BREAST IMPLANTS 101

 ONE HUNDRED AND ONE THINGS YOU SHOULD KNOW. ANSWERS TO THE MOST COMMONLY ASKED QUESTIONS.

TABLE OF CONTENTS

A.SALINE IMPLANTS

B. SILICONE IMPLANTS

 C.SHAPES OF IMPLANTS

D.SIZING

E.SCARS

F. SUBMUSCULAR VS. SUBGLANDULAR IMPLANTS

G. SUBFASCIAL IMPLANTS

H.SURGERY AND ANESTHESIA

I.RECOVERY

J.BRAS

K. EXPECTATIONS

L. COMPLICATIONS

M. SPECIAL BREAST PROBLEMS AND DEFORMITIES

1. What are saline breast implants?  A saline breast implant refers to the sac which forms the breast implant shell. These shells are made of a silicone elastomer which is like a very soft and pliable piece of soft rubber. These implants are inflated or filled with saline which is the same as physiologic water.

2.  What is the shell of saline implants made out of? The shell or lining of saline implants is made out of a special type of silicone elastomer. The shell is solid and comes in two forms, smooth and textured.

3. What are smooth breast implants? Smooth breast implants have a smooth surface just as the name states. These shells are thin and soft. Smooth breast implants have a greater tendency to move around in their pocket underneath the breast and more of a tendency to fall to the sides when you are lying on your back. Smooth walled implants have a lower rate of deflation than the textured implants maybe because the shell is thinner. Despite what one may think the thicker implant shell associated with the textured implants actually causes more rippling and consequently more shell fold fatigue which leads to breaks and leaks. The smooth implants may also feel more natural in some people.

4. What are textured breast implants? Textured breast implants have a textured surface. These shells are a little bit thicker than the smooth implants. They feel rougher to the touch when they are felt before they are implanted but are still extremely soft when they are implanted underneath the muscle. They have less of a tendency to move side to side within their breast pocket. Some surgeons feel they have less of tendency to form hard capsules, which are the scars that form around the implants. Textured breast implants are sometimes used to treat capsular contracture. They can also be used for primary augmentation. They can also be used in cases where primary augmentation and lifting is necessary. They however have a higher rate of deflation than the smooth walled implants.

5. Are saline implants safe? Yes, saline implants are safe. They have been safely used for breast enlargement for over 50 years.

6. How long have saline implants been around? Saline breast implants have been around for over 50 years.

7. What happens when a saline implant breaks? NOTHING! Don’t get me wrong, it is quite catastrophic psychologically when a breast implant deflates. However patients usually feel nothing although they notice that their breast is deflating or becoming smaller after a couple of days. Some patients report feeling a little warm in the area for a few days. The deflated implant either needs to be replaced or removed once it deflates. This is not a surgical emergency. It is not life threatening and can be done at your convenience, on an elective basis.

8. What is better saline or silicone implant? The choice of filler within the breast implant is really a matter of personal choice. They are both good implants. Rarely one type of implant may be more suitable for a patient but they are usually interchangeable. As a general rule the silicone implants are softer to the touch and the saline implants are firmer. When looking at an augmented breast it is visually hard to tell which implant is saline and which is silicone. Patients are equally happy with both products over many years of implantation. The silicone implants are a better choice for implantation for most patients if cost is not an issue.

9. What is rippling? Breast implants are usually round. These two circular components are brought together and hemmed or sealed at the edges, thus creating a sac or pocket.  This creates a space or pocket in-between the two sides for inflation. This pocket is now filled with either saline or silicone.  The redundancy at the edges where this seal is formed will manifest itself as folds, which visually looks like rippling, just like the rippling that you see in a body of water when you throw a rock into it. The larger the size of the implants, the more visible rippling one will see. The more breast and or muscle there are covering the implants the less visible this rippling will be. The manufacturers say there is less rippling with silicone implants and smooth walled implants. I am not sure that this is entirely true. Yes, the thicker shell of the textured implants is more palpable than the smooth walled implants in women who do not have much breast covering the implant. However the content of the shell, i.e., silicone vs. saline may not be as important as the manufacturer would like to lead you to believe.

10. What age do I have to be to get saline implants? The magic number is 18 years of age. You have to be a little older to get silicone implants, 22 years. There are some young girls who are having breast enlargement before the age of 18 years. This should only be done under very special circumstances and can only be done with parental consent.

11. What kind of guarantee do I get with saline implants? The manufacturers both have guarantees on their implants for deflation. Mentor Corporation which has been acquired by Johnson and Johnson guarantees their implant for lifetime. They will replace both of the implants and provide a very small stipend to pay for the surgical costs of replacement in the first ten years. Inamed which was formerly McGhan and is now owned by Allergan Corporation will only replace the deflated implant but has a lifetime guarantee. They also pay a small stipend for the surgical cost of replacement.  You can buy additional warranty with both companies that provide you with extra coverage. The new kid on the block is SIENTRA which also has a beautiful product and has a similar lifetime warranty. But they also now have a capsular contracture warranty for the first two years after implantation.

12.  How long does the saline implants last? They can last forever. There is a common misconception that the implants only last for 10 years or they have to be changed after 10 years. THAT IS NOT TRUE. There are many women who have breast implants in place for well over 10 years who are perfectly happy with them just as they are.

