For each body frame there is a range of proportionate breast sizes. Many women choose augmentation mammoplasty to better fit into clothing or replace volume lost following pregnancy and breast feeding. The ideal is to become proportionate with the desired volume and a natural appearance. Trying on “sizers” beforehand can help provide an objective picture of the size that looks right for you. The location of the incision, the placement of the implant on top of or beneath the pectoralis major muscle, and the type of implant, saline or silicone gel, depends upon your anatomy.
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Should your implant be silicone gel or saline filled? There are advantages and disadvantages to both. The withdrawal of the silicone gel filled implants by the FDA in 1992 scared many women. Unfortunately, when these implants were reapproved by the FDA in 2006 there wasn’t much publicity to address previous concerns. Microscopic amounts of silicone may always leak from intact implants and it is possible for implants to break. If a silicone gel implant breaks, in most instances the silicone remains within the capsule (the scar around the implant). Detection is difficult by physical exam or mammography and MRI, though more sensitive, is still not 100% accurate. It is also possible for silicone to leak outside of the capsule after implant breakage and form a palpable mass. If this occurs, the implant and implant material should be removed and may be replaced, sometimes under the manufacturer’s warranty. The advantage to silicone gel implants is their softness and natural feel.
By comparison, saline filled implants are significantly less expensive but they are firmer and more likely to have ripples. If a saline implants break there are less problems with detection and treatment. The implant breakage is apparent by the loss in breast volume. The body easily absorbs the saline.
Both silicone and saline implants of the current generation have a reported rupture rate of approximately 5% after ten years. The data for breakage rate at 20 or 30 years or longer is not yet available.
Should your implants be placed in the subglandular space [on top of the pectoralis major muscle] or in the submuscular space [behind that muscle]? The answer depends upon individual body makeup. Placement of implants in the subglandular pocket is less painful during the immediate post- op period and may also better fill out the skin if it is loose. If the implant is placed underneath the muscle there is more soft tissue coverage which can make the edges of the implant less visible near the neckline. With placement in the submuscular position there may be a decreased incidence of capsular contracture [tight scar around the implant that causes it to feel firm]. A thin woman with visible ribs may do better with submuscular implants while someone with more natural soft tissue may benefit more from subglandular placement.
What is the best location for an incision? Multiple incisions have been proposed for placement of breast implants. The most commonly used approach is to place the incision by the natural fold underneath the breast. This allows the surgeon direct access to the area, either subglandular or submuscular. This area is well hidden by the breast. Around the border of the areola is a second option. This requires an areola of sufficient size to fit the implant and works best when there is a distinct edge to the areola. Placement of the implant through an incision in the axilla [the armpit] places the scar away from the breast but may cause appearance concerns when wearing sleeveless clothing. It is also less commonly used because it increases the difficulty of the surgery. As a rule of thumb commonly performed procedures are more common because they are reasonably effective and reliable.
Can fat be transplanted to the breast area? Autologous fat grafting [transfer of your own fat cells to a new location] sounds appealing. We all seem to have some extra fat someplace that we would be happy to put to better use. In fact fat grafting has been attempted in one form or another for many years. Traditionally there was concern that if fat was transferred to the breast and cells did not survive then calcifications may form. There is a potential for calcifications to be confused with breast cancer on mammograms. There also needs to be adequate space to place the fat. The Brava is an external suction device that is placed over the breast for a period of time and is FDA approved to increase breast volume. The volume created, however, is commonly much less than what can be obtained with implants. Some physicians have combined using the Brava and fat grafting with survival of a reasonable volume of the fat. Currently this is “off label” use of the device [not approved by the FDA] unless done as part of an approved research protocol. Some surgeons remain skeptical of fat placement in the breast until larger, prospective, controlled studies have been performed to demonstrate the safety of the procedure.