1. Why are most breast implants below the muscle?
Dr. Bortnick: Most breast implants are placed under the muscle because most women seeking breast implants prefer the most natural appearance possible. Common sense dictates that the thinner the tissue that covers the implants the more potential for visibility . Therefore, the thinner the woman the more one leans toward the extra protection of the muscle. However, good scientific evidence shows that breast implants look more natural and feel better if placed below the muscle. It also does not obscure mammography (both silicone and saline implants) and there is substantial data to support that the implants (both silicone and saline) stay softer longer by a significant margin if placed below the muscle.
2. How do you prevent rippling in breast implants?
Dr. Bortnick: Preventing ripping of breast implants can be difficult. There are things that can be done to minimize the risk. Ultimately the detection of wrinkles depends on the overlying qualities of the beginning breast gland and thickness of tissue. Common ways to prevent rippling or minimize rippling are to place the implant below the muscle, make sure there is adequate breast tissue, and not oversize or under inflate a saline implant. There are different types,textures and firmness of silicone implants that maybe better than others at preventing ripples whether they are placed above or below the muscle. Under filling saline implants can cause more scalloping or rippling and more risk of deflation. The surgeon can elect to over inflate saline implants, like creating a tighter fit in blue jeans, the implants will wrinkle less for some time. The breast however, will feel more firm and may ultimately scallop more. Cohesive gel, “gummy bear” implants may ripple the least and be used in certain patients. Despite best efforts you can almost always feel any implant in the thinnest lower outer part of the breast.
3. Why should one choose textured or smooth implants implants?
Dr. Bortnick: Most of the time we use smooth implants. There is good scientific evidence to show that smooth implants, which feel like glass on the surface, have less risk of visible rippling and lower rates of shell failure than there textured counter parts. This varies among the manufacturers however generally holds true. These are usually the top priorities that help in deciding. Textured implants do have the advantage of less often forming a capsular contraction and in patients that have had problems in the past or are likely to have problems one may elect to use the softer velcro feeling textured implants, especially when placed above the muscle. The new “gummy bear” , style 410, Allergan and the CPG, Mentor, implants will be textured. All shaped or tear drop implants will be textured to help prevent movement and rotation of the implant, which may in itself, present other technical challenges.
4. What are the thoughts of replacing ruptured silicone implants?
Dr. Bortnick: The pivotal FDA study for silicone breast implants, which concluded in 2006, and included both major manufacturers of implants, addressed many consumer concerns of safety and health issues. Among topics studied were the recommendations for treatment and diagnosis of “silent rupture” of silicone implants. Several scientifically based conclusions arose. Ruptured silicone implants are best diagnosed by the use of an MRI. If diagnosed they should be removed and replaced. The rupture does not pose a systemic health issue and the silicone does not move around in the body to other sites. However, certain patients when exposed to free silicone in the breast tissue will develop small lumps, called granulomas at the site. These bumps may cause a diagnostic problem for the patient and doctor confusing them with benign or cancerous changes. Implants of today are long lasting and both saline and silicone last usually 15 years. The implants are among the best studied medical devices ever and are safe. However, both ruptured saline and silicone implants should be removed and replaced.
5. If my implants have ruptured is it an emergency to have them removed or replaced ?
Dr. Bortnick: No, it is not an emergency to have your implant replaced whether it is saline or silicone. There are several factors to consider. however, as a general rule it is better sooner rather than later and should be done within several months. Factors to consider are among others whether you will remove or replace the implants. Although the warranty varies from time to time and differs from one manufacturer to the other, implants and the costs associated with the replacement may often be covered by the company warranty. Also consider that longer the body has to form a capsule around deflated or ruptured implants often time the surgery required to replace them becomes more difficult and extensive. Silicone can, in some patients, cause a diagnostic inflammatory granuloma at the site of leaking. It is not uncommon for implants to last longer than 15 years but as they age the probability of wear induced failure grows. Careful yearly monitoring and periodic checks with MRI may be warranted. Replacement surgery is most often well tolerated and can correct problems with shifting and movement or sizing issues that have occurred with time. It makes sense to talk about these issues with the surgeon before any replacement surgery.
6. What are your thoughts on high profile or moderate plus implants, can they correct sagging breasts better than other implants ?
