PLASTIC SURGERY OF THE BREASTS – AUGMENTATION, REDUCTION AND MASTOPEXY

BREAST AUGMENTATION WITH SILICONE IMPLANTS (AUGMENTATION MAMMOPLASTY)

Indications – the women’s breasts represent some of the greatest symbols of femininity and contribute greatly to the sensuality of the female sex. Breast augmentation, or augmentation mammoplasty, is one of the most common plastic surgery procedures performed today. Over time, factors such as age, genetics, pregnancy, weight changes, sun exposure, and gravity can cause the size and shape of the breast to change. Women who are dissatisfied with the size of their breasts, or have experienced changes in breast appearance can achieve a fuller, shapelier breast with breast augmentation. The surgery is indicated after the age 18 when the breast structure completes its development.

Preoperative period (before surgery) – The type, style, and size of breast implants that are chosen are determined by the patient’s lifestyle, body contours, the amount of breast tissue the patient has, and the cup size and appearance that she would like to achieve. It is important to perform some laboratory exams and other evaluations previously requested. The use of medications containing salicylic acid or vitamin E should be avoided 10 days before surgery. Smokers should quit smoking 15 days before surgery. It is necessary to stop any oral intake (not even water) 8 hours before surgery.

Surgical Technique – The surgery can be performed as an outpatient procedure. Breast augmentation procedures typically last approximately 1 to 2 hours. Depending on the nature of the procedure, a local anesthetic in combination with intravenous sedation or general anesthesia will be used. The incisions in breast augmentation are small and positioned in hidden anatomical places. The inframammary and the periareolar incisions are the most common incisions used in breast augmentation. The inframammary incision is placed along the crease of the lower portion of the breast. A single, small incision is made along each breast. Using the periareolar incision, a single small incision is usually placed along the perimeter of the areola in each breast. Breast implants can be placed in 3 general locations, known as submuscular, subfascial and subglandular placement. Submuscular placement refers to an implant that is placed partially or completely beneath the pectoralis muscle, against the chest wall. In contrast, subglandular placement refers to an implant that is placed beneath the breast tissue, but above the pectoralis muscle. The subfascial placement refers to an implant that is placed above the pectoralis muscle but beneath the pectoralis fascia. The incision is opened in order to gain better access to the breast tissue below. Although the incision will be made as inconspicuously as possible, its length and appearance may vary depending on the type and size of implant and the patient’s body contours. The breast tissue is separated in order to reach the area of the breast where a pocket in which to place the breast implant will be carefully formed. Silicone implants are made of a silicone rubber shell and are filled with cohesive silicone gel. Breast implants differ by shape, texture, and profile. The shape of breast implants may be round or contoured, and may have a smooth or textured surface. The breast implant profile may be standard, moderate, high or ultrahigh. The size and volume of silicone implants also vary. They are long lasting (do not need to be changed, except in special situations). During breast augmentation, a breast implant is placed inside a pocket formed in the breast tissue. This can help to increase or balance the size of the breast, restore breast volume, or restore the shape of the breast after partial or total loss. It is important to realize that breast augmentation cannot correct significantly sagging or drooping breasts. In these instances, a breast lift is often necessary, which may be performed in conjunction with this procedure. There is no significant evidence that suggests silicone implants increase the risk for breast cancer, connective tissue disorders, or autoimmune disease. The incisions are sutured with stitches hidden into the dermis or intra dermal sutures, with no need to be removed. The stitches will dissolve with time.  A first dressing is applied, to be maintained dry until the first dressing change. The use of a bra is indicated.