13. SILICONE IMPLANTS what are silicone implants? Silicone breast implants are filled with a liquid/gel form of silicone polymer. The round implants have a thinner type of silicone and the anatomic implants have a thicker type of silicone.This is also called the gummy bear implant. Their shell is similar to the saline implants.

14.  What is the shell of silicone implants made out of? The shell of the silicone implant is similar to that of the saline implant. It is made out of a solid very soft form of silicone elastomer.

15. Are silicone implants safe? Silicone breast implants were reapproved for implantation for cosmetic breast enlargement about 5 years ago. They have always been approved for reconstructive use, even when they were under investigation for cosmetic use. During the period of time that the silicone implants were under investigation, The FDA essentially found most if not all of the previous allegations about their safety concerns to be unfounded.

16.  How long have silicone implants been around? Around forty to fifty years.

17.  Why were silicone implants taken off the market? The FDA says this was done for safety concerns but what has always perplexed me is they were still allowed for use in breast reconstruction in women with breast cancer even while their investigations were ongoing.

18.  What happens when a silicone implant breaks? Silicone implants are not as easy to deal with surgically as the saline implants when they leak or rupture. The silicone is not absorbed by the body like saline. The good news is the silicone that is used in implants today is what the manufacturers call a cohesive gel. In simple terms, in a free state, or when this gel breaks out of the implant shell, the silicone still stays in a lumpy form and does not break down, disperse, or spread around in smaller particles. This gel and the ruptured implant however needs to be extracted within a limited timeframe.

19. What is better a saline implant or silicone implant? They are both very good products. You need to have an open discussion with your surgeon about which implant is better suited for your needs.

20.  What age do I have to be to get silicone implants? You have to have 22 years of age before you are allowed to get silicone breast implants.

21. Are the scars longer for silicone implants? YES, because silicone implants are prefilled you need a larger opening for implantation under the breast. However with the use of a special funnel which I use, these prefilled implants are placed through smaller incisions with facility.

22.  What kind of guarantee do I get with the silicone implants? The guarantee is the same as for the saline implants.

23.  What is a gummy bear implant? The gummy bear implants are a form of silicone implant. The difference is that the silicone gel in these implants is more cohesive and therefore more solid. Some people feel that if these implants break there is less spread of the silicone although this silicone does not spread anywhere but locally. They are more firm to the touch and also a little heavier.

24. SHAPES OF IMPLANTS how many shapes of implants are there? There are many different shaped implants on today’s market. WE have the low profile, moderate profile, moderate plus profile, high profile, and anatomic implants. All of the listed implants except the anatomic implants are round implants. The anatomic implants in simplest terms are longer than it is wide. It is most suitable for taller women with a long chest that can accommodate the longer length of this implant. They are also the more aesthetically natural looking implant. Typically as the profile of the implant increases so does the projection.
 
25.  What is a low profile implant? The low profile implant is a round implant that has the least amount of projection.

26. What is a moderate profile implant? Moderate profile implants have been used for the longest period of time. They have moderate projection and are the standard which projection of the other styles is compared to. These implants are the most natural appearing of the round implants.

27. What is a moderate plus profile implant? Moderated profile plus implants are round implants with more projection than the moderate profile implants. They are a very good option for the most natural appearing round silicone implants.

28.  What is a high profile implant? High profile implants have the maximum amount of projection. In my opinion, they are also the least natural appearing of all implant types. They are beautiful implants for the right patient. They are most suitable for breast reconstruction.

29. What is an adjustable implant? Like the name suggests, adjustable implant volumes can be altered after they are implanted. These implants have a remote port that is implanted in a subcutaneous pocket on the chest wall. It is accessed with a needle and inflated or deflated with a needle which is placed in the port. This needs to be done in a sterile fashion by your surgeon and cannot be done repeatedly because of the risk of infection.

30.  What is an anatomic implant? Because a natural looking breast except in some very young adolescents is more pear shaped than round the manufacturers developed an implant that is similar in shape. These anatomic implants are longer than they are wide simulating this pear shaped image when inflated. However round implants also achieve the same shape especially when one is standing because most of the weight or the fluid in the implant settles to the bottom because of gravity. The anatomic implant looks best in tall women with a very long torso. It is not suitable for all women. PLEASE NOTE THAT ALL ROUND IMPLANTS ESSENTIALY TAKE AN ANATOMIC SHAPE WHEN YOU ARE STANDING BECAUSE THE CONTENTS OF THE IMPLANT NATURALLY FLOW TO THE BASE OF THE IMPLANT BECAUSE OF THE EFFECT OF GRAVITY.

31.  Does my height affect the size of the implant? Yes taller women as a general rule will need larger implants to fill out their chests. They also do better with the anatomic implants.

32. Does my weight affect the size of breast implants? Heavier patients generally can carry and may need larger implants than thinner patients with the same height. However, the most important criteria for sizing of breast implants are the chest width and height.

33.  Does the width of my chest affect the size? Yes. The chest width is the most important criteria used to determine the implant best suited for your body. The other criteria that are uses in this evaluation and determination are the height, weight, and hip width of the patient.

34. What is cup size? The cups are the pockets on a bra that are used to hold the breasts in a more upright position. They usually have a letter denominating the size. The smallest is A and the progressively get larger with size B, C, D, DD and so on.

