Dr. Bosshardt's Blog

An on-line consultation for breast augmentation

Breast Augmentation- Information for Patients

The decision to have a breast augmentation is a major one with life-long consequences. Please be sure you understand this operation well and have all of your questions answered before proceeding. Once surgery is done, it can never be totally undone.

The only way to add meaningful volume or fullness to your breasts is to use breast implants. You cannot do exercises, take pills, use creams, or use “vacuum pumps” to accomplish this goal!! There is a new technique, called fat grafting, in which fat is liposuctioned from your body and injected into your breasts. This technique is still not recommended for widespread use because long term results are not known and I am not yet offering it. The following information is being provided to you in order to ensure that you are fully informed about breast augmentation with implants. It is a comprehensive summary of this very popular plastic surgical procedure. Together with your consultation with me, the information contained herein should allow you to make an informed decision about whether or not this operation is for you.

Our facility-

The surgery is done in our office which includes a state-licensed ambulatory surgery center. Very few private offices in Florida have such a facility. The operating room is on par with those of hospitals and is subject to the same state inspection and credentialing. We have all the necessary staffing, equipment, and resources to perform surgery with the safety our patients deserve, and handle any emergencies. I recommend doing the surgery here because we can better preserve confidentiality, our staff are very familiar with the surgery since we do so many, and the facility costs are significantly lower than at other ASCÂ’s or hospital operating rooms. I have admitting privileges at Florida Hospital Waterman, LeesburgRegionalMedicalCenter, and South Lake Hospital. To date, no patient has chosen to have this surgery in the hospital. In the event of a problem, we can transfer patients immediately across the street to Florida Hospital Waterman. This has never yet been necessary after this surgery. Because this is a state licensed ambulatory facility, patients cannot be kept overnight. In over 25 years, no patient has been unable to go straight home after their surgery.

Anesthesia-

I perform breast augmentation under general anesthesia. Another option is using local anesthesia with heavy sedation but I do not recommend this. I do not believe sedation is any safer and it presents potential problems, such as patients feeling pain, becoming aware, or squirming while undergoing surgery, making the procedure more difficult to perform. Many practices that offer office-based breast augmentation perform this surgery under local anesthesia with sedation only because they are not accredited to do general anesthesia. We do not have this limitation. In 23 years of practice, I have never had a single patient experience any complication from anesthesia during, or after, a breast augmentation.

Incisions-

Several incisions are used for breast augmentation. They are along the edge of the areola (the colored skin around the nipple), in the crease under the breast, the axilla (armpit), and the umbilicus (belly button). The last one is known as the TUBA (Trans-Umbilical Breast Augmentation). I feel that it is a ridiculous approach and do not understand why anyone would choose this. It is not widely performed and only a tiny fraction of augmentations are done this way. I donÂ’t feel that the axillary approach or TUBA have any significant advantages over the others and choose not to offer then at this time. Of the first two, I prefer an incision in the crease under the breast. My aesthetic sense is that the nipple and areola are the visual focal point of the female breast and our eyes are drawn to this area of the breast. I do not like to put a scar there. In the crease incision under the breast, no breast tissue has to be cut, in contrast to the areolar incision. In patients who make perfect scars, there really is no difference between the two. If the scar is less than perfect, it is less conspicuous underneath the breast.  My incision is an inch or less, the smallest possible, to insert a deflated, rolled saline implant. Scar revisions are almost never necessary from this incision. Gel implants require a larger incision, usually around 5-6 cm, because they are put in pre-filled.