Postoperative period (after surgery)– In the first days after the surgery the breasts are maintained lightly dressed in order to avoid pressure on the operated area. The patient goes home around 6 hours after surgery, with a dressing that cannot be soaked during bathing, oriented to rest until the removal of the first dressing. At this time another dressing is done and the patient is free to take a full shower. Resting in a sitting position is indicated, avoiding arm movements for 3 days after the surgery. After that the patient can resume most of his normal activity and return to work, including driving vehicles. However, it may take 30 days to be able to return to full normal activity including heavy lifting and strenuous exercise. A tight-fitting bra reduces swelling by preventing fluid build up, as well as provides comfort and support during healing. Depending on the extent of surgery, the patient has to wear a special bra up to 60 days. As with any major surgical procedure, the patient most likely experience bruising and swelling, which subside after few days. While not being able to move her arms freely, it is important that the patient begin to walk for short periods soon after the procedure to facilitate blood flow. Although the surgery leaves a permanent scar, it will slowly fade over time. It is important to realize that if the patient become pregnant or experience substantial weight gain or loss, the results from the procedure may be compromised. However, with proper diet and exercise, the results from a breast augmentation can be maintained for several years. Sun exposure and sea or swimming pools bathing are liberated after 30 days. Customarily breast augmentations are not associated with pain, only sometimes patients equivocally interpret as pain a sensation of breast fullness caused by muscular and skin stretching, witch subsides after a few hours. Special bra provide support and comfort, minimize swelling, and help to maintain the position of the implants. It is important to realize that the breasts will continue to change shape over time. However, the results from breast augmentation are typically long-lasting, which means that the breasts will maintain the fuller, shapelier appearance that women desire for years to come. An esthetic result, however, is not defined by the volume gained by the patient’s breasts, but the adequacy and breast contour related to the rest of the body. Future pregnancies and substantial changes in weight following a breast augmentation may decrease the effectiveness and longevity of treatment, and that is the reason why we strongly recommend the patient to control body weight after surgery. Around the silicone implants a fibrous capsule develops, customarily thin and inconspicuous. In few cases a capsular contracture develops leading the breast to feel tighter throughout palpation. In rare cases it requires the withdrawal of the implant trough the same incision and wondering about the reintroduction of other prosthesis, different placement or another conduct best suited to the case. Capsular contraction does not depend on the doctor conduct, but reflects a reactive behavior of the patient’s body to the presence of the silicone implant. The surgery does not prevent women from breastfeeding, once it does not interfere with lactation (production of milk). Also, breast implants are not associated with the development of cancer or autoimmune diseases.

PLASTIC SURGERY OF THE BREASTS - REDUCTION AND MASTOPEXY

Indications – A woman’s breasts help define her femininity, and with the vast differences in shape, size, and appearance, breasts further help to define her individualism. Therefore, changes to the breasts can be dissatisfying and make women feel as if they are losing some of their femininity and youthful vitality. Like other areas of the body, the breasts undergo changes in response to factors such as genetics, the aging process, pregnancy and breast feeding, weight gain or loss, and hormonal fluctuations. Breasts that were once firm and shapely often begin to sag and droop giving them a loose or heavy appearance. A breast lift, or mastopexy, can help restore a firmer, shapelier breast, which will improve body contours and give the breasts a perky, youthful appearance. Although there are many factors that can contribute to sagging of the breasts, the aging process and the effects of gravity play a primary role in these changes. Just like facial skin, the skin around the breast loses its elasticity in response to a gradual breakdown of the skin’s support network, which causes it to become lax. In addition, the suspensory ligaments that attach the breast to the chest wall weaken and stretch in response to gravity. The breasts enlarge during pregnancy and breast feeding, which further causes the skin to stretch. As the breasts reduce in size following pregnancy, the skin that was once stretched, is now loose and sags. Lastly, fluctuations in your weight and even hormonal changes can cause your breasts to change in appearance. In combination, these factors can cause the breast to droop. The surgery is indicated after the age 18 when the breast structure completes its development.

Preoperative period (before surgery) – It is important to perform some laboratory exams and other evaluations previously requested. The use of medications containing salicylic acid or vitamin E should be avoided 10 days before surgery. Smokers should quit smoking 15 days before surgery. It is necessary to stop any oral intake (not even water) 8 hours before surgery.

