need your chest muscles, I generally recommend one week till you get back to those activities.
So breast augmentation generally is not gonna take a lot of recovery time. You don’t have to stay overnight, and it’s reasonably affordable. The range in price that you’ll see with cohesive gel implants can be as low as 5 or 6,000, as high as 15,000, depending on the city, depending on the practice, depending on the physician, depending on their purchasing power for the implants that they’re buying from the companies like Allergan that make them. So those are some of the less medical parts of the decision. ‘Is breast augmentation right for me?’
“What happens if my implant breaks?” Common question. Well, first and foremost, the probability of that happening is very low. The number of patients that will have their breast implant surgery with a cohesive gel gummy bear warrantied implant, lifelong warranty, having to replace that is well under 1%. So you have a 99% chance that your warranty will never need to kick in because the integrity of your breast and the implant lasts the rest of your life. Now, if you’re skiing a double black diamond and need to fall 30 miles an hour on your chest, you can fracture the implant. If you’re in a minor fender bender car accident, you hit the steering wheel with no airbag, you can fracture your implant. So they maybe withstand most forces, but not all.
And if you get a fractured implant with some sort of integrity violation and the shape is changed, you’ll notice that. Sometimes, you do monthly, I’m sorry, yearly ultrasounds to assess the integrity of the implant, an you find out there’s somehow, your implant got fractured and it changed shape slightly. So, we recommend monitoring your breast implant in Canada with a yearly ultrasound, a yearly MRI, if we can get it. There’s just not enough MRIs for a routine screening. In the United States, yearly MRIs are recommended for all breast implant patients. And if you happen to find an unsuspected clinical fracture of the implant, where it’s flattened and injured, and clinically obviously fractured, then it needs replacement. And then your warranty card kicks in. Allergan covers these implants for the rest of your life, as does Mentor. So you select a surgeon, the company will pay the surgeon not to charge you. You get a comp from your implant. And then through the same incision, likely the same pocket. There maybe some neo pocket or new pocket, depending on the problems you’ve had, and your implant in simply inserted, contour and shape is restored, and you go back to life.1% of the time, that may be a problem. 99% of the time, you’re gonna have these implants for the rest of your life.
Breast augmentation is here to stay. Women who seek to enhance their figure, shape, and form with lots of volume through weight loss, child bearing, or never had the chest bone to begin with are always gonna seek out options that involve either natural fat grafting for modest size improvements, or cohesive gel breast implants for the optimal size. Selecting the right surgeon with a lot of experience, with imaging technology, allows you to buy before you try, with a good reputation, you have a good rapport with, and his team or her team, are the critical questions you need to ask when selecting what’s the right, who is the right surgeon for me, and what’s the right center.
Fortunately, there’s lots of good breast surgeons around. Interview a few of them. And with the strategies and tactics we talked about today, you should have an extremely good outcome. You should be very happy. And with that kind of figure, shape, and form, you just can’t exercise or diet into on your own. Augmentation is the great solution for upper, lower body, chest, pelvic, shoulder, just proportion. And selecting the right surgeon and the right implant will give you the kind of shape you can be very confident with for the rest of your life.
So thank you for joining me again. Dr. Stephen Mulholland, here in Toronto, Canada for our podcast on breast augmentation. If you really like the content here today, found it entertaining for informative, please share this on your social media channels. And don’t forget to join us again for our next podcast here on ‘Plastic Surgery Talk’.
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