Breast Augmentation

Breast augmentation is a plastic surgery procedure that uses high tech, man-made, Health Canada approved prosthetic devices, called breast implants to augment the volume, proportion and shape of the breasts.  Breast augmentation is one of the most common procedures performed in North America. Dr. Mulholland has been an innovator and a pioneer in breast augmentation, with the use of VECTRA® 3-D pre-op breast imaging, to help patients decide which size and shape of implant best suit their conscious and subconscious goals for beautiful shape, figure, and proportion enhancement. With over 20 years of Breast Augmentation experience, Dr. Mulholland is one of Canada’s most sought after and reputable breast augmentation surgeons.

Breast augmentation is a very safe and quick procedure; usually performed in approximately 60 minutes or less. The procedure is performed as an outpatient, under light IV sedation, or general anesthesia.

The breast augmentation procedure can be broken down into selection of an incision, a pocket, and an implant.

The most common incision options include the under-the-breast or inframammary incision; the transaxillar or through-the-armpit incision; the periareolar or areolar incision; and the transumbilical or through-the-belly-button incision. (Figure 1.)

The armpit, periareolar and belly button incisions can be used when saline or salt water breast implants have been selected, as the shell can be rolled up and inserted through a small telescope (also called an endoscope) and the implant inflated with saline (sterile salt water) when the breast implant is in the pocket, which allows for small incisions. A very small, cohesive gel “gummy bear” implant can also be placed through a trans-axillary incision.

Generally, for any moderate- to large-sized silicone, cohesive gel breast implant, the under-the-breast, inframammary incision is the optimal incision, as the cohesive gel breast implant is often too big to put through the areola and belly button and can be more noticeable in the arms up position with a longer trans-axillary scar.

The secret to a good breast augment scar is a plastic surgeon that places the scar in the least visible location, closes the scar expertly, and uses high tech strategies to limit the length of the scar.  The under-the-breast incision can be elevated high up under the breast, creating a new fold, which is attached stably to the underlying tissue. Not only is the “new crease” placement for the scar difficult to see in the standing or lying position without lifting the breast, its attachment to the underlying tissue minimizes descent or drooping of the implant over time, like a built in underwire support.  The actual length of the incision is shortened by using a high tech insertion device called the “Keller funnel”, which is  soft, silicone lined sterile insertion funnel that greatly minimizes the length of the scar and insertion trauma and potential contamination of the breast implant. (Figure 2.)

Once the incisional approach has been decided, a pocket must be made for the breast implant. (Figure 3.)

The vast majority of breast augmentation patients tend to have thin upper chest walls with visible ribs and collarbones and therefore the under-the-pectoralis-major-muscle, also called “under the muscle” pocket, is generally the most favourable; providing soft tissue camouflage and coverage at the breast implant-chest wall juncture.

An under the muscle pocket will often avoid the rounded “bubble breast” look, where the circular shape of the upper pole of the implant is clearly visible. For those breast augmentation patients who have a large amount of glandular tissue that is somewhat deflated and mildly droopy, a sub-glandular, or under the breast gland and over the muscle pocket may be used, which is on top of the pectoralis major chest muscle, to give the breast enhanced projection, shape, and form.

Figure 3. Breast Implant pockets. A. Sub-glandular: the breast implant is under the breast gland but on top of the muscle. B. The Sub-pectoral pocket has the breast implant completely under the pectoralis muscle and C. The Dual Plane, which has the breast implant placed under the gland in the lower breast pole and under the pectoralis muscle in the upper pole.

What is a Dual Plane Pocket?

A Dual Plane pocket is very commonly selected approach and has the advantages of both the sub-pectoral muscle pocket and the sub-glandular “above the muscle” pocket. A Dual plan pocket involves the creation of a sub-glandular pocket up the areola, which gives the best “lift effect” and rotation of the lower pole of the breast. At the level of the areola, the pocket transitions to an under the pectoralis muscle pocket so that the upper pole of the breast has additional coverage of the pectoralis muscle over the implant, minimizing the risk of “bubble breast.” Many women benefit from the lift effect of the sub-glandular pocket in the lower half of the Dual Plan and the coverage of the upper pole in the sub-pectoral, sub-muscular pocket in the upper half of the Dual Plan approach.

How do I avoid an overly round, “bubble breast” appearance to my implants?

Most breast augmentation patients are fearful of the breasts looking like unnatural, round, “bubble breasts;” two round spheres sitting high on the chest.  This “bubble breast,” “Posh Spice” appearance of two round balls sitting high on the chest wall can be avoided by selecting the appropriate size implant for the shoulder, waist-hip ratio of the patient and selecting the sub-muscular or Dual Plan pocket for pectoralis cover and camouflage of the upper pole of the implant.