35.  Is there a standard on cup size? No, there is no standard on cup size. As all women have experienced, bra sizes from various manufacturers vary. In other words a C cup bra from one company does not fit the same as a C cup bra from a different brand.

36. Can cup size be used as a standard for breast enlargement? Since there is no standard for cup sizes and there is so much variance from brand to brand cup sizes are not a very accurate method for determining or discussing breast enlargement or sizing.

37. What size is right for me? The sizing of breast implants is a subjective matter with some science. The science is the measurement of the infra mammary crease and the amount of skin laxity. The rest is art and subject to many variables and individual taste. Therefore some variation is expected from one practitioner to another. Obviously, patient input is especially important when making this decision. As a general rule the smaller volume and size implants are used on shorter patients and the size and volume if the implants increase as the patients become taller.

38.  Can I pick my size? A surgeon who does this procedure regularly can pick a correct implant for you as long as you provide them with the right input regarding your wants and needs. THE SIZE OF THE IMPLANT NEEDS TO BE A MUTUAL DECISION BETWEEN WHAT YOU THE PATIENT WANTS AND WHAT THE SURGEON FEEL IS APPROPRIATE AND TECHNICALLY FEASIBLE AND SAFE. Computerized programs are notoriously misleading and inaccurate.

39. Can I be sized accurately by placing implants inside my bra? Not really! Remember when the surgery is done these implants are either placed underneath the muscle or underneath the breast. Thus they are subjected to some degree of compression. I do not use this method commonly for sizing but I am told by patients and other practitioners that one usually has to pick a larger in practice for the implantation during the surgical procedure than the size that fits in the bra. Adding to this uncertainty is the fact that there is no standard on cup sizes as we discussed previously.

40.  Can a computer generated image give me an exact size and picture of what I will look like after surgery? Computer generated images are a great sales tool but not very accurate in their depiction of a final result. Those practitioners who use this sales tool say that you need to know what size of implant to use for the computer generated image. Adding to this uncertainty is the added fact that many of these same practitioners end up changing the size of the implant during the actual surgery.

41. Should I pick larger implants or smaller implants? You need to pick the size that fits you. Smaller implants than the size that fits you will generally lead to discontent because you have undergone a significant expense and you may not look that much different or larger after the surgery. Unfortunately wanting and picking larger implants than the size that fits you is also not a great idea since all of the problems that go hand in hand with breast implantation are magnified.

42.  What size will I be after the surgery? If you are using the same manufacturer of bras before and after surgery you should expect to be one or more cup sizes larger depending on the volume of implant that is used. Most practitioners refuse to have a discussion regarding cup size because it is so inaccurate and subject to so many variables. The only accurate statement after breast enlargement regarding cup size is that the breasts will be a larger cup size.

43.  Will I have scars? Yes, you will have scars.

44.  Is the scar permanent? Yes, all scars are permanent. It is impossible to have surgery and not have a scar. However the scars are usually in a well concealed spot that are not as visible.

45.  What will the scars look like? It is impossible to tell you before surgery what the scars are going to look like. In the world of utopia where everything goes perfectly, the scars will be short, flat, and thin as a sharp pencil line. However depending on healing, they can be wide, dark, raised, irregular, and pink to a fleshy color. No surgeon tries to give their patient bad scar. I think if we could, we would all wish that the scars were invisible.

46. Where will the scars be located? There are a number of locations where the incisions for breast enlargement are placed. The infra mammary crease which is the crease between where the breast meets the chest wall is one location. Another is the peri areolar incision which is the junction between the areola or the dark portion of the skin which surrounds the nipple and the native breast skin. The peri areolar location usually gives very nice scars for many reasons. The skin in this area is thinner than the skin of the chest wall where the infra mammary scars are placed. The thinner skin usually makes a better scar. The scar is also well camouflaged by its location in between the darker areolar skin and the lighter breast skin. Another location is the axillary incision. This incision and scar is located in a natural crease in the hairy portion of the arm pit. This scar is the least visible of all. However this surgery is harder to perform because of its remote location to the breast. It can also be performed using an endoscope. Breast enlargement is also done using a tunneling technique through the belly button. THE INFRA MAMMARY SCAR IS BELIEVED TO BE THE BEST INCISION SINCE IT HAS THE LOWEST INCIDENCE OF CAPSULAR CONTRACTURE ASSOCIATED WITH THIS APPROACH. 

47.  What is sub muscular breast enlargement? During sub muscular breast enlargement the implant is placed underneath the large muscle of the chest which is called the pectoralis major. The lower and most dependEnt portion of the implant are still sub glandular or only covered by breast and skin, in the sub muscular breast enlargement. However, the upper portion of the implant in covered by the muscle, breast, and skin. This type of placement may provide better long term results and less of chance for symptomatic capsular contracture. Also since there is more padding over the upper portion of the breast the defects in the implants such as rippling are less visible, especially as time passes and the breasts atrophy, lose substance and volume.

48.  What is sub glandular breast enlargement? The implants are placed underneath the breast and over the large muscle of the chest called the pectoralis major with this procedure. The breasts look fantastic but probably for a shorter period of time. Mammograms may be a little more difficult to do and to read. There is less coverage over the surface of the implant therefore the defects in the implant are more visible. Rippling is much more visible because of the thinner coverage over the surface of the implant. There is a higher likelihood of developing symptomatic capsular contracture that will require treatment. Silicone implants are probably a better choice for this type or sub glandular implantation.

