A patient information handout from John B. Tebbetts, M.D., P.A. (Dallas, TX) IMPORTANT INFORMATION ABOUT BREAST ENLARGEMENT (AUGMENTATION MAMMAPLASTY)
INTRODUCTION Increasing the volume or size of the breasts surgically is called augmentation mammaplasty. When breasts are excessively small in proportion to the torso or hips, a figure imbalance exists which may limit clothing options or your feeling about your figure. There are two major causes of.small breasts: (l) an inherited familial tendency. (breast development during puberty may be limited by inherited factors) and (2) shrinkage (involution) of breast tissue volume following pregnancy. With pregnancy, most women experience significant breast enlargement. Following delivery or nursing the breast tissue shrinks (involutes) often to a size or volume smaller than before the pregnancy. Both types of small breasts can be significantly improved by adding volume (a breast prosthesis or implant) within the skin envelope of the breast. The two types of breasts are somewhat different: with inherited small breasts, particularly if the breasts have not been enlarged by pregnancy, the skin envelope is relatively tight. With a larger breast or following enlargement with pregnancy, the skin envelope is usually somewhat looser. Both types of breast can be enlarged significantly by augmentation mammaplasty. UNDERSTANDING CHARACTERISTICS OF THE NORMAL BREAST In any woman, the breasts are never exactly the same size or the same shape. Whichever breast is larger (even though slightly), will have greater weight or gravitational pull on the breast, and will stretch the skin envelope downward. Since the nipple areolar complex is attached to the skin envelope, it will move downward also as the skin envelope stretches. In most women, just as one breast is slightly larger than the other, one of the nipple areolar complexes will be slightly lower than the other. These slight size and shape differences exist in every woman, are quite acceptable, and seldom noticeable. Augmentation mammaplasty usually does not involve repositioning of the nipple, but by carefully measuring and noting differences before surgery, normal asymmetries can be minimized visually by surgical adjustment. In most women, breast cleavage is produced by a bra. Breast position usually is slightly "down and out." Very few breasts point directly forward off the chest wall. The space between the breasts also varies widely from woman to woman. The actual shape of the breast is determined by the shape of the skin envelope, not by the shape of breast tissue within that envelope. If breast tissue were removed from the envelope, it has no shape of its own, but acts as a "filler" which is shaped by the skin envelope. Hence, the basic shape of your breast following augmentation will be similar but with a fuller volume than before the procedure. Without a bra, the upper profile of the breast in side view is usually straight, regardless of the size of the breast. Excessive outward bulging with an outwardly curving contour in the upper breast is a telltale sign of excessive augmentation. Each woman's skin envelope is slightly different, and during your consultation and exam, we will discuss balancing size options with optimal aesthetic breast characteristics. When you lie down, the normal breast falls to the side, losing some of its upward projection off the chest wall. This characteristic can be maintained by proper techniques in the augmented breast, preventing the excessive upward projection often seen when augmented patients are lying on their backs in a bathing suit. An augmented breast can be totally natural, indistinguishable from a normal breast in or out of clothing. Breast prostheses are placed behind the breast, not within the breast. They do not interfere with normal breast function (for example, you can nurse a child following a breast enlargement). The breast can be examined and mammograms performed exactly the same as if the implant were not in place. There is no evidence to indicate that breast implants cause or hamper the detection of breast cancer. CHOOSING THE BEST SURGICAL APPROACH The small incisions necessary for augmentation mammaplasty can be placed in one of three different areas: (l) in the fold beneath the breast (inframammary location), (2) around the edge of the nipple areolar complex (the periareolar approach), and (3) high in the hollow portion of the armpit (the axillary approach). When an incision heals, a small scar results. The quality or visibility of that scar depends on several factors. The surgeon must place the incision in the proper and least conspicuous area. All scars are slightly reddened for a few months following surgery. How quickly the redness disappears and how thoroughly it disappears varies from individual to individual. At least 90 percent of all scars placed in any location, if properly closed, will result in an inconspicuous scar after maturation is complete. All scars, however, are not, good scars even when they are properly placed and incisions properly closed. Some individuals, due to their healing characteristics may form scars which are more visible, raised, or red in color. These do not mature as well and may not fade in color and firmness over time. Unfortunately, we cannot predict which patient will fall into the small percentage who form poor scars, and hence, a visible scar on the visible portion of the breast may not be necessary or desirable. Both the incision under the breast and the incision around the areola inevitably leave a visible scar on the breast, and fortunately in most instances the scar is quite inconspicuous. Both the incision beneath the breast and the incision around the nipple require surgery through breast tissue and introduction of the implant through a tunnel in the breast tissue. As the pocket