How do I avoid a wide space or wide cleavage between my breast implants?

Patients are also fearful of having far, too-wide space between the breasts. Being able to place an entire hand or more between two widely spaced implants, or the “Tori Spelling” look, can often be avoided by proper planning, implant selection and pocket creation. Excessively wide cleavage is often a simple problem of appropriate breast implant selection and proper release of the pectoralis muscle in the lower pole.  A breast implant with the appropriate base width needs to be selected to ensure an attractive space between the breasts, or cleavage is created. If the base width of the implant is too small, the sternal release of the lower pole of the pectoralis major is not performed adequately, or there is capsular contracture in the post-operative period, the intermammary space, or cleave can be unacceptably wide. Fortunately, enhancement surgery can usually correct this overly, widely spaced cleavage.

How do I avoid “uni-boob” or breast implants that are too close together?

If the implant base width is too large for the chest wall, or the inside pocket is over dissected, the breast implants can end up being too close together and actually touching in the midline, which eliminates the cleavage completely and is known as the “uni-boob.”  The goal is to have a natural 1-2 finger space between the breast when naked and, if desired, an overly accentuated, narrow cleavage using a push-up underwire bra in selected social environments.

Are breast pocket drains required?

Once the pocket has been decided, the incision made, the breast implant pocket is dissected and the implant is inserted inside the pocket using a Keller Funnel, the closure is performed.  A drain may, or may not be used to facilitate removal of fluid from the pocket. A drain is a small, thin, soft tube attached to a small suction bulp that in turn, attaches to your sports bra. The drain is not necessary, but can reduce the post-operative swelling and associated discomfort significantly. It is important to note that you can elect not to have a drain after your discussions with Dr. Mulholland. If it is decided that drains are to be inserted, they are removed on the morning of the 3^rd post-operative day. Often 200 cc of fluid and swelling can be removed through the drain in that first 2 days, which speeds up the recovery process, lessens swelling and discomfort, and hastens a return to a natural breast appearance.

Are the breast implant incision sutures dissolvable?

In general, a water-tight soft tissue incision closure is performed.  The sutures used are mostly absorbable and suture removal is not necessary. For the under-the-breast, inframammary incision, the scar ends up being the new inframammary crease and the incision usually can’t be seen in the standing, sitting, or even lying down positions, without the breast itself being lifted. Generally, avoid immersing your incision in water for one month, but showering is allowed, starting one day after the drains, if deployed, have been removed. Swimming in pools, a lake, and the ocean is allowed after 4 weeks and evidence of an air tight closure.

The modern era of breast augmentation surgery really evolved with the development of the cohesive gel, semi-solid, silicone gel breast implants, also called the “gummy bear” breast implant.  The “gummy bear” or cohesive gel breast implants have the advantages over saline breast implants of being more breast-like in feel and texture; very rarely do they ripple or have visible irregularities; they do not leak; and they have a lifetime warranty provided by the manufacturer.  In contrast, salt-water, saline breast implants have been around for 30 or 40 years and have the longest history. The problem is that saline breast implants lack viscosity and in certain positions, particularly bending over, one can often see collapse of the breast implant shell with ripples or visible rib-like structures under the skin. This is unlike the cohesive gel breast implants, which can hold the shape of the implant structurally in all positions. Saline breast implants do have a risk of rupturing and leaking (approximately 2% per breast, per year) and eventually the saline breast implant will likely rupture and have to be replaced. There is a probability you will have to replace and re-do your saline breast augmentation surgery every 10 years.

The cohesive gel breast implants come in a wide variety of shapes (round or tear dropped, also called anatomical breast implants), smooth or textured shells, and differing heights, widths and projections. The cohesive gel breast implant comes with a lifetime warranty that there will be no structural integrity faults within the breast implant and any fatigue or failure of the structural integrity results in a complimentary procedure on the compromised side. The modern cohesive silicone gel implants have smooth, non-textured surface to the shell and are “responsive” in nature, meaning that the breast implant changes its shape to match your position in space and with gravity. When you are standing, the responsive cohesive gel implant shifts downward adopting a more “tear dropped shape, while when lying down the shape of the cohesive , responsive implant is more rounded.

Breast augmentation patients will meet with Dr. Mulholland during their consultation, who, based upon his over 20 years of experience performing breast augmentation surgery will use your specific anatomy to recommend the potential sizes, styles and shapes that would meet your stated aesthetic goals and expectations.

