Surgery for breast augmentation can take one to one and one-half hours. Anesthesia is a general method whereby a tube is either inserted into the back of the throat only or into the airway itself. Intravenous fluids are administered as well as medications for comfort, infection control, and relaxation of the chest muscles when indicated.
Prior to surgery at consultation, the surgeon will discuss one of four sites for insertion of breast implants and place sizers in double test bras to get a very close approximation of patient expectations for cup enhancement. It is a reliable way to determine desired breast enhancement in this Practice, and eliminates the need for sizing the implant pocket during surgery. This figure demonstrates 3 of the 4 sites. A fourth site is through the belly button (TUBA) which requires endoscopic (video-assist) technology.
The latter method is more challenging but does limit the implant type to saline only since filled prostheses (such as silicone gel) cannot be maneuvered through a small endoscopic-directed incision. This method may not be preferred by implant manufacturers and carries a slightly higher incidence of liability in inexperienced hands. An experienced Plastic Surgeon will advise the incision, implant style, and method of insertion which achieves the best results for that particular Practice. There is really no difference in nipple sensation whether the incision is made near the breast or on the breast.
Larger skin incisions are required for insertion of silicone gel implants and the new gummy bear implants that are nearing FDA approval.
A breast implant may be placed in one of three locations: (1) behind the breast tissue but in front of the muscle (figure to the left, i.e. sub glandular), (2) behind the breast muscle (figure to the right. i.e. sub pectoral), or (3) between the muscle and the covering over the muscle (not shown, i.e. subfascial). In patients with small degrees of breast sag (ptosis), the surgeon can work in two pockets, one behind the breast and one behind the muscle (dual plane) which permits the nipple to elevate without the need for a breast lift (mastopexy).
Other internal tailoring methods may be used to position the implants with respect to the nipple. This can be done for minor and moderate ptosis, and pseudoptosis. There is no impairment as a result of placement behind the muscle. Sometimes when implants are placed over the muscle, the breast may sag over time and stretch away from the chest wall. It is therefore preferred to place most implants behind the muscle. For patients desiring larger breast implants, they are informed that the weight of the operated breasts can loosen the chest wall attachments and cause some lowering of the position, but the nipples will stay upright.
At surgery, the breasts will be inspected for symmetry and position of the implants which should rest just lateral to the vertical meridian of the nipple, and just below a horizontal line through the equator of the breasts. Often the implants will rest higher but soon settle over a period of 6 weeks. Breasts that are widely separated before surgery may not exhibit as much cleavage as do breasts which are closer together in the natural state.
Breasts that are tubular or pear shaped, or constricted at the bottom may not achieve the perfect round tear configuration most pleasing to patient and surgeon. Drains tubes may be inserted to remove fluids that can collect at surgery, although many surgeons do not use drains. Some surgeons feel that postoperative pain pumps are helpful and may insert small tubes for administration of local anesthetic in the first few days following operation. Local anesthetic may be used at the time of surgery by injection or irrigation of the implant pockets prior to insertion of the implants. The resulting scars are noted at the three main sites of implant insertion. These will fade in time. For re-operation to change implants or adjust the implant pockets, it is often more convenient to use the periareolar scar approach. For removal of implants, the lower breast fold approach may be preferred.