Elevate Magazine, Summer 2003
There you are, standing in front of your full-length mirror, checking out how you look in last summer's bikini. It still looks good - so do you - but once again, you're wishing that you had a little more cleavage to fill out that skimpy top. If this scene sounds familiar, there's no surprise. Maybe it's because our breasts are such a unique part of our sense of femininity that make women so sensitive about their shape and size - and eager to achieve the perfect breast. According to the latest statistics from the American Society of Aesthetic Plastic Surgeons, 249 641 women in the U.S. alone had breast augmentation last year.
If you're considering this type of surgery, doing your research beforehand helps you to make an informed decision about what you want. We live in an age where information is readily at hand, via newspapers, magazines and the Internet. But in the end, if you make a decision to go ahead with the surgery, you can't always be sure what to expect. With that in mind, Elevate asked four Toronto-area plastic surgeons what the process for a patient would be, from first time they walked through the door for their initial appointment.
THE CONSULTATION According to Dr. William Middleton, who has been doing this type of surgery for over 15 years, there are two distinct groups of women who are interested in breast augmentation. "I'd say roughly two-thirds of the women I see are younger - in their twenties - are unhappy with the size of their breasts and the other third are older women whose breasts are sagging and have lost volume due to childbearing and breastfeeding."
During the initial consultation, his patients are shown an introductory video about breast implants. Made by the implant manufacturers, they cover the pros, cons and options of breast augmentation. Next they meet with Middleton, who wants to know everything - well almost everything - about them: what is their motivation, how big do they want to be, what is their breast history. "Most people have done a lot of research when they come in and are quite specific about what they want," says Middleton. "I also have a female member of my staff on hand - usually my scrub nurse - who is very experienced and can offer her opinion."
Dr. Mitchell Brown feels one of the most important things a surgeon can do in this initial meeting is to listen. "I want to know what their goals are and whether we can realistically achieve them. I want to determine who is a good candidate and who isn't." While the consultation is important for the patient to determine if they feel comfortable with the doctor, it is also important for the doctor to feel comfortable with the patient. "I will not do bizarre surgery," states Middleton firmly. "If someone wants to be large, large, large, I'm going to want to know why."
Physical restrictions can also make some one a less than ideal candidate. "You need a lot of information," says Mississauga plastic surgeon Michael Weinberg. "How old are they, what is their medical history, how many children have they had, do they want to breastfeed, do they work out? All these things are factors. For some younger women who still want to have a family, it may make more sense to wait until their breasts are in their final shape." Finally, if their breasts are very small and the breast tissue very thin, achieving the size they want may be unrealistic.
IMPLANTS AND INCISIONS Then it gets down to basics: what kind of implant will be best and how will it be inserted. Doctors - and patients - often have a preference and this is usually worked out between them. There are two basic types of implants: saline and cohesive silicone gel. There is also responsive silicone gel. Cohesive gel implants come in round and anatomical or tear-drop shape and are available in several different sizes that vary in projection and height. Saline implants are most commonly round, though they are also available in either a smooth or textured surface, though most cohesive silicone gel implants are textured.
While most doctors can - and do - work with different types of implants, they tend to have their favourites. "I like the cohesive silicone gel," says Brown. "It provides an excellent augmentation, especially for patients who are very thin. Cohesive gel implants provide a result that is natural and proportionate with the rest of the body." Conversely, Weinberg likes to work with the round saline implant. "If it works, why change. I've had excellent results with it over the years. Approximately 95 per cent of patients in Canada are still getting saline implants, so that's still everybody's first choice."
"After the type of implant has been chosen, then you have to determine whether to place it over or under the breast muscle," says Brown. If the patient has a very small amount of breast tissue, then the implant usually look better placed under the muscle. Many doctors prefer to put the saline implants under the muscle to minimize the risk of ripping - a possible complication, especially with saline implants.
The implant can be inserted via the areola (if there is no developed fold under the breast and the areola is large and darkly pigmented), the underarm (if the breast is full without a definite fold and the areola is light), or under the breast (if there is a lot of sagging with a well-developed fold). However, cohesive silicone gel implants cannot be inserted through the underarm because they are too large for these small incisions.
