Myths vs. Reality About Breast Augmentation

There is a lot of excellent information on the Internet about Breast Augmentation surgery. However, it is extremely discouraging to read the generalized dogma on web sites and in chat rooms about what is the best method for breast augmentation surgery. The following are explanations to answer what is fact verses myth about the procedure.

General verses IV Sedation
Breast augmentation takes about 45-90 minutes depending on the surgeon, the technique used, and the individual patient’s anatomy. The procedure can be performed by being placed a sleep with a special endotracheal tube called a LMA tube ( a tube which is placed in the back of the throat with a special cuff and does not pass across the vocal cords, thus no sore throat) or by deep IV sedation.

Either method is safe and reliable. General sedation has a better guarantee that you will not remember or feel anything during the procedure. It is very important that regardless of the method you chose, that the procedure be performed in an accredited operating room, especially if this to be performed in a doctors office. Accrediting institutions are either JCAH, AAAHF, or AAAASF approved. This means that if the patient were to have a heart attack or respiratory arrest, they would have the appropriate training, equipment, and protocols for handling the situation.

Above the Muscle or Below
Breast implants can be placed above the muscle or below the muscle. The muscle in discussion is the pectoralis muscle. It runs from the upper arm to the sternum or chest bone. Only the upper two thirds of the implant is covered by this muscle. “Complete muscle coverage” will be discussed below. The inferior and side aspect of the implant is covered by breast tissue and skin. Implants placed on top of the muscle may allow more lift of the nipple if needed. The recuperation is less because muscles are not cut or stretched. Thus, the pain is less. Implants placed below the muscle have an added layer of protection and may give a more natural curve of the breast superiorly coming off the chest. The muscle adds some compression to the implant and may decrease the risk of rippling. The muscle may also massage the implant to decrease the risk of capsule contracture. The majority of plastic surgeons place implants under the muscle. This appears to give the most consistent results with the least amount of risk of rippling, capsule contraction, and provide the best mammograms.

“Complete Muscle Coverage”
“Complete Muscle Coverage” is in quotes because this is an inaccurate concept. This implies the breast implant is covered superiorly by the pectoralis, inferiorly by the rectus muscle, and on the side by the serratus muscle. This is anatomically impossible. The first reason is based on the anatomy of the muscles and their beginning and end points. The serratus originates as fingers from each rib on the side and inserts on the scapula. The fingers begin just under the pectoralis. Since this muscle is a bunch of thin fingers, if elevated it cannot be stretched enough to cover a breast implant. The rectus muscle begins at the lower ribs and inserts into the pubis. It is usually ending where the new breast fold is beginning. If elevated it cannot reach to the implants and it cannot be stretched to cover the implant. Thus, anatomically it is impossible to completely cover the implant with muscle like in a breast reconstruction.

Breast augmentation is different technically then breast reconstruction. In breast reconstruction an ‘expander’ implant is placed under these muscles and complete muscle coverage can be achieved because the expander/implant has no saline in it or volume. These muscles are extremely tight over this ‘expander’ implant and immediate inflation would rip the muscles. The individual then comes to the office and over weeks to months, saline water is placed in the ‘expander’ implant to stretch the muscles, fascia, and skin to create a new breast. Then a permanent implant can be placed which is completely covered by muscle. This is definitely not the case for breast augmentation.

Also, the incision used to create the complete muscle pocket should not matter. Any of the incisions are going to have to make a hole in this pocket so the implant can be slid into place and inflated. If this concept was true, the best incision would probably be the periareola incision since it would allow access to the pocket from the top and thus there would be no incisions around the base of the implant.

Individuals have stated that complete muscle coverage prevents bottoming out. This is where the bottom of the implant slides toward the feet. It has also been stated that the inframammary incision potentates this complication. Again this is a myth. Since one is creating a new breast crease, this area is violated no matter what incision or dissection is used. Special local muscle flaps and fascia flaps can be created to reconstruct the crease in individuals undergoing reconstruction, but this is not done in the primary breast augmentation patient. Bottoming out is caused by the skin and its components not being able to support the added weight of these implants. It is especially a problem in very thin individuals with very thin skin and a lack of breast tissue. Implants greater than 400cc in volume may have a greater risk of this. There are other individuals who have a predisposition to this which cannot be determined preoperatively.

Thus, the concept of complete muscle coverage is a myth with no scientific basis, and cannot be performed due the limitations of the basic anatomy of these three muscles.

Implant Styles and Textures
Implants can be smooth, textured, round, anatomic or tear drop, saline or gel. Smooth implants have been available the longest. Some physicians feel if they dissect a large pocket it allows the implant to move around and give a more natural and softer result. First a larger pocket initially increases the risk of the implant being in the wrong position after healing (i.e. too high, too low, or too much to the side). Second, after time,
the capsules will only be the size of the implant and not larger. Also, smooth implants have been shown scientifically to have a higher risk of capsule contracture than textured implants especially above the muscle. Gel implants have the highest risk of capsule contracture overall.

Textured implants have been scientifically shown to lower the risk of capsule contracture especially when placed under the muscle. The overall risk of capsule contracture has decreased since the increased use of saline implants over gel implants more than any other reason. Some physicians feel textured implants may cause more rippling especially if placed above the muscle, because the capsule grows into the texturing and if the implant ripples than it ripples the skin by pulling on it, also known as ‘traction rippling’. Rippling is more likely in extremely thin individuals with minimal skin and no breast tissue to cover the implant. These individuals are more likely to feel the implant on the side. To this day there is no scientific evidence that has shown one implant causes more rippling than another. The best answer is to place any implant under the muscle.

