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Breast enlargement (Augmentation Mammoplasty)


  The enlargement of small breasts, also when the glandular tissue diminished due to pregnancy and breast feeding, or of breasts that developed asymmetrically is only possible with implanted material, with breast implants.
 
 
Ideal – aesthetic breast shapes after breast enlargement

The transplant of the patient’s own fat (so called lipofilling) is only good for solving smaller contour defects, or for a very small volume enlargement (in our opinion for not more than 100-150 ml volume increase per breast, and also this amount requires several sessions). Regarding our experiences the volume of a breast enlargement that can be reached by lipofilling suits only 5% of our patients, considering also that fat must not be filled into the glandular tissue, but only around it, underneath and above, into the fatty subcutaneous tissue under the skin of the breast. It is still unknown if the fat filled into the glandular tissue could cause tumors along the years. Therefore, for patients with breast tumors in the family, or with any benign positive radiological findings (cysts, benign tumors, the scary degeneration of the glandular tissue called mastopathy) we absolutely do not recommend a breast augmentation with these fat injections. On the other hand this method also requires general anesthesia.
After breast growing hormone therapies or taking various “breast grow pills” and products, the incidence of benign and malignant tumors, cysts and inflammations is very high, they mean an enormous risk, and the occasional problems related to breast implants are incomparably smaller to these.
 
In 2009 and 2010 several articles were published of breast augmentations performed by hyaluronic acid injections with a product called Macrolene. By 2011, after the initial enthusiasm this is barely performed, principally because the price of this procedure easily reaches the two-thirds of a breast augmentation with a breast implant, but the result can be hardly seen after 6-12 months, so to avoid the disappointment we do not recommend this. 

In our opinion, the ideal aesthetic result after a breast enlargement operation is properly spectacular and attractive, still looking natural, conforms to the chest form and anatomic conditions of the patient, and even under thorough inspection does not show the artificial signs of an “operated silicone breast”, so even in the worst case only its proportion to the slender waist, and not its form raises the suspicion. That is a good, which raises the question if the breast was operated, but obvious signs of this are not visible.
Certainly this depends on anatomic conditions, too. Risks can be kept minimal only with implants which are not unnaturally big. On each patient implants different in size, shape and type might give the ideal result. Choosing the implant, the primary view points are the chest, the original breast and pectoral muscle size, and their proportion to each other. The diameter of the ideal implant can be measured on the chest, and taking the further anatomical conditions in consideration the height can be determined from charts (and not by guessing), thereby the exact implant size will be selected. The most frequent methods of placing breast implants are by the submammary (in the breast fold), periareolar and axillary (through the armpit) incisions.


 
 
2 months old periareolar,    6 months old submammary    and    6 months old axillary
incisions on patients of optimal scar formation after breast augmentations from different approaches.


 
 
Scar after subglandular breast augmentation by splitting the ducts and the glandular tissue, performed by another plastic surgeon – this method carries numerous increased risks – we do not perform it this way.


 
 
On the same patient, the change of the position of the nipple and the submammary fold after breast augmentation, compared to the position of a birthmark (black line).
 

Each method has its relative advantages and disadvantages, undoubtedly after the axillary incision is the scar the less visible (often it can’t be found a half year later). The scar of the periareolar incision might be hardly noticeable (not always), but the method can’t be performed on everybody. The “tear drop” shape (anatomical) implants can be inserted only through a submammary incision, mostly under the glandular tissue, and this incision can never be disguised in an intimate situation. The so-called asymmetric implants (especially made for the left and for the right side) can be placed also from the same incision, their use we consider to be forced and we experienced more disadvantages than benefits with them. The use of the endoscope (a camera inserted through a small incision, providing an enlarged picture of the operation on the monitor) makes the axillary approach modern and safe.


 

Picture of endoscopic transaxillary breast enlargement


The breast enlargement through the navel is only possible with saline filled implants and because of the high risks of postoperative bleeding and capsular contracture we consider it as a dangerous and senseless method.