is developed through breast tissue to receive the implant, tiny nerves may be damaged and loss of nipple sensation may result. With the incision beneath the breast or around the nipple, loss of nipple sensation is slightly more likely to occur than with the axillary approach in patients we have studied. Bacteria which normally live on the skin enter the breast through the nipple, and actually "live" in the small ducts inside the breast. When the implant is passed through any of these ducts the chance of infection around the implant is slightly higher than with the axillary approach which involves no passage through breast tissue, instead gaining access completely behind the breast tissue. The axillary or armpit approach for augmentation therefore, offers three distinct advantages for most breasts: (l) no visible scar on the aesthetic unit of the breast (and a scar about 1-1/2 inch in length high in the armpit). (2) a much lower chance of temporarily or permanently losing nipple sensation, and (3) less chance of infection since during introduction, the implant does not traverse breast tissue containing bacteria. The axillary approach can be used in over 95 percent of cases. In the extremely hanging or sagging breast, the inframammary or periareolar approach usually gives better results than the axillary approach. Certain types of implants (which will be discussed later) cannot be introduced and positioned well through the axillary approach. The axillary or armpit incision is placed in the highest portion of the armpit hollow. A tunnel is created from that point behind the breast for placement of the implant. After performing inframammary and periareolar approaches for a number of years, I became very interested and have developed and published refinements in technique for the axillary approach mainly because it avoids placement of a scar on the visible aesthetic unit of the breast. In refining this procedure in the laboratory and surgically over the past few years, 1 have accumulated data which strongly supports the three distinct advantages mentioned above. When properly placed, the incision in the armpit is not visible in any position except when lying down with the arms extended at more than 45 degrees to the body, a very unusual and unnatural position. Even with activities such as tennis or dancing in a sleeveless dress, light always comes from overhead and the armpit area is in relative shadow. The axillary scar is far less visible in all body positions than either of the other two approaches. In addition, the skin of the armpit is an area which seems to less frequently form undesirable scars compared to the skin underneath the breast or around the nipple. With any of the three approaches, the small scar is approximately 4-5 cm in length (about 1-1/2 inches) and requires approximately one year to totally mature to its best appearance. At first the scar is a very faint line which then becomes reddened and slightly firm for a period of two to three months. As the redness fades, the firmness also subsides. When the scar is mature it is faded inconspicuous and soft. Breast implants may be placed in front of, or partially behind the pectoralis major muscle, a large muscle on the front of the chest wall. When the implant is finally positioned, only approximately the upper one-third of the implant is actually covered by muscle. This slight pressure by the lower border of the pectoralis muscle on the upper part of the implant helps prevent the unnatural upper bulging appearance of the overly augmented breast. Most implants placed partially behind the pectoralis muscle are less likely to become excessively hard due to capsular contracture. TYPES OF BREAST PROSTHESES (IMPLANTS) WHICH ARE AVAILABLE Technology has improved drastically in breast prostheses manufacturing techniques in the past few years. Two basic types of breast implants are now in widespread use: (1) a smooth outer silicone envelope filled with.silicone gel and (2) a .similar silicone envelope filled with silicone gel but covered with an outer coating of a "porous" polyurethane material. The "smooth" outer silicone envelope implant was developed approximately 30 years ago, and has been refined since that time. When placed in a pocket behind the breast which is larger than the size of the implant, the implant can move and "flow" very much like normal breast tissue. For an optimal result, motion exercises are necessary to maintain an open pocket requiring a time commitment of about 5-10 minutes per day. When these "exercises" are properly performed, the chance of your developing a hard breast is approximately 5 percent (95 percent chance of a soft natural breast). In contrast, the polyurethane covered prosthesis encourages surrounding tissue to attach to the outer-surface of the implant. Motion exercises are not necessary with this implant. However, since tissues attach to the outer surface of the implant, the implant does not move and "flow" quite freely as the smooth outer envelope implant. The polyurethane implant therefore is slightly firmer to feel and does not fall to the side quite as much when you are lying down. When lying down, the polyurethane implant will project upward slightly more than the smooth silicone implant. The chance of a polyurethane covered implant becoming excessively hard (capsular contracture) is approximately 2-3 percent, very slightly lower than the smooth silicone implant. In summary, for the patient who desires a maximally natural breast and is willing to perform motion exercises 5 minutes per day, the smooth silicone covered implant placed via the axillary approach is most favorable. If, on the other hand, you do not wish to perform motion exercises or desire a much larger breast and do not mind slightly more upward projection when you are lying down and slightly less mobility