Information on Breast Implants from Our San Jose and San Francisco Bay Area Center

At An Enhanced You Cosmetic Surgery, Dr. Lowen works with each breast augmentation patient to understand her goals and help her make educated choices about her care. This individualized treatment planning approach makes it possible to decide the best incision placement and breast implants combination for her specific goals. Contact our San Jose area center, serving the entire San Francisco Bay Area, to learn more.

 

 

Choices of Surgical Approach

Every woman will have her own specific goals in having augmentation mammoplasty and our goal is to work with you to meet those goals. Since there is no one breast implant or one way to place breast implants that is right for every woman, we will help you learn exactly what your options are and what we think is the best approach based on your own specific desires and particular anatomy.

Since Dr. Lowen is experienced in all three incisional approaches and various styles of breast implants, he can offer the full range of options available today to patients at his San Jose area center.

It is usually unwise to be dogmatic about there only being one "right way" to do things, and this is as true in augmentation mammoplasty as it is in life. Should you be told that there is one best way to perform an augmentation or one type of implant that is best, we would say that this is not the case. If the surgeon is experienced in the use of all incisional approaches and types of breast implants, it is far more likely that the operation will be tailored to your specific needs.

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Choices of Incision Location

All incisions are precise, surgical wounds in the skin and as such must necessarily heal as a scar. The optimal outcome is healing with a thin, inconspicuous line, one that is barely noticeable except on close inspection. While this outcome is usually achieved, there is no way at present to predict which patients may heal with a less than optimal scar, despite careful surgical technique and gentle treatment of the skin.

Healing is affected by genetic factors over which we have insufficient knowledge and control to predict final appearance in any given individual. However, we do know how to create and suture incisions to accommodate the breast implants, and how to place them to make the scar as favorable as possible.

Wherever the incision is placed, favorable healing usually results in scar that is thin and barely detectable after the usual six to 12 months required for scars to mature. This means that if the ultimate goal is optimal breast shape, and if that shape may be best achieved by one or two but not all three of your incision location choices, the trade-off is usually well worth it.

 

The Inframammary Incisional Approach: Beneath the Breast

When there is sufficient breast tissue development, the lower border of the breast can be seen distinctly to meet the chest wall along a line of attachment that is called the inframammary fold. A larger, more developed breast may have a more defined fold than a smaller breast.

If the breast hangs down over the fold, an excellent location is provided for a well-hidden incision. The incision, properly placed, will only be visible lying down, not when looking at the breast from the front, and will be only slightly visible, if at all, when viewed from the side.

Even in a woman with little breast tissue, once some time has gone by, and the lower breast skin has stretched, the breast implants scar should be well hidden at the very lowest edge of the breast, and not visible when viewed from the front.

The scar is about 1.5 inches in length, is initially slightly raised, and gradually softens and flattens. Scar redness is normal for several months and gradually fades. No special treatment is needed to achieve optimal healing other than avoidance of sun exposure by use of sunscreen during the first six months.

The inframammary fold approach offers the most versatility in achieving specific improvement in breast shape. It allows direct surgical access underneath the breast and/or muscle, facilitating the correction of difficult breast problems including drooping, stretched out breasts, or breasts which are tightly constricted at their lower border.

When larger cup sizes are desired, the inframammary approach also offers more accuracy in pocket dissection to achieve optimum breast implant placement.

Textured breast implants may be placed by any incisional approach, so it is the nature of existing breast anatomy along with the patient's goals for change in breast shape and volume that most influence choice of the inframammary approach.

When there is no particular desire to change breast shape, and the desire for volume is moderate, any incisional approach can be used.

For those women who have a strong desire to achieve a specific shape using textured breast implants, those who want larger implants, or those who have difficult pre-existing problems to correct, the need for precise pocket dissection and implant placement influences the decision to choose the inframammary incision.

 

The Periareolar Incisional Approach: Around the Areola

The periareolar incision goes along the natural boundary between the pigmented areola and breast skin for half the circumference of the areola. In this position it usually heals as a thin, inconspicuous scar.

This incision technique requires that a tunnel be made through breast tissue to place the implant below the breast or pectoralis muscle. The width of the areola affects the length of the incision and thus the size of implant that can be placed through this approach.

The degree of injury to fine terminal branches of sensory nerves going to the nipple and lower breast skin is greater using the periareolar approach, so the risk of some degree of nipple or skin numbness is slightly increased. The sensation usually recovers as the nerves regenerate.

