By Dr. Lara Devgan
This is an invited editorial for physician online news magazine Healio.com.
Breast augmentation, or breast implant surgery, is the most frequently performed cosmetic surgical procedure in America, and the most common procedure in my Manhattan private practice. Over 300,000 breast augmentations are performed each year in the United States alone.
Women's motivations for breast augmentation are as diverse as their surgical goals. While most of us have seen women with extremely large and exaggerated breasts, most patients in my practice-- and most women in the United States-- seek a more natural, subtle result. In my practice, women who seek breast augmentation are often in one of two major categories: young women in their twenties who desire a fuller, more proportionate, more feminine figure, and women in their thirties, forties, and fifties who would like to restore youth and fullness to their breasts, after aging, childbearing, breastfeeding, and weight fluctuations have changed their figures.
So what is the secret to beautiful, natural breast augmentation? Safe surgery, appropriate expectations, and working within the constraints of your anatomy.
Pre-operative Evaluation
Breast augmentation is an elective procedure, so before undergoing surgery, women must be in good health, with an adequate exercise tolerance. For women with preexisting medical conditions, a full pre-operative medical clearance, including blood testing (BMP, CBC, PT, and PTT) and pregnancy testing must be performed. For those over 50 with cardiac or pulmonary issues, a chest x-ray or EKG may also be required. A mammogram is recommended for women who are over 40, or women who have a strong personal or family history of breast or ovarian cancer.
When meeting with your plastic surgeon, you will have a detailed discussion of your goals and expectations for surgery. You should discuss your current and desired breast size, any changes in your breasts over time, your history or future plans for childbearing and breastfeeding, and your personal and family history of breast or ovarian cancer and anesthetic complications. You will also discuss your full medical and surgical history. Breast augmentation has increased risks in women who are smokers, and in my practice, I require that patients cease smoking for at least four weeks before and after surgery before proceeding.
Your pre-operative physical examination is one of the most critical aspects of your initial plastic surgery consultation. Your plastic surgeon will palpate your breasts and axillae for lumps, masses, or evidence of irregularity or skin puckering. Your nipples will be assessed for any evidence of abnormal discharge. Your plastic surgeon will then assess your tissue quality, including skin pinch (the thickness of your subcutaneous tissue), skin elasticity, and body habitus. A number of measurements will be taken with a millimeter-marked measuring tape, including the sternal notch-to-nipple distance, the nipple-to-inframammary fold distance, the base width of the breasts, the intramammary distance, and the areolar diameter. It is very common for women to have some baseline degree of asymmetry in their breasts. Preoperative photographs in five views (front, left side, right side, left three quarters, and right three quarters) are important in surgical planning.
Planning for Surgery
Once your plastic surgeon has determined that you are an appropriate medical candidate for surgery and that your expectations are achievable, it is time to decide on several variables present in breast augmentation. These include choice of implants (silicone or saline), choice of incision (inframammary fold, periareolar, or transaxillary), and choice of placement (submuscular or subglandular). The factors involved in these decisions are personal and highly individualized. In my practice, a large majority of patients chose silicone implants placed in the submuscular dual plane, via an inframammary fold incision. It is important to have a detailed discussion with your surgeon about which approach is right for you.
The next important decision is size of the breast implants. This is dictated by two factors: the first is your personal desires and expectations for surgery, and the second is the constraints created by your anatomy and tissue. It is unsafe and unwise to opt for breast implants that your plastic surgeon advises you are too large for your "tissue envelope." Patients who do so often have unsatisfactory results with poor longevity. The most important anatomic guidelines to follow when selecting implant size are the distensibility of your tissue envelope and the base width of your breast. Discuss with your plastic surgeon the prudent, safe, appropriate size range for breast implants given your unique characteristics.
Preoperative Risk Discussion
Breast augmentation is a safe surgery overall, but it is real surgery, and all operations have risks. Chose a board-certified plastic surgeon (not a "cosmetic" surgeon-- which is a variable and unregulated designation) who operates with a board-certified anesthesiologist. Understand your expected results. Ask questions.
The risks of breast augmentation include but are not limited to bleeding, infection, undesirable scarring, asymmetry, capsular contracture, and implant failure. Many steps can be taken to reduce these risks. For example, in my practice, patients are counseled to avoid medications such as Advil and Aspirin, which inhibit platelets and can increase bleeding risk, for 2 weeks before and after surgery. In addition, I give patients a dose of preoperative IV antibiotics and a course of postoperative oral antibiotics to reduce risk of infection.
It is essential to have a frank and detailed discussion with your plastic surgeon about surgical risks, benefits, alternatives, and indications before proceeding with the operation.
Surgery and Recovery
Surgery typically takes one hour and is performed as an outpatient procedure. Postoperatively, you will stay in the recovery room until you are comfortable enough to eat a few crackers, drink water, walk around, and use the bathroom on your own. You will be sent home with a prescription for antibiotics and pain medicine.
In the first 24-48 hours, you will have a small amount of swelling, bruising, and discomfort. Many patients need to take pain medicine during this time period. Most patients spend the first 1-2 days resting, reading, watching TV, and going for short walks. After 48 hours, you will be able to shower normally.
If you have a desk job that does not require strenuous activity, you may be able to return to work by the 3rd or 4th day after surgery. At this point, most women switch to only taking Tylenol for pain. Many of my patients who have surgery on Friday are able to return to work by Monday or Tuesday, depending on the type of jobs they have. If you want to give yourself a bit of extra pampering, I suggest taking a week off.
By one month after surgery, the vast majority of patients say they feel "back to normal." Bruising, discomfort, and most swelling has disappeared. The breasts will still continue to "settle" into their final position over the course of the next few months, and a tiny bit of additional swelling will go away, but one month is when most women really feel normal again.
By 6-8 weeks, you will be cleared to do all types of physical activity again. Some exceptions may apply for elite athletes who put extremely high demands on their chest muscles. And of course, each person is different, so this timeline should be interpreted as a general guideline, rather than an unalterable rule.
By three to six months, you will have your final postoperative result. Plan to return to see your plastic surgeon at this time for a checkup and any recommendations for future screening that may be needed. For any questions about this article, I can be reached via www.LaraDevganMD.com.
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