of the implant, you may prefer a polyurethane covered prosthesis. At the present time, the polyurethane covered implant must be placed through an incision beneath the breast or if you have a very large areola, through an incision around the areola. Due to its lack of a "sliding" smooth surface, it cannot be predictably introduced and properly positioned through the axillary approach. Introduced through the incision under the breast or around the nipple, you will also have a very slightly higher risk of losing nipple sensation or of having infection following the procedure. These risks are quite low, and are acceptable for most patients. RECOVERY FROM AUGMENTATION All of my augmentation mammaplasty procedures are performed on an out patient or day surgery basis. I do not restrict your normal activity in anyway following surgery, but rather encourage you to immediately resume all normal activities. I ask you to restrict strenuous athletic activities for two weeks following your surgery. You will be allowed to shower the day following surgery but other than performing motion exercises if you select a smooth silicone implant, there are no restrictions whatever regarding your activity. Most patients resume normal activities the next day. and most return to work within 2-3 days. It's very unusual for our patients to require any type of pain medication for more than 24-36 hours. More specific instructions regarding postoperative care are detailed in a later section entitled "After Your Augmentation Mammaplasty." AT YOUR INITIAL CONSULTATION VISIT When I visit with you in the office, we will review your last medical history as well as your desires regarding augmentation. Age is not a limiting factor in determining who can have an augmentation mammaplasty as long as your general health is good. We will review extensively the information contained here, as well as more specific information with respect to your specific needs. After examining your breasts and making detailed measurements I can much more precisely define recommendations for you. When a decision is made to proceed with surgery, I will take all of your preoperative photographs, so that I am assured they will reflect all of the important things I need to see to make accurate surgical decisions. They are taken with you in the erect position (the position in which you are most often seen). You are lying down during the procedure and I refer to these photographs frequently since your tissues appear very different than when you are standing. BEFORE YOUR AUGMENTATION MAMMAPLASTY Routine laboratory tests including blood counts and blood chemistries, as well as an electrocardiogram if you are over 40 years old, will be performed prior to surgery. These tests are performed routinely to screen for any abnormalities which might complicate your anesthesia or surgery. DO NOT TAKE ANY ASPIRIN OR ANY DRUG CONTAINING ASPIRIN FOR AT LEAST TWO WEEKS PRIOR TO YOUR SURGERY. Aspirin may retard platelet function, a blood component which is important to normal blood clotting mechanisms There are many drugs which contain aspirin. Before taking any drug, check the label carefully to assure that it contains no aspirin. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT THE EVENING PRIOR TO SURGERY. Safety in the administration of anesthesia or sedation requires that your stomach be absolutely empty for this interval of time before surgery. Shower or bathe normally the evening prior to surgery. Do not shave the armpit area for at least twelve hours prior to surgery. A loose fitting shirt or a jogging suit which zips in the front is preferable to clothing which must be put on over your head. It is not necessary to bring any specific type of bra, since we will not place you in a bra immediately following surgery. Please be sure that you have all of your questions answered prior to going into the hospital. I prefer that you make additional appointments with me in the office if necessary to answer questions regarding your surgery. On the day of surgery, I will visit with you briefly immediately prior to surgery. THE DAY OF YOUR PROCEDURE I usually do not prescribe heavy sedation or premedication prior to your being brought to the operating room. In order to minimize total necessary doses of drugs, sedation is best administered through an intravenous line rather than given in shot form into your muscle. It is normal to be slightly excited or apprehensive immediately prior to surgery, and this will be alleviated quickly once your intravenous line is inserted. The nurse anesthetist or anesthesiologist will speak with you briefly and then insert a small intravenous line into your arm and begin giving you sedative medication which will relax you very quickly. Prior to surgery, I will ask you to sit up briefly so that I can make small marks to use as guidelines during your surgery. You will then be positioned comfortably and will have no recall of further events during your surgery. The operation is performed using local anesthetic injected in the armpit areas, supplemented by heavy sedation as necessary during portions of the procedure which might cause you discomfort. In addition, the medications have a profound amnesic effect, and you will have NO RECALL OF ANY EVENTS during the procedure, although technically you are not under general anesthesia. Incisions are made, the tissues are appropriately separated and pockets created to receive the prostheses. After the prostheses are inserted, you will be changed to a sitting position on the operating table. I carefully inspect both sides to assure symmetry and make additional adjustments if necessary. The incisions are then closed with sutures placed beneath the skin which will reabsorb and do not require suture removal. At the completion of your operation, you will be transferred to the