49.  What is the muscle that the implant is placed under? The name of this muscle is the pectoralis major which is the broad and large flat muscle of the chest. This muscle helps with the rotation and motion of the shoulder.

50.  When should I have sub muscular enlargement? I feel that sub muscular breast augmentation is the better placement for most patients. However this is something that you should discuss with your surgeon.  

51. When should I have sub glandular enlargement?  Most plastic surgeons feel that this procedure is best for patients with pseudo ptosis. As the name suggests, breasts with pseudo ptosis have the false appearance of being ptotic or drooping and are in need of volume augmentation only. It may also be a better choice for body builders since the pectoral muscle is not divided.

52. WHAT DO I HAVE TO DO TO PREPARE FOR THE SURGERY? All patients planning to have any kind of surgery need to be fully evaluated and cleared by a primary care physician. A few simple blood tests including a blood count, urinalysis and pregnancy test are absolutely necessary. Your surgeon may want additional tests depending on your needs.

53.  WHAT KIND OF TESTS DO I NEED BEFORE THE SURGERY?  A CBC or complete blood count is necessary to make sure you are not anemic. This means your blood count is high enough so your surgery and recovery will be without any problems. The urinalysis is to make sure there is no infectious process going on inside of your body. There is a small chance that the implants could become seeded with the bacteria in the urine if there is a urinary tract infection. This would mean that the implants would have to be removed. Finally the pregnancy test is to make sure that we are only operating on one person. If you are pregnant the surgery should be cancelled until the pregnancy is terminated or well after the baby is born. Other tests some surgeons may require are blood chemistry, bleeding and coagulation/clotting times, an electrocardiogram of the heart, a chest x-ray and mammograms depending on your age.

54. DO I NEED A MAMOGRAM BEFORE THE SURGERY? Depending on your age and previous family medical history mammograms may be necessary.  All women over the age of forty need annual mammograms. This should be done at an earlier age if there is a family history of breast cancer.

55.  CAN I HAVE THE SURGERY IF I AM PREGNANT? No. Surgeons don’t like operating on two people at the same time!

56.  CAN I HAVE THE SURGERY IF I HAVE A URINARY TRACT INFECTION? NO. The bacteria in the bladder can seed the breast implant with bacteria and cause the implant to become infected. This will necessitate removal of the implants.                                      

57. WHO DO I SEE TO GET A MEDICAL CLEARANCE? A medical clearance consists of a medical examination by your primary care physician including an evaluation of your blood tests.

58.  Can I have surgery with local anesthesia? Not recommended. I guess it can be done but it will be difficult for the surgeon and very uncomfortable for the patient

59.  Can I have surgery with twilight anesthesia? Yes, twilight anesthesia which is a combination of local anesthesia used to numb the operative site and intravenous medications which are a combination of sedatives, anesthetics, and narcotics which will make you more comfortable during the surgery. Versed, Diprivan, and Fentanyl are combination of drugs that are used most frequently. Some form of inhalational gas is also used. This is also referred to as MAC or monitored anesthesia care. The more comfortable you are during the surgery, the easier it will be for the surgeon to do a good job.

60.  Can I have surgery with general anesthesia? This is how this procedure is done most commonly. A combination of anesthetic gases and intravenous medications plus local anesthesia is used to make you most comfortable during the surgery and after. General anesthesia today is very safely done in a controlled setting like an accredited operating facility found in most plastic surgery practices. Intubation which actually means the airway is inserted into the trachea or the passageway which we use to normally breathe is rarely used. Using a LMA or laryngeal mask airway which is a breathing apparatus that is placed in the back of the throat, a combination of oxygen and anesthetic gases are then passed through this tube to the lungs. These gases in turn keep you comfortable and safe while the surgery is done. Today most practices use a LMA or a laryngeal mask airway which is a tube with a component attached to it that fits in the back of the throat and mouth. This LMA forms a tight seal and allows the oxygen and gases to also be passed through the airway and to the lungs without actually placing the tube in the trachea. It can be safely done by a trained anesthetist who is in charge and responsible for your airway during the procedure. 

61. What kind of anesthesia is best? I think the LMA/GENERAL anesthesia is the best combination for the patient and the surgeon. However this is a discussion you should have with your surgeon prior to the surgery.

62. Will I be nauseous and throw up after surgery? Nausea and vomiting after surgery is usually a direct result of how the anesthesia is administered, what kind of drugs are used for pain control and what kind of medications are used to prevent the nausea , vomiting after anesthesia. Diprivan/Propofol which is the most commonly use drug used to induce anesthesia today is actually a very powerful anti emetic and is very helpful in reducing the post operative nausea and vomiting. The dosage of narcotics used and the individual reaction to these narcotics are the most important factors determining your nausea and vomiting after surgery. Minimizing the amount of narcotics during the surgery will reduce the post op nausea and vomiting. The use of other medications is also helpful. Zofran also known as Ondansetron which is a powerful antiemetic initially used to treat nausea and vomiting in patients having chemotherapy is now also used for elective surgery and is usually administered intravenously. This drug is also available as pills and can be taken after the surgery if the nausea and vomiting persists. Some surgeons like to use scopolamine for post op nausea and vomiting. After surgery the earlier you stop the use of narcotics and start Motrin/Ibuprofen and Tylenol/Acetaminophen the less nausea and vomiting you will have.

