Breast Augmentation

Dr. Capella has a very large experience in breast augmentation. He has personally placed over 800 breast implants for cosmetic purposes.

The Breast Augmentation Implant

Several varieties of implants have been developed for breast augmentation over the last several decades. The implants in use today in the United States all have a silicone shell and are either saline filled or contain a silicon gel. In addition, the implants may have a surface that is smooth or textured and their shape may be either round or tear-drop. Dr. Capella’s preference for saline or silicon, smooth or textured and round or tear-drop shaped depends on a patient’s particular clinical scenario. Dr. Capella will have a very detailed and thorough discussion with you over these various options.

Breast Augmentation Incision
The technique of breast augmentation can be performed through a number of different incisions.

The three most common approaches are:

– inframammary, at the crease between the base of the breast and the chest wall

– axillary, through the armpit

– areola, at the junction between areola and the surrounding skin

Every plastic surgeon has their preference for incision and each approach has its benefits and disadvantages. Dr. Capella varies his choice of incision depending on the specific characteristics of the individual. To produce a pleasing appearing breast in augmentation surgery, a pocket below the breast must be created with very specific boundaries. In addition, through whatever incision is used, the patient’s privacy regarding the procedure should be preserved as well

Level of Breast Augmentation Implant Placement

In addition to several types of incisions and implants, there are also two possible locations for placement of the implant. The implant can placed beneath the breast tissue, but on top of the pectoralis muscle. The second more common method is to place the implant beneath the pectoralis muscle, between the pectoralis and the ribs. The advantages of placing the implant above the muscle are that it is less painful for the first few days and the appearance of the implanted breast matures faster. In addition, contraction of the pectoralis muscle, more noticeable in body-builders, has no effect on the appearance of the breast. The advantages of placing the implant under the muscle are several.

1.	It provides a more natural appearing breast with a better transition from the upper chest to the breast mound.
2.	The rates of scarring around the implant are significantly lower when the implant is placed beneath the muscle.
3.	The risk of visible ripples or folds in the implant envelope (a more common problem with saline than with silicone implants) is diminished because of the greater amount of the patient’s own tissue overlying the prosthesis.
4.	The ability to obtain an adequate mammogram is enhanced with placement under the muscle, as the mammogram technician is better able to separate the breast from the implant when the muscle is interposed.

With the exception of patients who are body builders, Dr. Capella recommends the subpectoral technique to his patients.

Breast Augmentation Consultation

At the initial consultation, Dr. Capella obtains a pertinent medical and family history, with a particular emphasis on breast issues. The timing of the most recent mammogram may be requested. He will also need to define the general goals and expectations of the patient. A focused physical examination will be performed. The doctor’s examination will address issues such as the size and symmetry of the patient’s breasts and chest wall, and whether sag is present, and if so how much. If the patient’s breasts are sagging, breast augmentation alone may not be satisfactory. In these cases, a procedure to lift the position of the nipple (mastopexy) may be combined with augmentation to achieve a satisfactory result. A difference in the size of women’s breasts or asymmetry is very common. It is common for a patient to require implants of a different volume to achieve greater symmetry.

The other important objective of the initial visit is for the patient to clearly relay her desires for size. While bra cup size is a widely used method for categorizing breast size, it is imprecise and subjective. Dr. Capella’s goal is to place the choice of implant size in the patient’s hands and to provide suggestions when he feels necessary. While several techniques exist for sizing implants for prospective patients, Dr. Capella prefers to review photographs of other women with similar sized breasts following augmentation with various sized implants. In this way, a more realistic image can be obtained about what your breasts would look like following augmentation. He may also have you place different sized implants over your breasts within a bra to help further define your desired breast size.

Breast Augmentation Pre-Operative Visit

You will meet with Dr. Capella approximately two weeks prior to the planned procedure. After the initial consultation, it is important that you have adequate time to reflect on the planned procedure in particular on issues of implant size. Scheduling surgery involves payment of a deposit. A period of at least two weeks off any medications containing aspirin, ibuprofen, vitamin E, or other medications that could adversely affect the ability of the blood clotting mechanism is required to prevent any bleeding complications. At this point, we require a consent form be signed for the procedure. The size of the implants to be placed is finalized. Photographs are taken. All questions relating to the surgery are answered in detail. The surgical fee is due in full at this time. Arrangements should be made for transportation for the day of surgery.

The Day of Breast Augmentation Surgery

The operation usually lasts from 1 to 1 and ½ hours. At the conclusion of the operation Dr. Capella will place dressings, a bra and a binder over the upper portions of the breasts. The function of the binder is to provide gentle downward pressure on the implants.

Patients usually remain in the recovery room for one to two hours before being discharged home.

Breast Augmentation Recovery Process

It is necessary that a responsible adult transport the patient to and from the surgical suite and be available for the first 24 hours following the procedure. Patients should anticipate some discomfort until the blood level of the narcotic pain medication reaches a therapeutic threshold. This may require a double dose of the pain medication for the first two to three doses, after which a single dose is usually sufficient to manage the discomfort. Most patients are off narcotic pain medication within 24 to 48 hours. Antibiotics are continued for 24 hours following the procedure to lower the risk of infection. Activity should be restricted to no lifting, pushing, pulling or driving for the first 48 hours although walking is encouraged. It is not advisable for patients to drive a motor vehicle until they have been off narcotic pain medication for 24 hours and they experience no restriction of upper extremity mobility, such as may be required in an avoidance maneuver with a car. The bra, dressings and binder may be removed 48 hours after surgery for showering. Water and mild soap can be used. The region of the areola should not be scrubbed. A small amount of oozing at the incision sites is to be expected. Following the shower, the surgical bra provided should be replaced as should the binder over the upper portion of the breasts.