When the areola is large, or when there is a pre-existing periareolar scar, the periareolar incision is a suitable approach to breast augmentation and allows the precise pocket dissection and implant positioning needed to use larger breast implants or implants specifically designed to affect breast shape.

There is some evidence that the presence of bacteria in the breast pocket may be linked to hardening of the capsule surrounding the breast, also called capsular contracture. Since the periareolar incision goes through the breast tissue, and it is known that bacteria such as staph epidermidis are present in breast ducts, it is possible that there may be a slightly increased risk of infection or capsular contracture using the periareolar approach.

 

The Axillary Incisional Approach: Deepest Hollow of the Armpit

In the axillary approach the incision is placed high in the armpit off of the esthetic unit of the breast. There is no scar on the breast. A tunnel is made from the incision to the pectoralis muscle and a pocket is then made underneath the muscle.

Breast implants of any type may be placed through the axillary incision. Larger breast implants with an increase of two cup sizes may also be placed.

The axillary incision has a lower risk of sensation loss than the periareolar incision. The pocket is made entirely under breast tissue and muscle so there is no contact with breast ducts that may harbor bacteria.

Certain problems with breast shape, such as sagging of the breast and skin envelope below the inframammary fold or constriction of the lower half of the breast cannot be addressed well through the axillary incision, and are best approached by one of the other two incisions.

The axillary incision serves the needs of those women who want no visible scar on the breast and whose desires for changes in breast shape is within the range that can be achieved with this incision.

The final choice of incision will depend on your personal preference and an analysis of breast anatomy and specific needs and desires for changes in shape and size. We do not prefer any particular incision, but attempt to help you understand what can and cannot be achieved most predictably in our goal of creating the most natural-looking and attractive breast.

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Types of Implants Currently Available: Saline and Silicone-Gel Filled Implants

Types of Breast Implants Currently Available: Silicone Gel and Saline Filled Implants There has been a steady evolution and improvement in implant manufacturing and design such that the gel-filled and saline breast implants available today are greatly improved over previous generations. They are more durable, available in more shapes for specific augmentation needs, and have either smooth or textured surfaces.

The Food and Drug Administration (FDA) now allows silicone gel-filled implants as well as saline-filled breast implants for cosmetic augmentation. In addition to the information being provided here, we have appended FDA Information for Women Considering Saline-filled or Silicone Gel Breast Implants, an independent overview from the American Society of Plastic Surgeons with references to the medical literature, and further safety information from the Breast Implant Task Force. Further information can be obtained from the Institute of Medicine Report on the Safety of Silicone Implants.

It is in the nature of medical technology to gradually evolve. New implant filler materials and implant designs are being actively researched. We can expect these to gradually become available and widen our choices. This does not mean that today's breast implants will be obsolete. With currently available gel and saline implant technology, it is possible to achieve better results, with a much more natural-appearing breast than ever before.

Nevertheless, it is in the nature of breast implants that a woman might someday either want or need to have another procedure. The reasons for doing so include the following:

 

  • Simply a desire for a larger size. Since the size of the implant that can be initially placed in a woman with a tight skin envelope is limited, a larger size may be possible after the skin envelope has had time to expand.
  • Capsular contracture, or hardening of the breast that can occur due to thickening of the fibrous capsule around the implant. Should this occur, removal of the capsule is recommended whenever the capsule is firm enough to distort breast shape or position.
  • New implant development that offers a substantial gain in desired characteristics of durability, feel, or appearance.
  • Deflation of a saline-filled implant.

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Shell Surfaces

There are two types of shell surface available, smooth and textured. Textured shell breast implants do not have any advantages, in my experience over smooth implants. It has been claimed that there may be a smaller incidence of capsular contracture with textured implants. I have not seen any such difference. The risk of capsular contracture using the saline implants has been exceedingly low in my practice. As of this writing, there has been no known incidence of contracture in my patients during the four year period beginning in February, 2003, to early 2007.

Gel implants, now available since December, 2006, for first-time breast augmentation patients, might have a higher risk of capsular contracture. Historically, they did. But the implants used in the 1980’s were not the same as the very low gel bleed implants available today. They allowed more gel to migrate through the shell. Theoretically, this was a factor in triggering capsular contracture. It remains to be seen if smooth surfaced gel implants will have a higher incidence of capsular contracture in my practice, going forward. At this time, I would not recommend the use of textured implants for the purpose of decreasing the risk of capsular contracture, but would have no objection to using them at a patient’s request.