63. How long will the surgery last? This can vary depending on the surgeon but the surgery usually takes anywhere from one and one half to two and one half hours.

64. What kind of facility will the surgery be done at? Most of these procedures are safely done in an office based ambulatory surgery facility. Much less commonly they are done in the hospital setting.

65. Does the surgery have to be done in the hospital? No, the surgery is safely and well done in an ambulatory office based surgery facility.

66. What is an accredited office based surgery facility? These are offices that have functioning operating room suites/facilities. These units have undergone a rigorous process of accreditation and have to maintain certain standards in order to remain accredited. They are equivalent to hospitals in terms of what they have to offer for ambulatory surgery. In many ways they are better because the only person sometimes being taken care of in the facility at one time is only you. Therefore all of the resources of the unit are solely devoted to your care.

67. Are anesthetic gases used for anesthesia? If the surgery is done with LMA/GENERAL anesthesia anesthetic gases are used. The newer generation gases such as sevoforane and others are very short acting meaning they take effect quickly and wear off just as fast when they are stopped. Some of these gases only take minutes to wear off allowing you to recover and leave the ambulatory surgical facility in a very short period of time.

68.  How long will I be in the recovery room after surgery? This will vary depending on the surgeon and the anesthesia. Most of the medications that are used for anesthesia should be worn off within one half hour to at most 2 hours. When you are fully awake , ambulating and have gone to the bathroom and voided, you should be OK to be discharged home with the accompaniment of someone responsible who will stay with you at least for the first 24 hours. This allows you to recover fully and adjust yourself to the new you.

69. Will there be swelling after the surgery? There is swelling after any kind of surgery. The degree of swelling will vary person to person. You should expect 30-40% of the swelling to go down by 3-4 weeks and another 30-40% to go away by 3-4 months. The remainder may take longer, up to 9 months or one year to resolve.

70. When will I know the swelling is gone? The swelling manifests itself in many ways. Fullness in the upper pole of the breast or upper chest immediately after surgery is usually due to swelling. The areola is also usually tight and shining after the surgery. This also usually means that there is swelling in the breasts. You should expect some degree of bruising after the surgery. This will take up to 3 weeks to resolve. If there is bruising there is swelling.

71. Are my breasts going to be bandaged after the surgery? Some surgeons bandage the breasts in wraps and some use bras or compressive bras after the surgery. This will vary depending on individual surgeon preferences. There is no one option that is best. Sometimes the surgeon may alter his choice of bandages and dressings depending on what was done during the surgery.

72.  Will I have pain after the surgery? Yes. But this will be well controlled either with the use of pain pumps, local anesthesia, narcotics, muscle relaxants, motrin, tylenol or a combination of all of these. Your surgeon should be able to find you a combination of medications that keeps you very comfortable after the surgery.

73. How long will the pain last? Pain is a very individual type of reaction to trauma or surgery. Some patients have a high tolerance to pain and others have a lower tolerance to the same type of surgery. As a general rule I tell my patients that 40-50% of the pain will resolve within one week after surgery. The other 30-40% will resolve by the end of the second week and the remainder will be gone by 3 weeks.

74.  Will I get pain medication and what kind of pain medication will I get? There are many different medications available; they are a combination or non narcotic pain medications such as Tylenol/acetaminophen or aspirin and a narcotic. They are known by a variety of names including Percodan, Percocet, Tylenol with codeine called Tylenol #1, #2, Or #3 which describes the amount of codeine in the tablet. As the numbers increase so does the concentration of codeine in the tablet. Other medications include Dilaudid and Vicodin.

75.  Will I get any other medications? Yes, most surgeons use a combination of medications including muscle relaxants, anti anxiety medications, anti nausea and vomiting medications and antibiotics.

76. Will I get muscle relaxants? Muscle relaxants are especially helpful after the sub muscular type of breast enlargement. The muscle goes into spasm after the surgery and needs time to accommodate to the new volume and pressure caused by the implants. Muscle relaxants relax the pectoralis major muscle and help reduce the pressure type of pain after the surgery. I sometimes recommend to the patients who are especially sensitive to the narcotics and have a lot of nausea and vomiting to stop the narcotics and just take the muscle relaxants with Tylenol or Motrin. This combination seems to work very well also.

77.  Will I get a medication for nausea and vomiting?  You may get Zofran or ondansetron or scopolamine if you are sensitive to the narcotics. Reducing the amount of narcotics you are taking may be the better first step if there is a lot of nausea and vomiting. If the higher dose is necessary for pain control then another medication or a combination of medications may be necessary.

78. Will I get antibiotics in the operating room? Yes, since breast implants are a foreign body it is recommended that antibiotics are used prior to the incision during surgery. The use of antibiotics after the surgery is not uniform. If one were to go strictly by medical teaching, this procedure is considered a clean case, and therefore, there is no need for post operative antibiotics. However most surgeons use these pills for a short period immediately after the surgery. HOWEVER RECENT STUDIES SHOW LOWER INCIDENCE OF CAPSULAR CONTRACTURE WITH THE USE OF POST OPERATIVE ANTIBIOTICS SINCE THIS MAY REDUCE THE DEVELOPMENT OF BIOFILMS.

79. Do I need to get antibiotics after surgery? No it is not absolutely necessary. The only time that this is necessary is right before the surgical incision is made in the operating room.