Certain events should be reported to the office immediately. A temperature over 100.0 degrees, chills or sweats, a markedly different degree of swelling between sides, and/or increasing, rather than decreasing pain.

Patients are seen approximately one week after the operation. At this time, Dr. Capella may indicate that the upper pole breast binder is no longer necessary. Most patients can resume a reasonably normal level of activity within 3-5 days after surgery. Following your first visit to the office, you no longer will be required to wear the surgical bra provided by Dr. Capella. At this time, and for at least two months following the surgery, we suggest you wear a sports bra or other garment that does not provide upward pressure on the breasts. It is critical during the recovery period that the implants are allowed to settle. Some bras, especially those with underwires, do not allow this process to take place. Dr. Capella’s physician assistant will make suggestions for obtaining a sports bra. Some of the bras patients have found comfortable include: ·

	The Body Wrap #44610
·	Nike Inner Actives #281103
·	Warner-Friday’s Bra #02083 or #01058

It is not critical that you find one of these bras. There are many available that are satisfactory. Not wearing a bra at all until you find one suitable is preferable over wearing a bra with an underwire. Once again, here are some suggestions when looking for a postoperative bra:

·	No underwire bras
·	Buy the cup size you are going to be
·	Try on the bra before you buy-some bras run small
·	The color black is preferable

Implant Displacement Exercises

Implant displacement exercises may be started as early as two days after surgery. The technique is described below. The exercises are performed with greater frequency early on to displace the implant around the generous pocket, in an attempt to prevent the body from closing down the pocket and compressing the implant with a thick scar (capsular contracture-see below). While there is no scientific data to demonstrate that implant displacement exercises help prevent capsular contracture, some women report that their breasts resume a more normal feel sooner with these exercises.

Dr. Capella’s protocol for breast massage is as follows:

1.	Use your right hand to move your left breast implant and your left hand to move your right implant.
2.	Cup your breast on the bottom and lift straight up toward the collarbone. At first this should be done gently, but increase the force with which you displace the implant until you can move it up to the collarbone. Hold the position for 10 seconds in the up position.
3.	Next, cup the breast on the lateral, or outside, aspect and move it inward toward the breastbone. Hold it there for 10 seconds.
4.	Now do the opposite breast
5.	2-4 is one repetition. Do 10 repetitions to complete a set.
6.	Do a set of exercises every other hour while you are awake, for the first two weeks after you start them; after this, we recommend you do two sets a day for the rest of your life.

Risks of Breast Augmentation

1.	Bleeding (hematoma formation). Significant bleeding into the space around the implant can occur in this operation, although it is unusual. Large collections of blood around the implant require a return to the operating room for removal. Not doing so would produce an abnormal shape to the breast and a potential for hardening in the future.
2.	Infection. Some of the tissues of the breast normally contain bacteria and are likely to come in contact with the implant during augmentation surgery. All of our patients are placed on antibiotics during surgery and afterwards. The risk of infection is less than one percent.
3.	Loss of nipple sensation. Most patients experience some change in nipple sensation following augmentation surgery. The change may either be increased or decreased sensation and lasts several weeks. Nevertheless, the change is usually temporary. Permanent loss of sensation is unusual.
4.	Malposition of implants. Every effort is made to make the breasts appear as symmetrical as possible. This requires fine adjustments in implant placement. On occasion, a second procedure is required to achieve satisfactory symmetry. For further information about the possible risks of breast augmentation, click here.

Long Term Complications

1.	Capsular contracture (hardening of the breasts by the presence of scar compressing the implant). Every individual forms some scar around the implant. This is a normal response of the immune system to a foreign body. For not completely understood reasons, some individuals form thicker scars than others. A thick scar may distort the breast and even cause discomfort. The incidence of this problem is decreased with submuscular implant placement and is approximately 10%. When treatment is warranted, the scar is incised or removed and the implant is replaced.
2.	Interference with mammography. Implants interfere with the ability to image the breast by mammography to a variable extent. Implants placed behind the pectoralis muscle allow the breasts to be imaged more effectively by a method called the Eklund Technique. Using this technique, the presence of implants does not represent a statistically significant risk to the patient of missing an early breast cancer.
3.	Deflation. The incidence of saline implant leakage is approximately two percent in Dr. Capella’s practice. Today’s implants are better than a decade ago and so it is difficult to accurately predict what the true leakage rate is. It may actually be lower. In the event of implant deflation, saline (the solution of which 70% of our bodies are made) leaks into the surrounding tissues and is absorbed. A relatively brief, simple surgical procedure is required to remove the old implant and replace it with another. In the case of demonstrated saline implant leakage, the implant manufacturers provide a new implant at no charge for the lifetime of the implant and assist with the costs of anesthesia and the operating room for 10 years. Dr. Capella’s surgical coordinator will provide more details regarding implant warranties.
4.	Interference with breast-feeding. Although an interference with breast feeding following breast augmentation is extremely rare, it is possible that the breast gland ducts that empty the breast gland may be divided during breast augmentation and thus interfere with lactation. Additionally, the breasts may be too uncomfortable when engorged, and so lactation may be hindered in this way.
5.	Visible rippling. Individuals with small breasts who have had a large augmentation can be at risk for visible rippling of the overlying skin. This problem is much more common with textured implants and those placed above the pectoralis muscle.