There are now tear drop implants or anatomical implants. These implants are shaped more like a natural breast. They are elliptical and thus are longer than they are wide. They provide more cleavage for this reason. When comparing round verses tear drop implants the volume is not the same. One needs to compare the diameter or base width of the each implant to see the difference. An anatomical implant has a higher volume compared to a similar round implant and provides more nipple projection. Round implants do look like a tear drop when placed under the compression of the muscle. However, since they are not as tall, they do not provide as much cleavage. Also round implants can look more ‘stuck on’ due to their round appearance especially in very thin individuals. This is less likely if they are placed under the muscle.

There are two major implant manufacturers: Allergan (Inamed/McGhan) and Mentor. Both make excellent products. The Mentor shells are thinner than the McGhan saline shells. In reality, this is imperceptible when placed under the skin or muscle. Both work well. The McGhan tear drop implant is taller for a given base width than the Mentor and may provide for more cleavage and a natural look.

Recognize that no one type or style of implant is better than another. They all are designed well. Thus, selection is based on the individuals’ needs and desires.

Incisions
There are three different incisions that can be used. Each has its pros and cons. The first is a trans-axillary incision or under the armpit. When this incision heals well, it can be well hidden in the armpit and it precludes any incision on the breast. However, this incision in some scientific studies has been shown to have a higher incidence of bleeding. Also there is a tendency with time for the implants to be pushed more lateral or to the side if the muscle is not released along the inferior edge of the sternum or chest bone. Many surgeons will use a endoscopic camera to dissect the pocket and to release the muscle. If one has a complication such as a capsular contraction, or one side is not like the other it can be very difficult to correct because this incision is remote in relation to the where the implant is. Approximately 5% of plastic surgeons use this incision as their first choice.

The second incision is a periareola incision or around the nipple. This location allows a more direct access to
the site of implant placement and can be used if the patient requires a nipple lift also. However, this incision may limit the ability to breast feed because it can violate duct tissue and may increase the risk of infection. Neither of these have been shown scientifically. Also, it is an incision on the front of the breast. Approximately 10 -15% of plastic surgeons use this incision.

The third incision is through the belly button.  This allows placement of the implants without any incisions on the breast. However, release of the muscle cannot be performed and can lead to the implants moving to
the side with time. Also, it is extremely difficult to accurately place tear drop implants through this incision. Any surgical revisions would necessitate the use of another incision. Less than 2% of surgeons prefer this method.

The final incision is an inframammary incision or in the breast crease. This incision allows the best access to the implant pocket with the best view. It does not violate nipple ducts if the implant is placed under the muscle. It allows for easy access if a capsule needs to be released or there is implant asymmetry. It is an incision under the breast and will fall in the breast crease or slightly above it.  Some doctors feel since this violates the inframammary fold and the underlying fascia that there is a greater risk of bottoming out. However, this is not true since one of the basic teaching aspects in plastic surgery is that the inframammary fold has to be lowered in order to accommodate the diameter of the implant. Thus, it does not matter what incision you use, the fold needs to be lowered and a new fold is created. Also, the fold does not have muscle or fascia in it. At
this time the best anatomical explanation of the fold is it has a set of ligaments from the underlying fascia to the skin. However the exact nature of this and how to reconstruct a new fold is still left for debate.

Each incision allows the surgeon to create the same type of pocket for the implant whether it is above the muscle or below the muscle. The incisions’ sole purpose is to provide access to the site of the pocket. It does not dictate whether the implant is placed above or below the muscle or the type of pocket to be created.

Recognize that one incision is not better than another. Excellent results can be achieved with any of the methods. The answer depends on what the individual wants to achieve, the patient’s and surgeon’s decision, and the pros and cons of each.

Post Operative Massage
There is no scientific evidence that massage decreases the likeliness of capsule contracture or results in a softer breast. Period. It can help reposition a malpositioned implant after surgery. There is no harm in performing massage so there is no reason not to do it. There are also no special techniques that are better than others.

Photo Analysis
Photo analysis from digital images on the Internet is extremely difficult. The resolution is extremely low when compared to 35mm slides, photographs, or high definition digital images. In order to get an accurate picture the dpi should be significantly larger. Thus, assessing incisions and breast symmetry can be less then optimal.

In Conclusion…
A surgeon should be capable of performing any of the techniques equally well and be able to use all the different styles of implants so the patient can be well and honestly educated on the differences and can have the incision and type of implant and site of placement of the implants they want.

Excellent results can be achieved with any of the above incisions, types and styles of implants, as well as sites of placement of implants. There is no one right answer except what the patient and surgeon feel comfortable will work in each individual case. The operation should be customized to the patient to achieve the most natural result and what the patient desires. Some of this information is very technical, but it is necessary in order to give an in depth answer to the information being distributed on the Internet and to take the mystery and myth out of the procedure and provide accurate, scientific, valid answers and not just opinion.

Recognize board certified plastic surgeons are perfectionist trying to provide the most optimum results for their patients. Thus, like anything else, if something is truly better and a better way it will be rapidly accepted by the majority of them and incorporated in their techniques and management.

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