Implant position-

Once an incision is made, I have to create space for the implant. This space is called a “pocket” and can be placed either under or over your pectoralis muscle, a large, flat triangular muscle which sits under the breasts. When I examine you, I have you contract this muscle to assess its size, position, and degree of development. Most breast augmentations are done with the implant placed beneath this muscle. Advantages of this position are several. With more tissue over the implant, it less prone to be seen or felt through the skin. Under-the-muscle implants are less likely to experience tightening of the scar tissue that naturally forms around the implant. This is called capsular contracture and will be explained below. Under-the-muscle position makes it a little easier to obtain acceptable mammograms later. For some patients, such as those with very developed muscles or some breast sagging, above-the-muscle placement may be advantageous. The pectoralis muscle must be partially released from it’s attachments to the ribs in under-the-muscle placement. This should result in no appreciable loss of upper body strength or arm motion. With under muscle implants, breasts will usually demonstrate some change in shape when the muscle is contracted. This may be minimally to very noticeable. It does not cause any problem beyond this and only rarely justifies attempts at correction. Most breast implants done in theU.S.today are done under the muscle.

The Implants-

On November 17, 2006, the FDA lifted the moratorium on the use of silicone gel implants for breast augmentation. This means that women now have the choice of silicone or saline implants for their surgery. I still feel that for the vast majority of women, saline implants (filled with sterile, salt water) provide a result that is on par with silicone gel implants and will for the forseeable future will continue to recommend them to my patients. They are excellent implants and provide wonderful results for most patients. One advantage to saline is that if the implants ever rupture or leak, the saline is harmlessly absorbed by your tissues and eliminated. Replacing a leaking implant is quite simple and easy to do. Women with unusually thin skin and minimal breast tissue, may benefit from the gel implants because they tend to produce less rippling. This fact may be more important when the implants are under thinner tissue. The new gel implants have a more viscous gel that will not run, so leaks should not be as messy as in the past. One of the potential problems with gel implants is difficulty detecting leaks and it is recommended that women get an MRI 3 years after implantation and every 2 years after that to check for leaks. The cost of an MRI is around $1000 and insurance will not cover this examination for the purpose of diagnosing a leak in a cosmetic implant. I do not feel that it is realistic to expect a breast implant to be in your body for decades without a significant chance of a leak at some time in the distant future.

Both saline and gel implants come in several styles. There are round/smooth, round/textured, anatomical/smooth, and anatomical/textured. Textured implants have a higher leakage rate and are more prone to show visible rippling through the skin than smooth implants. I donÂ’t use them. Anatomical implants may move around inside the pocket. They can rotate, spin, flip, etc. and this can affect the contour of the breasts. Anatomical/textured implants can be useful in some patients but the majority of breast augmentations in the U.S.are done using round smooth implants because these produce the best results in most patients. For most of my patients, I recommend round, smooth implants.

The most important decision to be made, which will determine your results, and satisfaction, is the size of implant chosen for you. This is an inherently subjective process. There is no formula, computer program, or method outside of surgery which can precisely determine the best implant for you. Putting implants in your bra will not tell you what these will do for you inside your breasts. I believe that intra-operative sizing is the best way to decide the ideal implant size for my patients. I encourage you to tell me what your goals are. Unless, you wish otherwise, I try to produce a result that will look natural, look well proportioned to your body, have normal sensitivity, and feel as normal as possible. Sizing is done by putting a sizer into each breast and inflating these until the desired result is seen. I have sized nearly every patient I have done over 23 years and less than 1% have not been satisfied with the size chosen. When patients have chosen their own implants, they have almost invariably been disappointed. If you are unhappy with your implant size, I will recommend that you live with them for one year. Some patients simply take longer to adjust to their new appearance. If, at the end of that time, you still wish for a bigger, or smaller, implant, I will offer to exchange your implants for new ones at a discounted feeThis offer is good for one year from the date of your surgery.

Bra cup size-

Please understand that there is no established standard for what is an A, B, C, or D cup bra. The cup size of one manufacturer’s bras is not identical to that of anothers. Patient preferences often determine what cup size they wear. This is why using cup size to describe breasts is very imprecise and I have not found it very useful. While I will do my best to get you the cup size you wish, my primary goal is not a specific cup but, rather, a happy patient. If you are happy with your results, then cup size is secondary. If you desire something more conservative, or “showy”, please let me know. As long as it is not medically inappropriate, or dangerous, I will do my utmost to help you achieve your goals.