Breast implants can be placed subglandular (under the glandular tissue of the breast), or deeper, subfascial (under the fascia of the pectoral muscle – which is a sheet of connective tissue covering the muscle), and also submuscular (under the pectoral muscle). In aesthetic surgery the “submuscular” placement means that the pectoral muscle covers a larger or smaller proportion of the implant usually in the upper part and mostly inside. At the bottom outside there is no muscle coverage. Complete muscle coverage is only necessary in reconstructive surgeries (e.g. after breast amputation because of a tumour). For safer long term results, if it matches the characteristics of the patient, the submuscular placement of the implant should be preferred. In this case, in exchange for the disadvantage of the greater but not long lasting postoperative pain, advantages like smaller risk of capsular contracture and infections, more natural shape and touch without drooping can be expected. Unfortunately this can’t be performed in each case, especially when the pectoral muscle is strong, thick, and the patient desires a relatively high breast shape or has to do a heavy physical work. For such patients in our practice, since 2001 we do not place the implant simply under the gland, but we add one more layer to cover it, the fascia of the muscle (subfascial placement). Implants placed this way give a good result only if the patient has sufficient fatty tissue, because on a very thin patient breast contours might be pronounced. The operation must be planned individually for each patient, considering anatomical characteristics, work conditions and particular aesthetic expectations and it shouldn’t be performed for every patient after the same pattern.
 



Possibilities of breast implant placement


 
 
Sketch of submuscular (under the pectoral muscle) implant placement. Distinctly visible, that the outer part at the bottom of the implant is only covered by the gland even so, because of the anatomy of the muscle.



CAPSULAR CONTRACTURE

Usually the body creates a thin layer around the implant which can not be palpated. In pathological cases as the result of a defensive process around the foreign material a scarred, thick capsule develops, this is the capsular contracture. The extent of the capsular contracture and thereby the change of the breast shape and touch might be different. The plastic surgeons rate its’ outward shape on a scale of I-IV., where I. is the mildest, only a thin, not palpable layer is present, and IV. is stone-hard, painful, nearly dome-shaped, produced by a hard, scary capsule compressing the implant.
Factors reducing the risk of a capsular contracture are well known:
- quality of the surface and of the wall of the implant
- proper selection of the implant size
- fine and caring surgical technique
- expressively careful and high level selection of all materials in touch with the field of operation (the quality of rubber gloves of the surgeon, single use materials instead of resterilized, etc.)
- antibiotic prophylaxis
- suction drains (closed system, contained use) after the surgery, which can remove all blood and serom from the operation field safely
- narcosis, and not local anesthesia
- the use of special external taping, bra and banding already on the operation table
- early massaging by the patient as trained and instructed by us
- elimination of too early and too heavy training of the pectoral muscle (specially with weights) and physical activity
- avoiding sudden early hormonal changes after the surgery (pregnancy, changing birth control pills)
- reducing the possibility of infectious diseases before and after the operation (upper airway, gynecological or urological infections), or adequate antibiotic treatment of them on time

Certainly, most of the above raise the costs of the operation, but safety can be increased only this way. If in spite of all these a capsular contracture develops, its’ correction, which means the opening-splitting the capsule and reshaping the pocket of the implant if necessary, can be performed also from axillary approach, but this requires long years of training with endoscopic technique. The old, traditional, savage method of capsule cracking without an operation in narcosis is highly dangerous, and was out-of-date even 15 years ago, mainly causing implant rupture, bleeding, irregular forms, nowadays it counts as an obvious professional mistake.


 
 
Correction of capsular contracture and the wrong position of implants by endoscopic transaxillary operations. Implants didn’t have to be exchanged for new ones. Though this kind of operation does not overstrain the patient, it is technically very demanding. The cause for the condition requiring correction was a car accident on the 3rd postoperative week in the first case (upper left picture), and intense competition training (basketball) soon after the primary operation in the 2nd case (lower left picture). The results remained constant even years after the corrections (upper and lower pictures right), justifying that the problem didn’t originate from the implants, method or from the patient herself.




Correction of capsular contracture grade III. after multiple complications of a breast enlargement performed by ANOTHER SURGEON (upper pictures), with implant exchange, and capsule removal. Unfortunately we were forced to use the previous long scars under the breasts (lower pictures).



Comparison of ADVANTAGES and DISADVANTAGES at subglandular (or subfascial) and submuscular placed implants in AVERAGE built patients, with well chosen implant size

subglandular submuscular
advantage
disadvantage
advantage
disadvantage
- technically easier operation

- less postoperative discomfort for the patient
- sharp contour on a thin patient on the upper part

- the implant might droop if connective tissue is loose
- with an average or thin muscle the upper contour looks natural - more difficult operation, requires extensive experience

- in the first postop. days requires more intense analgesia
  - implant edges palpable on thin patients - implant edges not palpable on the average patient  
  - implants droop more-less with the time - implants don’t droop even after a longer period  
  - after a longer period the glandular tissue might become thin due to the pressure - the implant doesn’t press the gland directly, touches it only outside at the bottom  
  - higher risk for infections - lower risk for infections  
  - higher risk for capsular contracture - lower risk for capsular contracture  



Our procedures

Taking into consideration the above, in our practice, if there is no contraindication, we always use textured implants filled with cohesive gel, preferably placed under the muscle, which we can insert from any approach (axillary, periareolar, submammary) according to the wishes and characteristics of the patient. For a high degree of asymmetry we use the double shell (gel filled external and saline filled internal chambers), variable size implants with valve. If the pectoral muscle is too strong, the patient has a heavy sport or work activity and is not too thin, we rather place the implants under the fascia of the muscle.