Dr. Bortnick: Most of the time I do not use higher profile implants, whether the patient needs a breast lift or not. Higher profile implants will not prevent a sagging breast from requiring a lift, it may however compound the problem. Saggy breasts are much like sagging skin after weight loss in any other area of the body. The solution is a combination of tailoring the skin and increasing the volume that fills the skin. Over filling the skin only subjects the breast to greater effects of gravity. It has been suggested, in the plastic surgery literature, that high profile implants may have a much higher and faster incidence of causing atrophy and thinning of breast tissue, leading to more risk of rippling and premature stretching of the skin. They definitely produce more roundness to the breast and may be used in select patients depending on the compromises and results the patient desires. To date higher profile implants have not been studied extensively.
7. Does the number of cc’s in a breast implant correlate with the breast size?
Dr. Bortnick: This question is asked very often and is usually a result of misleading information on the internet. The larger the volume of the implant the larger the cup size. However, the resulting breast cup size is a combination of existing breast plus the volume of the implant. Therefore, one implant on one patient produces different sizes on another patient. Interpreting results from the internet is misleading and does not take into account the critical relationship of skin compliance. For example, the figure of the body will look different if it is in a girdle or a loose pair of jeans. In other words “fit” is both a factor of size of the implant and compliance of the skin.Additionally, bra sizes vary from one to another. Remember the goal of good breast augmentation is to look natural. The size of the implant used should be determined by chest wall fit and skin compliance, not by cc’s. One can never predict 100% what the final cup size will be.
8. What causes the breasts to become hard and should it be treated?
Dr. Bortnick: There are many factors that contribute to implants becoming hard. Some of these factors are under the control of the surgeon and others are not. There is no one cause, but factors that contribute may be the amount of bleeding at the time of surgery and contamination at the time of surgery. There is certainly well documented scientific evidence that incisions placed in the armpit increase the risk of capsular contraction. Additionally, implants of both types placed under the muscle have a lower rate of hardening. Finally, textured implants have a lower risk of hardening compared to smooth implants. This is not to suggest a certain, one, surgical plan for all patients as there are many other variables that have a higher priority. After all a patient does not make decisions based on potential low risk outcomes. Rather, one makes choices on the anticipated goal of looking natural after surgery. When possible if all else is equal choose those variables with lower risks. Fortunately, hardening happens rarely and most times can be treated effectively by surgical revision.It is also generally believed that massage of the breast implant after surgery helps reduce the incidence of contracture.There are early reports that the new “gummy bear” or cohesive gel implants have the lowest rate of hardening yet for silicone implants.
9. Do people often lose sensation to the nipple after breast augmentation?
Dr. Bortnick: No, loss of sensation after breast implants is rare. Most of the time sensory changes are accompanied by a temporary increased sensitivity to the nipple often described as hitting a nerve or a shooting sensation to the nipple. Less often a decreased sensation is the complaint. Most of the time this is temporary and can be explained by a similar mechanism as your foot falling asleep. The larger the implant the more compression of the nerve. Until the pressure lessens on the nerve from the tight fit the nerve feels “sleepy”. Usually this resolves within six months. There is a lower risk of permanent numbness from incisions placed at the bottom fold of the breast. Depending on the studies reported the incidence of loss of sensation is less than 5%. Most of the time sensation does return.
10. What is the most common reason for revision of breast enlargement surgery?
Dr. Bortnick: This is a common question and has an intuitive answer. Despite the apprehension surrounding any surgery, breast augmentation, remains a lower risk surgery and a predictable surgery. Complications do not account for most revisions. Rather, it is size change that by far and away accounts for most revisional surgeries. Most often the change is to go larger. When considering going larger one must weigh compromises from the correct size, as determined by chest wall diameter. Like life, deviating from the best choice carries compromises that may seem good at the time but often become the poison pill. The initial tight appearance of the breast wains with time and relaxation of the skin, thus loosing the fit and appearance. This changing of the fit often makes patients second guess the size of their implants, forgetting the initial tightness of their skin immediately after surgery. Requesting a larger implant often ignores the physical rules of gravity and aging. A corollary might be that a ten pound pregnancy will have unescapable changes on the body that a six pound pregnancy will not. It is acceptable to plan one size larger than you measure if you want a slightly rounder look but deviation from common sense leads to certain long term problems.