Recovery and convalescence from surgery-

Some postoperative discomfort is to be expected from all surgery and breast augmentation is no exception. You will receive medications for pain and this will usually keep you fairly comfortable. Most patients are off of the prescription medications within a few days. A few may need a refill. You should remain sedentary and quiet for the first 5-6 days. After I see you for your first postoperative visit, if you are doing well, I will no longer restrict your activities. This means that you can resume doing whatever you can do comfortably. Just use common sense and donÂ’t overdo things like exercise, etc. for a week or two. You should be back up to 100% within 4 weeks. The total recuperation  period is between 3 and 6 months and I always follow patients for at least 6 months before discharging them, to be sure everything has turned out well. I recommend my patients return for a brief check up every 2 years or so to verify that all is well with their breasts and implants. There is no charge for the visit, ever. If you have a concern about your implants, there is no charge to see me for this, ever.

Photographs-

Photographs will be taken of your breasts before surgery and at your final visit. This is to help plan your surgery and assess the final results. They do not show your face and are not shown to anyone without your express, written permission. You are welcome to have copies of your before and after pictures if you wish. You may be asked for your permission to use your photographs in our practice and this would be greatly appreciated but you should feel no obligation to allow their use if this makes you uncomfortable.

Breast augmentation; the upside-

Among operations in general, and cosmetic surgery in particular, breast augmentation has one of the highest satisfaction rates. In studies of patients who have had breast implants for over ten years, the satisfaction level is consistently greater than 90%. It is very uncommon for patients to be less than satisfied with the results of their surgery. Even those patients who have complications, or less than perfect results, tend to prefer their breasts with implants over how they were before surgery. My goal is that six months after your surgery, you will be able to say that you are delighted with your decision to have this surgery. 

Breast augmentation; the downside or risks/complications/limitations-

Breast augmentation, like all surgical procedures carries risks, and complications can occur. Every effort is made to prevent complications but no operation, and no surgeon, is perfect. Every procedure has limitations in what it can accomplish. Below is a listing of the more common risks and limitations.

 Capsular contracture- All breasts will form a layer of scar tissue around the implant. This scar is called a capsule. If the capsule shrinks (contracts), and/or thickens, it can begin to squeeze the implant and this can make the breast feel hard. Severe contracture can distort the breast shape or even be painful. No one knows exactly why a few patients do this. Contracture to some degree occurs in between 3 and 5 % of patients and it is not possible to predict who these will be. If a contracture occurs severe enough to produce an unacceptable outcome, correction will require revision surgery. There will be an additional cost for this revision which will cover the expenses of surgeryYou may be asked to follow a program after your surgery to prevent contractures. This may include taking vitamin E orally, massaging your breasts, and wearing a compression bra or strap. Not all surgeons do all these things.  It is very important to follow my instructions carefully, but even diligent adherence to this program does not guarantee that a contracture will not occur. If you experience capsular contracture, undergo a revision attempt, and the contracture re-occurs, I will not do another revision, since I feel the chance of success at that point is very low. If the result is not acceptable, I will offer to remove your implants at no additional cost to you.

Capsule stretching- Less common than contracture, in some patients, the implant pocket may gradually stretch. This can result in too much visible movement of the implants. When you lay down, the implants may shift too far to the side. When you sit up, the implant may sit too low on the chest, making the nipple look too high on the breast. This problem is difficult to correct and requires surgery to tighten the implant pocket with stitches. This is more difficult to fix than contracture. There will be a fee for this type of corrective surgery just as for a revision as noted above. Successful correction of this condition cannot be guaranteed.