In our opinion, the so called „tear drop” shape (anatomical) implants provide a real advantage only for a few patients. Their disadvantages are the harder touch, they can’t be inserted from transaxillary or from periareolar incisions, and in lying position of the patient where the breast should stretch out in a softer natural form, they remain in their original tear drop shape. We only offer them for patients with extreme thick pectoral muscle (body-builders) where the submuscular placement is not suitable, rather the subglandular placement from submammary approach, unfortunately with all of its’ disadvantages.
The so called „round” implants we use also have a tear drop shape in standing positions of the patient (if there is no capsular contracture around), and stretch out softly in lying position, therefore we think they give a more natural look (without capsular contracture) than the anatomical ones. In all cases you can see in our Before & After Gallery for breast enlargement we used “round” implants (but never the highest models available) and not the “tear drops”.

In our routine the ultrasonography and/or mammography is obligatory to avoid that a cyst, benign or malignant tumor will have been discovered only after breast augmentation. For these we offer the adequate professional and we can organize an appointment in short term. The operations are performed in narcosis, under the safety of a detailed medical check-up, prior examination by our anesthetist, and with the background of a private clinic, with one day stay and full board. It is necessary to wear a special taping (for 1 week), bra (for 1.5-2 months) and banding (for 2-4 weeks) after the surgery.

 
 
To keep the implants in the right position, we apply a so called “taping” immediately after the operation, already on the operation table. Its’ sizing depends on the dimensions of the chest and the size of the implants, and it stays on for 1 week. We never use the elastic banding, which compresses the chest, and is not only uncomfortable but mostly forces the implants in improper positions. The implants try to emerge from the pressure of the elastic banding always in a direction which descends, usually sideways. This is the most common cause for implants too far away from each other. Fully visible on the 1 week postop. picture is the fresh wound of the axillary incision, which we do not dress any more and the patient can wash the armpits.



Besides the taping above, the bra and the banding are also applied on the operation table. The banding has to stay on for 2-4 weeks, and the bra for ca. 2 months.


With submuscular implants the discomfort and distension which can be calmed by analgesics is greater than with subglandular or subfascial implants. In this case the proper training of the neck and shoulders is very important, which we show how to do. Our patients get a detailed list of instructions for the pre- and postoperative periods. For many years we have been using special sutures, which don’t even have to be removed, only their ends, thereby our scars are significantly more aesthetic and the discomfort is less. The small details of the end result (together with the natural process of softening) can be seen 2-3 months after the operation. With well placed implants, without complications (after appropriate time) breast feeding is possible just the same way as otherwise would be, according to the original conditions of the breast. With increasing time gaps, but for life we recommend regular control examinations, the cost for this is already included in the price of the operation of our patients. Pregnancies, breast feedings for more than 3-4 months, or significant changes in weight can impair the aesthetic result, but these can be corrected. We have several among our breast enlargement patients, whose star as a model or artist was rising due to the natural look of the result; some of our patients married and their husband never noticed that they had been operated, many of them had children and were breast feeding without problems.

Before & After Gallery

Frequently asked question: How big is the sagging (drooping) which can be corrected with breast implants without simultaneous mastopexy?
Unfortunately only a very small extent of it can be corrected by implants, most of the patients with sagging breasts hope for more, because they know that the mastopexy means more scars. If the margin of the areola reaches or exceeds the inframammary fold, there is no technique or implant size and shape, which would give a good result without a mastopexy. It changes individually, which scars are necessary for the mastopexy.
If the implants are placed under the glandular tissue of the sagging breasts without a mastopexy, they will droop even more in a very short time. If the implants are placed under the muscle, but also without mastopexy, then the implants will remain in a good position, but the breasts will be sagging underneath.
A much better result can be achieved by a breast enlargement with simultaneous mastopexy, than performing the same in two separate procedures.



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