Figure 4. Cohesive silicone gel breast implants and saline breast implants come in a large variety of sizes and shapes, heights, widths and projections. You will use the Vectra 3D breast imaging station to select PREOPERATIVELY, the best possible breast implant size and shape for you. What you see is what you will get, the Vectra 3D imaging system will allow you to “try-before-you buy”. The more modern, “responsive” cohesive gel implant will appear more tear dropped when standing and more rounded when lying down.

Dr. Mulholland has been one of Canada’s pioneers on the use of 3D computer imaging to help patients decide on the right size and shape implant for them. The Vectra 3D is the world’s leading computer imaging system. It will allow you to see your figure in 3 dimensions with different sized and shaped implants, in different pockets, to help you decide before the surgery if breast implantation is right for you and what size, shape and pocket offers the best possible aesthetic outcome. Dr. Mulholland and his breast augment team will guide you through the computer simulated process of deciding upon the best possible breast implant. Using his 20+ years of breast augmentation experience, Dr. Mulholland will also guide you on his opinion of the best implant size and shape for you.

Figure 5. The Vectra 3D is a computer simulated process, allowing to see the close approximation of different sized implants on your figure shape and form. This “try before you buy” concept, using Vectra 3D imaging process, will help you decide on the best breast implants for you.

The best candidates for breast augmentation procedures are those patients who are realistic and have given careful consideration to the advantages of having breast implants to create volume, shape, proportion, and figure enhancements.  Good candidates have often tried diet and exercise to achieve the ideal figure, shape and form and generally use breast augmentation surgery to increase the projection and volume of the breast to better match their shoulders, hip and waist ratios.

Contraindications to breast augment surgery may include unrealistic expectations, medical diseases that prevent general anesthesia and various severe and advanced forms of multiple sclerosis and ALS, scleroderma, rheumatoid arthritis or other immune diseases.

Breast augmentation can be performed under tumescent local anaesthesia with oral sedation but generally IV sedation or general anesthesia is the preferred choice for most patients, as the pectoralis muscle needs to be fully relaxed to allow subpectoral dissection and often also needs to be partially divided while eliminating all sense of discomfort.

The IV sedation, unlike traditional general anesthesia, generally does not involve a tube in the throat, ventilation or intubation, but more similar to the kind of IV sedation commonly used during a colonoscopy.

For healthy patients with no medical diseases, the risk of an anesthetic related complication is extremely rare, to the point, where the average breast augmentation patient take more risk driving on Toronto highways that undergoing breast augmentation surgery.  Dr. Mulholland and his government-certified SpaMedica plastic surgery center and OR have been conducting surgical procedures safely for over 20 years, without serious complication. Dr. Mulholland uses only the very best anesthesiologists, who practice in large teaching hospitals and have expertise managing the most difficult patient medical problems. The location of these teaching hospitals is very close, in the rare event there is an anesthetic reaction.

All patients experience and interpret pain in different ways. Breast augmentation often involves dissection under the pectoralis major muscle and there can be significant pain and discomfort for the first 2-3 days and then the discomfort becomes more of a “bruised sensation.”  In terms of ranking the order of discomfort with breast augmentation, breast augment patients generally rank child-bearing as number 10/10 in pain; an 8/10 would be a tummy tuck, with repair of the rectus abdominis muscle; a 6/10 may be laser resurfacing of the face; followed by breast augmentation.  The pain of the dissection under the muscle and placement of the implant in that location is generally short-lived – 48 to 72 hours – after which most patients are fine using a nocturnal narcotic and anti-inflammatory medication during the day.

Breast augmentation pain lasts approximately 48 hours, whereupon there’s a significant decrease in discomfort and the patient is able to gently massage the breast and start decompression breast massage exercises.

The recovery during the first 2-3 days after Breast Augmentation is characterized by pain and discomfort, but by the third or fourth day, gentle breast massage can start being performed to soften the implant pockets and reduce the frequency of wrinkling and the risk of capsule formation.  In the first two to three weeks, the implants generally tend to appear swollen and ride a little too high and take two to three weeks to drop down into the pocket and assume a more natural appearance.

After leaving the clinic, you will go home in an elastic breast band or soft, supportive bra. The band or bra helps keep the breasts in the correct position. Initial discomfort is controlled with oral medication. There may be some sutures that need to be removed.

Light activities can be resumed almost immediately. Aerobic activities and upper body strength training can be resumed in approximately six weeks.

In general, by six weeks, most breast augment patients can return to full activities, including exercises which involve the pectoralis major muscle, such as push ups, and more assertive intimacy.  Toronto breast augmentation patients should plan to look good in bathing wear, a cocktail dress, or a tank top within a few weeks and should plan social events after surgery accordingly.