Leakage- Saline implants have a risk of leaking of between 5 and 9% in the first 10 years. After that, the failure rate increases by 1% per year. Your implants carry a lifetime replacement warranty. If they leak or fail for any reason, you will be given 2 new implants by the manufacturer. For the first 10 years after surgery, the manufacturer will pay the costs of replacing one implant ($1200). You can obtain $2400 of coverage, for replacement of 2 implants by paying the manufacturer $125 within 30 days after your surgery (I strongly recommend this). You will receive a brochure explaining this. Leakage is harmless, as noted above. Some implants deflate overnight. Others may take weeks to become obvious. All leaks eventually become obvious. The presence of capsular contracture increases the risk of implant failure. Gel implants have a leak rate of between 0.5-2.7% over 3-4 years. As I explained earlier, gel implant leaks are much harder to detect.

Visible rippling and wrinkling- Implants cannot perfectly mimic the breast tissue that you do not have naturally. Saline implants, as they settle, can produce visible and/or palpable ripples and winkles in the skin of the breasts. This is more likely the larger the implant is relative to the natural breast. Contracture of the pocket makes implant rippling and failure more likely. You must understand that breast augmentation is an unnatural process that tries to produce a natural result. A few patients may get that perfect result which looks and feels entirely natural. Most patients get excellent results, albeit not perfect. Rippling and wrinkling only rarely cause dissatisfaction with the procedure.

Abnormal movement of the implants- because implants are not the same as your natural breast tissue, the way they move in your breasts will not exactly mimic breast tissue. You may see the implants shift as you change position. This is more likely in patients with very thin breast tissue and skin. If your implants are under the muscle, when you forcefully contract the muscle, the inner, lower area of the breasts will probably flatten and the implant will visibly move. This is only rarely objectionable. Correction requires additional surgery to move the implants to an above muscle position. I have never been asked by a patient to do this. There would be a fee to cover expenses.

Loss of nipple/areola sensitivity- 90% of women will not lose any of the natural sensitivity of the breast, especially the nipple/areola area. Most patients will have some numbness in the breast skin, most often in the lower half of the breast. This usually resolves in a couple of months. Hypersensitivity of the nipples can occur and this usually resolves more rapidly, but may persist in some patients. In a few patients, loss of some degree of normal sensitivity may be permanent, and in a rare patient, the breasts may be quite numb. So far, no patient of mine has ever returned dissatisfied with the surgery because of loss of feeling. Removing the implants is not expected to reverse loss of sensitivity.

Calcifications in the breast tissue- over years, calcium deposits may form in the tissue around your implants and this can appear on a mammogram. The calcium deposits are harmless but can make interpretation of mammograms difficult. Rarely, clarifying the nature of calcium depostis may require a biopsy of the breast. Any surgery on your breasts carries the risk of harming the implants in some way.

Cancer and other illnesses- At this time, it is almost universally accepted that women with breast implants do not have an increased chance of developing breast cancer. Numerous studies over the past 20 years, of tens of thousands of women, have failed to demonstrate any link between breast implant surgery and increased risk of developing any disease, whether autoimmune or not. While this is not a guarantee that this cannot happen in some exceptionally rare circumstance, it should reassure patients that the chances are extremely remote. In January of 2011 the FDA  began a registry to look at a possible connection between breast implants and an extremely rare form of lymphoma of the breast- anaplastic large cell lymphoma (ALCL). The risk is measured in the fractions of a fraction of one percent. To date, only 80+ women, worldwide, with implants have developed this lymphoma. The numbers are too small to draw any conclusions. Most case seem to involve implants placed for reconstruction, implants older than 8 years, and textured implants. There appears to be a connection but we do not know what it is. The FDA has not felt this problem justifies any change in the status of breast implants as a medical device.