appropriate recovery area where you will remain until you awaken. I purposely like for you to remain drowsy, since you will be much more comfortable. After an appropriate interval of observation, usually a few hours, you will be allowed to leave with someone to drive you and stay with you the evening of surgery. Prior to leaving the hospital, you will be given prescriptions for pain medication with instructions. AFTER YOUR AUGMENTATION MAMMAPLASTY Since I want you to remain drowsy and comfortable the evening of your Surgery, fill your prescription for pain medication on the way home (or have the hospital fill it) and take one or two capsules immediately on arriving at home. Pain medication is best taken with a small amount of food and not on an empty Stomach since nausea may occasionally occur. Make yourself comfortable, not necessarily in bed, a couch or comfortable chair is fine. You will continue to be drowsy and will awaken intermittently during the evening. Use the pain medication every 3-4 hours as necessary to remain comfortable. Do not try to eat any heavy foods the evening of surgery - liquids or light foods are preferable, assuming normal diet the next morning. Should you experience any nausea the evening of surgery, drink small amounts of liquids only - no food until morning. Anti-nausea medications are generally not very effective, and any nausea experienced from the medications used in surgery should be gone the next morning. Bandages placed at the time of surgery over your incisions may be removed the next morning. Your incisions require no special care. All stitches are placed beneath the skin and will reabsorb. If steri-strips are in place, do not remove for 5-7 days. You may shower and wet the incisions the morning after surgery. After showering, dry the armpit or other incision area normally with a towel. Spray deodorant which converts to dry powder when sprayed is preferable, and may be used two days following surgery. Do not use wet spray or roll-on deodorants in the armpit areas for at least two weeks. You may shave the armpit areas beginning two days following surgery. As we explained to you preoperatively, the ridges formed by the incision lines will regress over a period of weeks as the skin stretches. Until this area flattens, you may shave over the ridges, but simply take reasonable care in these areas. You may experience some small lumps in the armpit area following surgery. These are small lymph nodes which will generally regress without any treatment over a period of 7-10 days. If you see redness spreading one half inch or more from the incision area or any drainage from the incisions, notify me. Light drainage for 24 hours is normal. If you are given a prescription for antibiotics following surgery, take the prescription until all the antibiotics are completed. RESUME NORMAL ACTIVITY AS RAPIDLY AS POSSIBLE. Postoperative discomfort is most marked during the first 24 hours and regresses rapidly thereafter. Resumption of normal activities, for example, lifting the arms to comb the hair speeds the recovery process and reduces the pain more rapidly. Immobility tends to cause continued discomfort and increased muscle spasms. THE ONLY LIMITATION TO ACTIVITY IS IF YOU FEEL SIGNIFICANT PAIN. DISCOMFORT IS NORMAL WITH MOTION INITIALLY, AND THERE IS NOTHING WHICH CAN BE HARMED BY NORMAL ACTIVITY. Call my office for an appointment to be seen within three days following surgery. At this time, my nurse or I will begin instructing you in motion exercises to maintain the pocket into which your breast implant has been placed. YOUR COMPLIANCE AND EFFECTIVENESS IN CARRYING OUT THESE EXERCISES IS ABSOLUTELY ESSENTIAL TO MAINTAINING A SATISFACTORY RESULT FOLLOWING THIS PROCEDURE. Normally following this procedure, a small amount of fluid will accumulate within the pockets surrounding the breast implant. You may be able to feel or hear a slight slushing of the fluid as you move your implants. This fluid is reabsorbed by your body over a period of two to three weeks and is normal. Massive accumulation of fluid or blood within the pocket occurs very rarely (approximately 2 percent of the time) postoperatively and should this occur, your breasts would become extremely large, tight and painful, and you should notify us immediately. YOU MAY WEAR OR NOT WEAR A BRA AS YOU DESIRE. It is usually best to wait at least two to three weeks following surgery and try a number of different brands and shapes of bra cups in order to find one which is comfortable and fits best. During the first few weeks to months, stretching of the skin envelope in the lower part of the breast with change in contour will occur more rapidly if a bra is worn less. Nevertheless, whenever you are doing strenuous exercises, or desire wearing a bra, it will not in any way affect the result of your surgery. In the first few weeks following your procedure, your breasts may appear slightly full in the upper portions, with a slight outward (convex) curvature to the upper portions of the breasts. As explained preoperatively, this fullness regresses as the lower portion of the breast envelope stretches from the weight and gravitational effect on the implant over time. As the stretching in the lower portion of the breast is complete (up to six months), the upper pole profile of the breast becomes straight or slightly concave. Since discomfort from this procedure diminishes rapidly, pain medication should be necessary for a maximum of three to five days. Most patients usually require pain medications for only 24-48 hours. Should you develop any of the following signs or symptoms, please call our office: (a) elevation of temperature to or above 101 degrees, (b) extreme swelling or tenderness in either breast, (c) any prolonged or significant bleeding from incision lines (slight drainage for 24 hours is