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Implant Shape

There are two shapes of breast implants available: the round implant, either textured or smooth, and the textured “anatomical” implant. The anatomical implant is teardrop shaped and designed to maintain its shape when a woman is in the upright position. It therefore does not collapse downward on itself, and does not fall to the bottom of the pocket as does the round implant. Although it provides control of upper pole fullness, unless the implant is chosen carefully to match the patient’s anatomy, it may appear too full in the upper part of the breast. This is more likely with larger implants and smaller initial breast sizes. In the United States, experience with textured anatomical implants for initial augmentation has been limited to saline implants. In Europe, a wide range of shaped, textured gel implants has been available.

Although patient satisfaction has been high in the women who have chosen textured anatomical implants, the demand for them has been minimal for the past several years. “Natural-ness” has been subjectively defined as a feminine, round full shape by my patients. Avoiding an “un-natural” look has been controlled by careful communication with my patients about desired size. Avoidance of excess lateral projection and/or excess upper pole roundness can be done by matching the patient’s anatomy to specific choices of implant size. Implants can also be chosen in three different widths, with increasingly narrower widths providing more projection for the same volume. Most women choose the moderate profile, smooth round implant.

Patients should be aware, however, that limitations and trade-offs occur with any implant in terms of too much visibility of the underlying implant shape or palpability of the edges of the implant when an overly large implant is used or very little fat or breast tissue is available to cover an implant. Fortunately, gel implants are now again available. Gel implants help greatly to minimize the problem of visible or palpable wrinkling in the lateral or inferior breast when women have little breast tissue to cover the implant. Change of previously implanted saline to gel implants helps greatly to resolve this problem.

Round breast implants that are not too large and not over-filled, and that are covered adequately by soft tissue in a breast without sagging, give a very soft and pleasing result. Most women seem to prefer this rounder look. Problems can occur over time as the skin envelope stretches out under the weight of large implants, weight gain and loss, or subsequent pregnancy. Implants that were initially held up in place by a tight skin envelope now descend on the chest and some upper pole fullness is lost. Saline implants may become more palpable or traction wrinkling or lateral palpability may increase. Use of gel implants cannot prevent stretching of the skin but a more naturally feel will be preserved.

Smooth, round breast implants move more naturally than textured anatomic implants.

Many women have definite preferences for either a round or anatomic implant. Over the past five years, I have noted that after having made their choice, 95 percent of patients who selected the round implant shape, and close to 100 percent of those who chose the anatomic shape are happy with their decision. The key to patient satisfaction is explaining that trade-offs occur with any of the current breast implants. During your consultation at our San Francisco Bay Area center, the trade-offs of palpability, mobility, and size limitations will be thoroughly discussed. This step usually helps patients make the decision that is right for them.

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Summary of Implant and Incision Options

The information below is an overview of the many options available to patients considering breast implants. These can be discussed more fully during your consultation at our Mountain View practice near San Jose.

 

Implants

If your goal is to achieve the most aesthetically-pleasing breast shape with the least risk of capsular contracture, an anatomically-shaped implant with a textured surface is most likely to meet your needs.

For women with sufficient breast and soft-tissue coverage, a desire for enlargement of two cup sizes or less, and who prefer a rounder, more globular breast appearance, round breast implants can be very satisfactory.

 

Incision

If your goal is to have no scar on the breast, the incision in the axilla is the least conspicuous location. Using sophisticated techniques of endoscopic surgery and special instruments, both precise pocket dissection and placement of breast implants can be achieved using a small axillary incision.

If you have a particular choice of incision location, it is usually possible to offer you that location. Since the choice of implant and incision location takes into account such factors as a tight or loose skin envelope, tissue coverage for the implant, and lower breast sagging or constriction, Dr. Lowen will advise you if the best result would be more predictably achieved with a different incision.

Dr. Lowen uses all incision locations routinely, so there is no best incision. If the goal of a natural-appearing and soft breast is obtained, the resulting scar, regardless of location, fades rapidly from attention. During your consultation, all of your options for type of breast implants, implant size, and incision location are open. Only after discussing all of the factors affecting you individually, will we jointly arrive at a final decision.

We have attempted to stress that the decision to have breast augmentation is a personal decision that any woman is entitled to make. Once that decision is made it is our goal to help you achieve the results you want: a natural appearing, soft, and esthetically pleasing breast. We want you to have a choice, and we want you to be informed.

We hope that the information we have provided will help you in your educational process. Since there is no one best implant or incision for every woman, researching breast augmentation can be a difficult task unless you are given a chance to examine and understand your choices. For more information on breast implants, contact our plastic surgery center serving San Jose and the entire San Francisco Bay Area today.

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For more information on breast implants, contact our San Jose area center serving the entire San Francisco Bay Area.