Breast Augmentation: Initial Evaluation
The key to a successful breast augmentation surgery lies in a thorough preoperative evaluation. In your medical history, Dr. Thomassen needs to know any risk factors you may have to surgery, including medical conditions like diabetes, bleeding disorders, liver disorders, and any heart or lung conditions. Any medications you take regularly, including steroids, anti-inflammatories, or homeopathic medications need to be reported as these could have an adverse effect on wound healing and bleeding. Any history of prior breast surgery is important to report as scarring from prior surgery may affect your results. A history of smoking is very important to report as this could adversely affect your wound healing as well. The use of controlled substances like opioids is also important to report as this could affect your response to anesthesia. Exercise history and habits are also important to discuss as larger implants could affect your ability to undertake some of these activities.
You will also be asked your current and desired breast size and the type of “look” you desire. Some women desire a very natural look that does not suggest an augmentation was performed. Other women desire a very voluptuous look.
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Breast Augmentation: Physical Exam
Dr. Thomassen will examine you to determine how best to undergo the surgery. Key information gathered in exam is your current size and amount of native breast volume, the symmetry of your breast volume and shape, and the size and symmetry of your nipple-areolar complex. Your breasts will be palpated as well as your axilla to ensure there are no suspicious masses. If you have noticed any nipple discharge, you may require a workup for galactorrhea, that includes testing for your thyroid function and prolactin levels, as well as other tests.
Your chest wall will also be evaluated for any asymmetries as well as your back to determine if any spinal curvature could affect the final result.
If you had prior breast implants and are considering a revision, the position of your current implants are evaluated as well as the degree of capsular contracture. This will determine if more involved procedure like a capsulectomy is required.
Measurements are taken of your chest width, pinch thickness, and skin stretch in order to determine the size of implants that will give you the best result. These measurements also help to determine if a breast lift is also necessary in addition to an augmentation to obtain the results you desire. The recommendations may be different in patients with significant stretch marks as the skin may not support a very large implant. Asymmetries are important to address as these can sometimes be exacerbated by an augmentation. Surgical techniques to correct asymmetries will need to be employed, for example a unilateral breast lift to correct ptosis on one side only.
Breast Augmentation: Implant Types
Breast implants come in many different sizes, shapes and textures and fills. The sizes are typically expressed in milliliters of fluid usually termed cc or cubic centimeters. Typical breast implants sizes are in the 275 cc to 400 cc range. Breast implant shapes range from flatter wider implants termed low profile, to more narrow and more projecting implants termed high profile. There are also round and shaped implants which need to be considered. Benefits of each will be discussed with you by Dr. Thomassen. Implants can be either smooth or textured and these are indicated in different situations. Finally, the fill of the implants can be of saline or silicone. In general saline implants are used in younger patients with substantial soft tissue cover where the implant fill will not be that palpable. There are advantages and disadvantages of each which will need to be discussed to determine the best type for you.
Breast Augmentation: Sizing
There are multiple ways in which to size a proper implant for a patient. There is no best method but employing a combination of measurements and trial and error will result in the right choice for you. Based on your chest width and skin stretch, an average implant size can be selected. Then, using implants to simulate your augmentation in the office can help you visualize your result. Digital imaging can also be performed or the use of sizing systems supplied by implant manufacturers.
There are some rules of thumb when selecting an implant. Implants should be chosen at a base width that is slightly under the current breast width. In thin women, 100 cc equals 1 cup size, so going up to 300 cc should get you in the C cup range. In larger chest walled women, 200 cc equals 1 cup size, so you should adjust accordingly. In general if unsure between two sizes, the larger option is generally selected as frequently in the postoperative period, a desire for a larger result is frequently expressed. When sizing for an implant, you should pay attention to the weight of the implant as well as the appearance over a fitted blouse to get an idea of the best choice for you.
In addition to the size of the implant, the approach and position of the implant needs to be decided on. Approaches include a small incision along the breast inframammary fold, a small incision along the areolar border, and an axillary incision. The position of the implant will also be determined and these include a subglandular position, subpectoral position, or dual plane position. Risks and benefits of each of these will be discussed and the proper approach and position for your body will be selected.
Breast Augmentation: Preoperative Testing
Standard preoperative testing is performed which consists of blood work. If you are healthy without any risks factors, you will not require a clearance evaluation by your primary care doctor.
Preoperative mammography is recommended for patients over 35 years of age or pts of any age with significant risk factors for breast cancer.
Breast Augmentation: Day of Surgery
Dr. Thomassen will go over the consent form with you to ensure you are in agreement with the procedure as well as the size of the implant chosen. Markings will be made on your skin to delineate your inframammary fold, the midline, and possibly the incision lines for the mastopexy if this is also planned.
The surgery for an augmentation alone will take between 1 hour to 1 ½ hours. It is typically done under general anesthesia. When you wake up, you will have a bra and some gauze in place and should be comfortable. You will be able to go home after you meet criteria for discharge. Dr. Thomassen will call you the evening of the surgery to ensure you are doing well. You should be comfortable with only the oral pain medication prescribed. Sometimes additional muscle relaxant is given in cases of a tight skin envelope over a large augmentation.
Breast Augmentation: Follow Up
Your first follow up with Dr. Thomassen will be in 1-2 days after surgery. You will have small steri strips or tapes along your incisions. These will be removed in your second visit. Your breast size will be larger in the first few weeks due to swelling.
Breast Augmentation: Postoperative Course
No strenuous exercise should be undertaken for 3 weeks after surgery. Light walking is fine.
You will be started on implant mobility excercises at 2-3 weeks after surgery. Implant mobility exercises are important for two reasons. First, they appear to be helpful in preventing capsular contracture. Second, as patients are able to stretch their tissues with the exercises, they are able to become comfortable more quickly.
You should wait at least 6 months to a year after surgery to undergo a mammogram if needed. Be sure to have the mammography center utilize compression or displacement (Eklund) techniques when doing the study so as not to damage the implant.
Breast Augmentation: Risks
Bleeding after surgery in the area around the implant can occur. Swelling of one side greater than the other and some bruising develop on the skin. It may be a surgical emergency so you should immediately contact Dr. Thomassen if this is noticed. It can occur as late as 2 weeks after surgery so limiting activity for this period is required.
Loss of sensation to the nipple and areola complex is a rare complication in breast augmentation. The nipple-areola complex is innervated by the lateral and anterior cutaneous branches of the third, fourth, and fifth intercostal nerves. The location of these nerves needs to be considered when performing a breast augmentation surgery as well as avoiding sharp dissection in certain areas.
Capsular contracture consists of a thick scar envelope that forms around an implant causing hardness of the implant to develop as well as possible displacement. It occurs at a rate of between 4.6% in the augmented breast. Several surgical techniques have been developed to reduce this risk substantially.
Infection risk after breast augmentation surgery is very rare. Appropriate antibiotics are given before the surgery and afterwards to cover the more common type of bacteria present on skin.
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