Most patients look quite good in the first day or two following a breast augmentation procedure.  Patients start to massage their breast implants by the third week and most breast augmentation patients look good by this time. Implant contour, shape, and form continues to evolve or remodel fully over one year following the breast augmentation procedure.

Harvesting fat from areas of the body with an excess of localized fat, like the hips, thighs or tummy and transferring this fat through injections into the breast can be a very good option for those patients who want a very modest increase in volume and projection.  The advantages of fat grafting breast augmentation is the use of natural tissue like your own fat to increase the volume and projection of the breast and the procedure can be performed under local anesthesia. The harvest of the fat from donor sites can improve your shape and contour in other areas and the fat grafting can survive for many years. Fat graft survival ranges from 30%-70% of the volume of the fat injected and often a slight ‘over grafting” is performed to account for those fat grafts that might not survive. The biggest disadvantage of Fat Grafting is the degree of volume and projection improvement is very modest, often less than ½ cup size, or approximately the size of a padded bra. For the breast augmentation patients who desire a full 1-2 cup or more increase in volume and projection, then a breast implant is recommended.

Breast implants do not cause breast cancer but regular home breast examinations and regular yearly breast ultrasounds, mammograms, or MRIs are recommended according to the Canadian Cancer Society guidelines. Breast implants do not generally impede the treatment of breast cancer. Breast implants are not felt to cause MS, ALS, Lupus, Rheumatoid Arthritis, Fibromyalgia, or any other chronic disease.

Can I breast feed if I have breast implants?

Breast augmentation patients who then get pregnant have an over 85% probability of breast feeding successfully.  The inability to breast feed after implantation may be related to factors other than the implants themselves.

Will I have to change my implants if I get pregnant?

Generally, patients who get pregnant after having breast augmentation experience a natural engorgement during the breast feeding phase but the breast tissue gradually shrinks back to pre-pregnancy size by 6 months after stopping breast feeding. The appearance of the augmented breast usually remains quite similar to before the pregnancy.  Rarely, involution of the glandular tissue after breast feeding may result in a desire to change out the implants for a larger size.

Generally, a procedure to simply increase or decrease the size of an implant is a relatively simple operation performed under local anesthesia. The removal of an implant is called explantation and the swapping out for a new breast implant is called re-implantation. The recovery from the explantation and re-implantation procedure with a smaller or larger implant is far simpler that the primary (first) breast implant surgery, with far less pain, swelling, and firmness and a rapid return to normal activities.

Over time, patients may occasionally experience ongoing loss of their natural breast tissue with a loss of the original upper pole fullness provided by the original breast augmentation. Alternatively, the skin of the inner cleavage or outer skin may thin with age and reveal more of the edges of the cohesive gel implantation. For these conditions, fat grafting of the breast tissue over the implants, or “over grafting,” can be a simple and successful solution to the loss of volume. Fat grafting to the breast can be performed under local anesthesia as an outpatient and shows very good long term survival. One of the advantages of “over grafting” of fat in the soft tissue of the breast over top of an implant is the increase of natural soft tissue coverage and the improvement in contour and shape from the donor sites, where the fat was taken.

Chronic illnesses like elevated high blood pressure, asthma, diabetes, lupus, rheumatoid arthritis, MS (multiple sclerosis), ALS (Amyletorphic lateral sclerosis), or a mental illness (depression, anxiety) mean you may not be a candidate for breast implantation surgery. However, if under control these disease processes may not be a contraindication to a breast augmentation procedure but a letter from your primary internal medicine specialist that clears you for breast augmentation will be required.

Breast implants, either saline salt-water filled or the cohesive “gummy bear” solid silicone cohesive gel breast implants come in round and teardrop shape.  In general, round breast implants provide the most natural and attractive shape for those individuals who have some loss of upper pole volume and some flattening of the upper pole projection following weight loss, age, breastfeeding or combinations of those physiologic processes.  Occasionally, individuals with very little glandular material may benefit from an anatomic teardrop-shaped breast implant and the 3-D VECTRA® imaging helps decide which shape is best for you.

Most breast augmentation complications are rare and can be corrected. The most common risk, is selecting a breast implant that is smaller than you really wanted and working with Dr. Mulholland, his surgical team, and the Vectra 3D breast imaging system should virtually eliminate the risk of not being happy with the implant size and projection that you select. There is a small risk of a small skin infection treated with an antibiotic, or a small collection of fluid in the pocket that may need to be drained. The most common breast implant related complications are hardening of the tissue around the breast implant, called capsular contracture, or softening and enlargement of the breast implant pocket, called pocket expansion. Both of these complications are usually easily managed with a revision breast procedure, often performed under local anesthesia as an outpatient.