80.  How long do I need to take antibiotics? Strictly medically speaking you do not need antibiotics after this procedure. However most surgeons use them for a short period of time. You should not need the antibiotics for over one week. However this may vary depending on your recovery and individual surgical needs.

81. Will I get constipated after the surgery? Yes, the pain medications or narcotics have a tendency to cause constipation. You should supplement your diet with spinach, raisins, prunes and prune juice during this time. If you prefer medications you may take some stool softeners also.

82. How much time do I need to take off from work? This is also quite varied and depends on the individual and what kind of work they do. You will be sore and your chest will feel tight after the surgery. The ability to work depends really on what kind of work you are doing and how much pain and other medication you are taking. I ask patients to refrain from any physical activity for the first 3 weeks after surgery. Your judgment and cognitive abilities will be limited when you are taking narcotics. Therefore you can probably resume office work when you are off your medications.

83. When can I drive after surgery? You should not be driving when you are on narcotics or other medication that affects your sensorium. It will also be hard for you to steer a vehicle or make a sudden turn if necessary when your chest is hurting. Staying away from driving for one to three weeks after surgery is probably a very good and safe idea.

84.  When can I resume exercise after breast augmentation surgery? Once you are off narcotics you can resume exercise. Again balance is an issue if you are on medications and you may fall or injure yourself. I would refrain from weight lifting for the first three weeks. Any lower body exercise and aerobics are good. Start slow since you will find your stamina will not be the same as before the surgery. This will improve quickly as you recover. Exercise and activity are good. The worst thing you can do after surgery is to lie around in bed.

85.  When can I wear a bra? Some surgeons place you in a surgical bra immediately after the surgery. You can
continue in this kind of bra or a sports bra for the first few months. Bra shopping after this surgery is always something all women look forward to. Find yourself a bra that is comfortable and not tight.

86.  Do I have to wear a surgical bra? No, you can wear a sports bra also or any bra that is soft and comfortable.

87.  When can I go shopping for a bra? You can comfortably wear any bra about 3 weeks after surgery. Probably 40-50% of your swelling has also resolved by this time. Your bra size will not change significantly after this point in time.

88.  What happens if I don’t wear a bra? Some patients are very comfortable not wearing any support after surgery. I think it is important to wear support in the immediate phase since you don’t want the weight of the implants placing a strain on the suture line. After the first couple of weeks anything goes. But you need to remember breast with or without implants need support otherwise the skin will stretch and they will drop with time. They will drop with time anyway, but they will drop faster without the support.

89. Are both of my breasts going to look the exact same after surgery? Probably less than .1% of the population has breasts that are symmetrical. Most women have breasts that are similar but not perfectly the same. One side is usually larger than the other side. Therefore you should expect that small degree of asymmetry to persist after the surgery. The good news is that when the breasts are enlarged the proportion of asymmetry relative to the size becomes less and therefore these differences are less visible. Some surgeons try to adjust volume to correct for these disproportions. Others may use different sizes in implants. I am not sure how helpful either of these techniques is. I personally do not like the idea of using different sizes in implant on opposite sides. The size of the implant is determined by the base diameter of the implant. Visually 2 implants with different base diameters will usually look different.

90. How much bigger is my breast going to be? Very unscientifically speaking every 100-200cc. of volume will correspond to one or more increase in cup volume. However this number changes significantly the larger the size and volume of the implant. Also adding to this uncertainty is the shape of the implant, since the different shaped implants change sizing in varying ways. As I have said before since there is no standard on cup size it is impossible to standardize the amount by which size will increase using cup size as the parameter.

91. Am I going to have cleavage after surgery? Cleavage is created by the bra and not by implants. However, you will have the volume to create the cleavage with your bra after the breast enlargement.

92. Are my breasts going to drop with age? Breast enlargement does not slow down the natural process of breast aging. With age, the retaining ligaments of the breast lose their integrity and the breasts start to drop. The skin also loses its elasticity and contributes to the ptosis. Normally with the aging process the relative volume of breast tissue to fat volume decreases. I n other words as you age more of the breast will be composed of fat and less glandular breast.

93. What happens with pregnancy? Pregnancy does not affect breast implants. Your breasts will undergo the changes they were going to have without implants

94. What happens if I want to breast feed? You should be able to breast feed normally with implants especially if the implants are in the sub muscular position.

95. I want perky breasts, am I going to have them? Your breasts are going to be larger, fuller, and firmer. The degree is impossible to quantify. The shape of the implant, moderate, moderate plus or high profile determines a lot of this post operative appearance.

96. What kinds of problems are possible immediately after surgery? The most common problem after this type of surgery is having no problem. Smokers, especially heavy smokers may have problems with healing of the incision. Sometimes, the dissolvable deep sutures dissolve and are absorbed incompletely and come to the surface. They may need to be removed and once this is done the incision heals without a problem. Even less common are problems with bleeding and or infection. These require additional procedures and may result in loss of the implant and the need to redo the operation again at a later time.

97. What can cause short term pain after surgery? Pain is a very individual feeling. Some people will have a considerably greater amount of discomfort than others who have had the exact same procedure done. In other words pain tolerance is very hard to differentiate and quantitate. Some of the problems one can have after surgery including bleeding and infection may manifest itself as pain. Early capsular contracture may also be a cause. Sometimes a return to too much activity with the upper extremity or lifting and carrying of heavy objects early after surgery can cause pain. And sometimes the pain is just a sign of healing within the body. As the pocket within which the implant has been placed heals it forms scar around the implant. This scar is called a capsule and this is totally normal healing. I start an early massage schedule at this time and this actually will help keep the implants soft and will ameliorate the pain also. 