Surgical Technique - The surgery can be performed as an outpatient procedure. The breast lift procedure may last approximately 1 to 4 hours, depending on the complexity of the procedure and whether an additional procedure, such as breast augmentation, is performed at the same time. Prior to the start of the procedure, the treatment area will be cleansed and an anesthetic will be administered, most likely general anesthesia in which the patient is asleep during the procedure. In addition, incision guidelines are drawn to indicate the areas of skin that will be removed during the procedure.  During a breast lift procedure, loose, excess skin is removed, and the remaining skin is tightened. As a result, the overall shape of the breasts is improved, and they are lifted to a new, more upright position. The degree of ptosis, or sagging, of the breasts is accessed, to determine the best procedure for each patient. There are generally three degrees of ptosis classified as minor, moderate, and severe, which are determined by the position of the areola relative to the inframammary fold and the sternum. In general, minor ptosis exists if the areola lies at the inframammary fold. If the areola lies approximately one to two centimeters below the inframammary fold, the breasts have moderate ptosis, whereas the areola may lie two to three centimeters below the inframammary fold and rotate downward in cases of severe breast ptosis. There are four basic breast lift techniques known as the periareolar, circumareolar, vertical, and anchor technique, used to correct increasing ptosis, respectively. The periareolar, or crescent, technique involves a crescent, or half-moon shaped incision made around the top of the areola. This technique is a minimally invasive procedure that achieves a small degree of lift. Therefore, it is appropriate for individuals with small breasts or minor breast ptosis. The circumareolar, or doughnut, technique involves a circular incision made around the areola. This technique is a minimally invasive procedure that achieves a small degree of lift. Therefore, it is appropriate for individuals with small breasts or minor breast ptosis. The vertical technique involves a v-shaped incision that extends around the top of the areola and down the midline of the breast. Although this procedure is slightly more invasive, it achieves a large degree of lift. Therefore, this type of incision is appropriate for individuals with larger breasts and moderate to severe breast ptosis. The anchor technique involves an anchor-shaped incision that extends around the top of the areola and laterally across the lower portion of the breast. Although this technique is the most invasive type of breast lift, it achieves the greatest amount of lift. Therefore, it is appropriate for individuals with large breasts and severe breast ptosis. An incision is carefully made along the pre-marked lines. The incision extends beyond the upper perimeter of the areola. This area marks the new upper perimeter of the areola. The area below the areola will be pulled together and tightened, resulting in a more upright breast position. The skin is lifted and separated from the underlying tissues below. The areola and nipple are left intact, as the areas of surrounding skin are removed. In order to ensure that the breast has complete mobility, it is necessary to undermine, or remove, tissue along the perimeter of the incision line. Once the excess skin has been removed, a suture of the uppermost perimeter of the areola to the outermost perimeter of the incision is done. In doing so, the areola and breast tissue are lifted to a new, more upright position. The incision is closed by placing hidden sutures along the vertical midline and inframammary fold, as well as around the perimeter of the areola. Then, external sutures are placed along the incision as well. Lastly, steri-strips and gauze bandages may be applied in order to protect the incision sites, and this first dressing is changed in 3 days. Until there the dressing must be kept dry. The use of a special bra is indicated.

Postoperative period (after surgery) - In the first days after the surgery the breasts are maintained lightly dressed in order to avoid pressure on the operated area. The patient goes home around 6 hours after surgery, with a dressing that cannot be soaked during bathing, oriented to rest until the removal of the first dressing, 3 days after the surgery. At this time another dressing is done and the patient is free to take a full shower. Resting in a sitting position is indicated, avoiding arm movements for 3 days after the surgery. After that the patient can resume most of his normal activity, and return to work, including driving vehicles. However, the patient must avoid strenuous activity such as exercise and heavy lifting for 30 days after the procedure to allow the body sufficient time to heal. The patient will be able to notice a dramatic difference in the shape and position of the breasts immediately following the procedure, and may continue to notice a change in the appearance of the breasts as swelling subsides and they settle into their new positions. As with any major surgical procedure, the patient most likely experience bruising and swelling, as well as numbness around the areola may occur, all of which subside after few days. The tight-fitting bra reduces swelling by preventing fluid build up, as well as provides comfort and support during healing. Depending on the extent of surgery, the patient has to wear a special bra up to 60 days. While not being able to move her arms freely, it is important that the patient begin to walk for short periods soon after the procedure to facilitate blood flow. The majority of the stitches may dissolve with time. However non-dissolving stitches will be removed in approximately 7 days. Although the surgery leaves a permanent scar, it will slowly fade over time. With proper diet and exercise, the results from a breast reduction or mastopexy can be maintained for several years. Sun exposure and sea or swimming pools bathing are liberated after 30 days. Customarily these surgeries are not associated with pain, only sometimes patients equivocally interpret as pain a sensation of breast fullness caused by muscular and skin stretching, witch subsides after a few hours. Although there will have permanent scars following a breast lift, the scars will slowly fade to thin, white lines with time. It is important to realize that if the patient become pregnant after having a breast lift, the effects of pregnancy and breast feeding may compromise the results, and cause the breasts to sag and change shape. Although a breast lift cannot stop the aging process, it can help not only to improve the position of the breasts, but restore the fuller, shapelier appearance desired for years to come. An esthetic result, however, is not defined by the reduction of volume in the patient’s breasts, but the adequacy and breast contour related to the rest of the body. To improve the effectiveness and longevity of treatment, we strongly recommend the patient to control body weight after surgery. The surgery does not prevent women from breastfeeding, once it does not interfere with lactation (production of milk).