Interfering with mammograms- implants do block x-rays and produce a shadow on mammograms. To get around this, mammogram techniques are modified for women with implants. An Eklund, or displacement, technique is used to push the implants out of the way, and additional views are taken. Most, but not all, of the breast tissue can be seen. It is theoretically possible that a small lump might be missed, and if this lump were cancerous, this could result in a delay in diagnosis and treatment. Studies have compared breast cancer patients who had breast implant surgery with those who never had implants. No statistical difference has been found in the results of the cancer treatment between the two groups. Capsular contracture, by making the breasts difficult or impossible to compress can compromise mammography. Breasts that stay soft can be examined by mammography more effectively. This is why I feel compliance with the  program of breast massage, taking vitamin E, and using a compression garment to help keep your breasts soft is so important. I recommend adherence to the American Cancer Society guidelines for obtaining mammograms for my patients.

Complications common to all surgery- Breast augmentation also has many complications in common with other surgeries. These include, but are not limited to, such things as infection, bleeding, poor quality scars, delayed healing, injury to structures in or around the area of surgery, complications related to anesthesia, and complications which can be serious, or even life threatening, such as blood clots in the legs or lungs, heart attack, stroke, pneumonia, and more. The likelihood of any of these happening to you is less than 1%. There are many more potential complications of surgery, enough to fill a book, but most are exceedingly rare and will probably not be seen in a surgeonÂ’s career.

Summary of complications- While complications from breast augmentation are rare, they can and do occur. The only way to completely eliminate the potential for complications is to avoid having breast implant surgery.

Future surgery-

It is highly likely that at some time in the future you will need, or simply desire, another operation on your breasts as a result of implant surgery. The most likely would be to replace a leaking implant but you may also elect to remove them at some time, exchange them ( for something larger, smaller, or, perhaps, a newer, better implant than is available today), correct a late occurring contracture (this is rare but can happen), perform a breast lift for sagging, or some other procedure. Because breast augmentation is a cosmetic procedure, any surgery related to this will probably be regarded as cosmetic by most insurance companies and, therefore, not covered by insurance.

What will your breasts look like years from now?-

Many things will affect your appearance over the years. Pregnancy (if applicable), weight loss or gain, health issues, habits (exercise, sleep, diet, smoking, drinking, etc.) the manner in which you age, and your genetic makeup, to name a few. It is therefore impossible to predict how your breasts will look years from now. After implant surgery, your breasts will be heavier and gravity will affect them more. I recommend that you not go braless routinely. Beyond your skin and some fine ligaments within the breasts, both of which will stretch with time, a bra is the only support your breasts have.

Smoking and breast augmentation-

Besides being one of the worst things for your health, smoking can have very significant adverse effects on the results of breast augmentation. Patients exposed to cigarette smoke during the critical period before and after surgery are much more prone to developing capsular contracture, which I discussed above. This holds for those who smoke themselves, and those who inhale much second hand smoke. This serves as my disclaimer that states you will be responsible for any ill effects of smoking. If capsular contracture occurs in a smoker, the fee for revision surgery is higher than for non-smokers as an added inducement to quit.  Smoking should be stopped for 6 weeks before surgery and abstained from for a full 3 months afterwards. Ideally, you should stop altogether!

Guarantees-

When I perform breast implant surgery, I can only guarantee one thing; that when I do the surgery, I will bring to bear all of my skill and experience on that day to provide you with the best result that I can. There are innumerable variables and intangible factors that can affect the outcome of any operation. Many of these are out of my control, and yours. You must understand, and accept, this small degree of uncertainty if you wish to undergo a breast augmentation. If you decide to move forward with the surgery, it is my hope that six months later, you will be very glad that you had the surgery. I will do my utmost to achieve that goal.  

I have read all of the  information in this handout and/or it has been explained to me. All of my questions have been answered to my satisfaction. I understand and accept the risks and limitations as explained to me and listed in this handout. I desire to proceed with breast augmentation as discussed.

 

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Patient signature                                 Date

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Witness signature                                Date

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Richard T. Bosshardt, MD, FACS     Date

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