98. Can I have long term pain after surgery? Most patients who have breast enlargement are very happy and without pain. Long term pain is usually a sign of capsular contracture. There is a medication which may help reduce this but there are no real data to support long term or even short term use of this medication. Early capsular contracture can be helped with aggressive massage schedule. If the implants are large for your frame the pressure from the expansion may cause pain. Sometimes replacement with a smaller implants my help. If the implant is in a sub glandular position changing the location of the pocket may help. Some surgeons believe that an exchange of a smooth implant which has formed a capsule with a textured implant may alleviate the pain. The other option is to exchange them for silicone implants. Do not be mistaken into believing that silicone implants do not cause capsular contracture. They may follow the same course of history as the saline implants. In rare occasions the implants may actually have to be removed.

99.  Can I get hardening of my breasts? Yes, but this is not very common. This is usually due to capsular contracture.

100.  Can the breast implants break? Just like any other manufactured product breast implants also have a limited lifetime. They do break with normal wear and tear. That time frame is however very variable. I have seen these implants break after one year and I have also seen them to stay intact for over 25 years. The manufacturers have limited warranties on their products. One company guarantees their implants for leaks for 10 years with a better coverage plan. They will replace both implants and pay for a part of the surgical cost of replacement. Another company provides a lifetime warranty but will only replace the ruptured implant and pay for the part of the surgical cost. Additional coverage can also be purchased from both companies.

101. What happens if my saline breast implants break? Nothing will happen that will harm you. The implants are filled with saline which is physiologic water. The water is fully absorbed with no consequences to your health. The breast will however be deflated and will need surgery either to replace the implant with a new one or to remove both implants.

102. What happens if my silicone breast implants break? Unlike saline implants which deflate when they break the silicone implants do not deflate. It can therefore be harder to determine if the silicone implants have leaked or broken. Sometimes it is easy to determine just by physical examination, and then confirmed with a CAT scan or MRI. Leaking or ruptured silicone implants have to be removed. They can be replaced. Other options include a capsulectomy, or removal of the scar around the implant, with no replacement and leaving the breasts as they are without the implants, or some sort of breast lift with or without replacement implants.

103. Are my implants guaranteed if they break? Yes, the guarantee is provided by the manufacturer.

104. What do I do when I need a mammogram? Your schedule for mammograms should be unchanged with or without the implants. The recommendation id to start yearly mammograms at the age of forty. Women with family history of breast cancer should start at an earlier age. The presence of sub muscular implants does not make mammography or the visualization of the breasts any harder and does not change the ability of the radiologist to detect breast cancer or other changes within the breast.

105. Can I get a mammogram after surgery? Yes, this process is called xeromammography. All centers which perform mammography are able to perform these tests on women with breast implants without any issues.

106.  Can I get a cat scan after surgery? Yes. There is no metal in the implants and therefore they will not cause any distortion of the pictures with the CAT  scan

107.  Can I get a MRI after surgery? Yes. There is no metal in the implants and therefore there will be no problems with the magnetic fields that are created in order to visualize areas with the MRI.

108.  Can I fly in an airplane after surgery?  Yes. Some women early after surgery feel a sensation I their breast especially during the ascent and descent of the plane. This may be due to the small amount of retained air in the saline implants. There should be nothing felt with the silicone implants since there is no air in these implants.    

109. REVISIONAL SURGERY

110. ALTERNATIVE METHODS FOR BREAST ENLARGEMENT: Can my breast enlargement be done with fat? Yes. In a process called fat transfer and fat grafting, fat can be liposuction from various parts or the body and injected in multiple planes into the muscles and actual breast tissue for enlargement. Like any other fat transfer some of this fat is absorbed by the body. Therefore there is not a direct on to one correlation between the volume that is injected and the volume that is retained. There is also some long term loss of volume with this technique. Finally the volumes that can be safely harvested with liposuction and injected are relatively small. Therefore this is probably not the best alternative for larger volume enlargements. It is very good for refinements and touch ups that may become necessary after long term placement of the implants. There is some fat and breast involution that happens normally with aging and the long term presence of implant within these pockets. 

111. Can my breast enlargement be done with muscle? Yes. But this probably will not last since the muscle will atrophy with lack of activity. The secondary scars from the donor site will be significant. This is not a good choice and I don’t know of any surgeons who perform this procedure for breast enlargement.

112. Can my breasts be enlarged with silicone injections? Free silicone injections into the breast have been done for years. FREE SILICONE INJECTIONS ARE NOT SAFE AND SHOULD NOT BE DONE. THEY ARE USUALLY PERFORMED BY UNSCRUPULOUS INDIVIDUALS POSING AS MEDICAL PROFESSIONALS. The silicone will usually migrate to lymph nodes or to other distant areas of the body. The removal of this silicone can be difficult and usually will necessitate a mastectomy or removal of the breast and a reconstruction.

113. PREGNANCY AND POST PARTUM INVOLUTION OF THE BREAST. What happens to my breasts when I get pregnant? Your breasts will undergo the same changes with or without pregnancy.