Weinberg favours a breast fold or a areola incision. "I find going through the underarm leaves the implants too high and there's not enough cleavage." As for implants he prefers the smooth saline. "I find the textured too thick and while the textured is supposed to cause less scarring, that's not been my personal experience."
Like Weinberg, Dr. Wayne Carman prefers the saline implants "because they allow me to use an underarm incision and I find the cohesive implants tend to feel a little stiff. The skin under the arm is very good for healing so the visibility of the scar is minimal. Once it's healed, it looks just like a small crease. I try to avoid leaving any sort of scar on the breast, if possible." That is another reason Carman prefers not to use the cohesive silicone gel, because he feels the incision is too large - over two inches - and leaves a visible scar on the breast.
The approach Middleton takes depends almost completely on the are and situation of his client. "With young women, I prefer to put a saline implant beneath the muscle, inserting the implant through the underarm. The main reason is to leave the nipple undisturbed in case the patient wants breastfeed when they have children." For older patients, who have already had their children, he usually opts for a cohesive silicone gel implant above the muscle that is inserted through the areola. "This implant, above the muscle is a very natural augmentation, and going through the areola allows me to get the best positioning." Middleton does not like inserting the implant through the fold under the breast. "If there is no droopiness, the scar can be very noticeable, especially if a keloid (thickened scar tissue) forms".
PRE-OP AND SURGERY As for implant size, this is determined at the pre-operative appointment. Patients will try on a bra, padded either with rice-filled baggies or with implants to see what they are happy with - and this helps them determine the final size. Some doctors suggest the patient bring pictures in to give them an idea of what that person really wants.
At this time, the patient is also given a list of specific instructions that patients should stick to if they want the best results. "Giving up smoking is really important," says Brown. "This will help the patient heal faster. And absolutely no crash diets." Other instructions include avoiding any blood thinners like aspirin or any drug containing ASA. (Always make sure you get a complete list of medications to avoid, both prescription and herbal).
The surgery itself usually takes just over an hour. The patient is given a general anesthetic and once the incision is made, the surgeon creates space for the implant. Saline implants are inserted without fluid inside them: the saline solution is added via a tube after the implants are placed. After a short period in recovery - usually 2 - 3 hours - the patient is free to go home. Breast augmentation is usually done on an out-patient basis.
However, Carman is an exception to this rule. "I routinely keep patients overnight. It can be a very uncomfortable night and I prefer to have a nurse watching them." Patients usually come back for a follow-up the day after surgery, so Carman feels he avoids having them make an extra trip because he sees them in the morning before they are released. "I have very few phone calls from patients who have problems afterwards and I think that is one of the reasons."
RECOVERY "Twenty-four hours after surgery, the breasts are bruised and swollen, and it's at least a month before they look good," says Middleton. According to Weinberg, if the implant is placed under the breast, recovery is faster and less painful than if it is placed under the muscle. "You'll be sore and tender for a while, but most people have a pretty standard recovery," he adds. The do's and don'ts are straightforward: limited physical activity for the first month, a compression or cotton sports bra to be worn for the first several weeks and, if you have had saline implants put in, massage exercises to prevent capsular contracture, which is when the pocket where the implant has been placed hardens, making a tight, uncomfortable capsule.
Aside from seeing their surgeon the day after, patients usually have two or more follow-up appointments, just to make sure that things are progressing properly and that there are no complications.
WHAT ARE THE RISKS? Complications are few and far between. "There can be excessive pain, but we rarely see this," says Brown. Patients are usually prescribed painkillers to take after their surgery and can manage any discomfort they might have.
Capsular contracture can be a problem, but Weinberg feels its occurrence is overstated. "It occurs in less than five per cent of cases and can be corrected with surgery," he says. Other complications may include a leaking or breast asymmetry. In both cases, a second surgery will be required to fix the problem.
"It is a very important when you are discussing this surgery to discuss the possible risks with your doctor," says Weinberg. "But this is a surgery with a very high success rate and, in my experience, women who have breast augmentation are usually very happy that they had it done."
Editorial source: Dr. Mitchell Brown, Sunnybrook and Women's College Health Sciences Centre, 416-323-6336
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