The most common complication of breast augmentation surgery is a hardening around one or both of the implants, a process called capsular contracture. The risk of a capsular contracture is under 2% and if it occurs, the shape of the implant can become distorted and the breast hard and sore. The contracture or tightening is caused by an foreign body immune reaction of your system to the implant. The exact reason why the body reacts against one or both of the implants is unknown but the treatment is removal of the hardened capsule tissue and re-placement with a new implant. The capsule revision procedure, which removes the hardened capsule tissue and replaces the implant, is successful 95% of the time in correcting the hardness and returning the breast to a soft, natural feel, without pain. This procedure is called a capsulectomy or capsulotomy and the cost of the capsular contracture revision surgery is usually covered by the manufacturer if it occurs in the first 10 years. The implant pocket may actually become lax and may need to be tightened up with sutures to tighten the pocket.

The modern cohesive gel, smooth-shelled breast implant is very well tolerated by the human body and its immune system. Occasionally, about 1% of the time, the implant does not harden but quite the opposite occurs. The implant stretches the pocket out over time, enlarging the space and allowing the implant to move too much and too far. This pocket expansion can result in hypermobility of the implants and they can “flop around” too much and compromise the shape in certain positions (eg. the implant can tend to fall into the armpit when lying down). Alternatively, over time the implant can push the under-breast fold down, causing implant descent, lowering, and loss of the upper pole fullness with a “bottoming out” of the implant shape.  For these pocket expansion complications, a relatively simple revision procedure, called capsulorraphy or “tightening up of the pocket” using sutures is often the fix. This is NOT covered by the manufacturer of the implants, but is made affordable by Dr. Mulholland.

The most important way to ensure the breast implant scar is less visible, is to place it in a inconspicuous location. If the scar stays red, raised, or otherwise has not turned back close to your skin color, complimentary improvements in the scar are offered until the best possible scar characteristics are achieved. These scar treatments include: IPL laser, Pulsed Dye laser, injectable scar softening, recommendations on the best topical silicone strips, and bleaching hyperpigmented scars.

Most patients who have their breast augmentation with Dr. Mulholland find his surgical team extremely supportive and the pre-operative process with the VECTRA® 3-D imaging very informative.  Most patients are extremely happy with their breast augmentation procedures, with well over 95% happiness index, and the cohesive gel being the most commonly-selected breast implant. Most patients are extremely happy with the results of their procedure and the care and attention given by Dr. Mulholland and his SpaMedica breast augmentation team.

The results of a breast augmentation performed with a cohesive gel silicone breast implant, are designed to last the rest of your life.  If your breast augmentation was performed with a fat transplantation, there’s a natural loss of fat substance and volume as women age and there may be a loss of breast shape and volume over the 5-10 years following the fat grafting to the breasts.

Although there are no guarantees and warranties when it comes to the human body and the biology, there are two manufacturer warranties that greatly ease a breast implant patient’s concerns and provide “peace of mind.” First the manufacturer warranties the integrity of the device, meaning no fracturing or disruption in the implant for the rest of your life. What does this mean? If for any reason you sustain a fracture or rupture (they don’t leak) in your cohesive, gummy bear, breast implant at any point in your life, the company that makes them will cover the cost. Second, if you get hardening of your breast implant any time in the first 10 years after your breast implant surgery, the company will cover the cost of replacement.

There is no specific “in office” maintenance following your breast augmentation procedure, although it is recommended that a gentle massage is performed on a daily basis to keep the capsular collagen tissue soft and mobile and to feel for any suspicious breast lumps.  The cohesive gel implant brand of the breast augmentation procedure have devices (breast implants) that are warrantied for life and should never have to be replaced in patients with relatively normal activities of daily living, including golf, sleeping on your stomach, normal intimacy, and high impact sports.

SpaMedica has a tremendous reputation as a facility with good service, excellent care, and attention to detail.  By choosing Dr. Mulholland, you choose one of the most pre-eminent and recognized faces of plastic surgery, having spoken multiple times on Cityline, Breakfast Television, CBC The National, as well as numerous appearances on The Today Show and The Doctors in the United States.

Dr. Mulholland is one of the world’s leaders in aesthetic plastic surgery. He has been using the cohesive gel breast implants exclusively for over 10 years.  Dr. Mulholland has an excellent reputation amongst Toronto breast augmentation patients for delivering natural, beautiful breast augmentation results.