normal), and (d) redness along the incision lines or elevation of temperature in the breasts. A small amount of bruising may normally occur in the armpit area or beneath the breast, and may appear one to four days following your surgery. If bruising occurs, it subsides in one to two weeks. If you should have any other questions or problems, please contact my office. LIMITATIONS, RISKS, AND POSSIBLE COMPLICATIONS FOR AUGMENTATION MAMMAPLASTY With any surgical procedure, a very small percentage of untoward complications can possibly occur. These complications are extremely rare, and I mention them not to alarm you, but to inform you. As we discussed previously, no two breasts even in the same patient are the same size or shape. Placing an implant changes the content of the skin envelope, but it does not change the shape or size of the envelope itself. Hence, size and shape differences will inevitably be present to some degree following surgery, just as they are present before surgery. I make every attempt to equalize the volume of the breasts, but due to differences in the size and shape of the skin envelope which I am not modifying, some differences always persist. These differences are usually quite subtle, and within the normal range of variation of breasts. Although in careful long-term follow-up of a large number of my patients, I have had no instance of total loss of nipple sensation, this loss is nevertheless remotely possible. With the transaxillary approach, it is distinctly less than with periareolar or inframammary approaches. Due to stretching of the breasts and nerves of the breasts, about one-third of my patients experience very subtle tingling sensations or pin-pricking type sensations on the outer- half of the breast, as well as on the inner aspect of the upper arm. A similar number (about one-third) of my patients notice a slight increase in nipple sensitivity for a few weeks following surgery. All of these effects are subtle, of no concern, and all subside spontaneously within a brief period. Whether you receive local anesthesia with sedative medications or general anesthesia, it is possible to have untoward side effect to any drug which is administered. Severe side effects are extremely rare, but can be life threatening. It is for this reason that we insist on performing your surgery in an optimal setting where all appropriate equipment and medical backup are available should you have an untoward reaction. Anesthesia or sedation risks are extremely minimal. Many have been vastly over-publicized by the media and most have occurred in settings where less than optimal facilities, equipment, and personnel are present. Although at the time of operation, I obviously stop all bleeding which is present, it is possible for additional bleeding to occur within the pocket following the procedure. This complication occurs in approximately 2 percent or less of cases, but may require returning to the operating room, removing stitches from your incisions, and removing blood which may have collected. If bleeding occurs, it most commonly happens in the first 48 hours following surgery, but may very rarely occur later. In my experience, it is in no way related to your activity, hence I do not limit your activity in any way following surgery. As with any surgical procedure, infection may occur following your augmentation, despite administration of antibiotics, and meticulous sterile technique during surgery. Fortunately, this complication occurs in less than 1 percent of cases. If the pocket containing the implant becomes infected, the implant must be removed. It must be left out for approximately three months in order to allow all infection to subside, and then can be replaced. Although extremely rare, this complication is a significant nuisance to you. One implant may be in place while the other is removed for a period of time, requiring artificial filling of the brassiere cup on the affected side. Excessive firmness of the breast caused by pocket closure and/or capsular contracture may occur in up to 30 percent or more cases if motion exercises are not properly performed. Your total compliance with motion exercises reduces this risk of contracture to less than 5 percent, but it nevertheless can occur despite all efforts. Should contraction or excessive firmness occur, it may require open capsulotomy (opening the incision and releasing the contracture). I do not routinely perform closed capsulotomy (manually squeezing the implant to tear the capsule) due to the incidence of complications such as implant rupture, hematoma, and high recurrence. With closed capsulotomy or manual compression, the capsule may tear, but the pocket is never totally re-established, hence the breast can never be as normal as the opposite breast. If this firmness occurs, I basically must repeat your operation in order to achieve a satisfactory result, and this may require a second incision beneath the breast. All of the above-mentioned complications of augmentation mammaplasty are unusual, but occur occasionally despite the most vigorous standards of surgical practice. They are listed not to alarm, but simply to adequately inform you prior to your surgery. CONCLUSION Augmentation mammaplasty is a reliable and rewarding procedure which enlarges and improves the appearance of the breasts in properly selected circumstances. In addition to a significant positive effect on the individual's self-image, patients often describe a feeling of increased self- confidence and increased versatility in types of clothing which can be worn. In addition to the information contained here, during your consultation and examination we will review even more specific factors which pertain to your individual case. As you review this sheet, please write questions in the margins that we may answer during your consultation.