114.  Will I be able to breast feed? Yes. Breast feeding is safe with breast implants. It is easier to do if the implants are in the sub muscular plane.

115. Is it safe for me to breast feed? Yes. Breast feeding is safe with breast implants.

116.  What will my breasts look like with breast implants after my pregnancy is completed? It is impossible to determine what changes the breasts will have after pregnancy. The changes your breasts are going to have are the same with or without the implants. These changes are very dependent on skin tone, weight gain with pregnancy, the amount of breast engorgement that will happen during lactation and breast feeding.

117.  Will my breasts drop with pregnancy even if I have implants in place? There is usually some amount of ptosis or descent of the breasts after pregnancy. The presence of implants does not affect the normal aging of the breast and the changes that breasts have with pregnancy.

118. COMPLEX COSMETIC PROBLEMS OF THE BREAST. TUBULAR BREAST/CONSTRICTED BREAST.

119.  I have inverted nipples. What happens to them after Breast enlargement? Inverted nipples are common. There are usually same ligaments or tightness underneath the nipples that keeps them buried. Sometimes there is inadequate volume underneath the nipples so it cannot project to the surface. When the implants are placed underneath the breast the added volume can cause the nipples to project and partially or totally correct the problem.

120. One breast is much bigger than the other. Will they be the same size after surgery? Most women have breasts that are asymmetric. There are actually far more asymmetries in a pair of breasts than most women realize. Part of the evaluation and consultation process involves pointing out this difference s and discussing to what degree any of these can be corrected or improved. A pair of breast that are not the exact same before surgery, will not be the same afterwards. They will be similar in shape and size only.

121. Most of my breasts hang through the areola? Can you help me? This is usually a sign of the TUBULAR BREAST. There are many different degrees of presentation of this problem. In its simplest and least level of deformity there is a small amount of difference in the base diameter or the width of the breast. One breast may appear to be tighter than the other at the level of the infra mammary crease. Let me also say at this time that most if not all women have some degree of disparity and difference in their base diameter and this goes hand in hand with the 2 breasts which are usually if not always different in size. However the tightness in the tubular breast is caused by tightness within the breast as opposed to the normal variant which is essentially a difference in chest wall size between two sides of any woman. The tubular breast is also called a constricted breast and there are various degrees of constriction which differ. In its most severe presentation most of the breast herniates through the areola. As the degree of deformity becomes less there is less lower pole constriction and less breast herniating or protruding through the areola.

122. Breast lifts – when are they advisable instead of breast augmentation? There is only a very specific subgroup of patients who can have breast augmentation in lieu of a breast lift. These patients have what we call pseudo ptosis. The nipple position is normal in these patients and we only have loss of volume with some bottoming out of the breasts that project or manifest itself as ptosis. Breast enlargement with breast implants will provide proper and adequate filling of the upper pole and central chest with significant improvement in appearance. The use of very large implants to make up and fill large excesses in skin leads to poor outcomes over the long term. In other words when a breast lift is indicated then you are always better off having a lift and smaller implants to make up the deficiency in volume in the areas which are necessary.

123. Is a breast lift less involved than getting breast augmentation? No, a breast lift is more surgery. There are usually more scars.

124.  My breasts hang. Will implants help lift them? Only if you have pseudo ptosis. Otherwise you should have the breast lift also.

125.  When do I need a breast lift in addition to breast implants? If the position of the nipple is below the level of the infra mammary crease then a lift is necessary in addition to the implants.

126. Will people be able to tell that my breasts are augmented by touch? The larger the implants are the more of your breast will be composed of implant. These breasts feel more like implants. Smaller implants that are just used for small volume adjustments are much harder to detect. The feel of augmented breasts mostly depends on the amount of soft tissue coverage there is over the implant. The more breast and muscle that is covering the implant the more natural they will feel. Silicone implants are softer implants and they generally feel more natural. This however does not mean that the saline implants do not feel soft. I have plenty of patients with saline implants where the breasts are perfectly soft and natural. This also does not mean that if you have silicone implants you will not have hardening of the breasts.

127. Can I still get a mammography and sonogram with breast implants? Yes, just tell the radiologist that there are breast implants in place.

128. What if I need breast surgery? Are the implants guaranteed? Most non plastic surgeons who are operating on breasts will have a plastic surgeon also available for implant exchange at the same time

129. What if I get my breasts done and they are too large/small? What are the options? You should give the surgery time to heal and achieve their final shape and form. This usually takes at least one year. A re evaluation after one year with your surgeon may then be appropriate.

130.  What is the breakdown of the total cost for surgery?  This includes anesthesia, nursing pre operative evaluation and post operative care, follow up.

131. Can you do additional procedures on me while I am under anesthesia? Yes additional procedures can also be performed. However keep in mind that the more additive the procedures the more time you will need to recover. Also the cumulative time that you are under anesthesia is of most importance. You are better off staging multiple procedures than to have a marathon one day session. REAL LIFE IS MUCH DIFFERENT THAN THE DRAMA THAT IS CARRIED OUT ON THE TELEVISION SCREENS.

132. Will I have back pain after surgery and my breasts are bigger? This is possible but not very likely. It is possible especially if the implants are silicone and larger since this is additive weight which you are carrying.

133. What happens if I gain weight? If you gain weight your breasts will get larger just as they would if the implants were not in place.