Breast Implants
Iowa Plastic Surgery
IMPLANT PLACEMENT: SUBGLANDULAR, SUBMUSCULAR OR BIPLANAR
The breast implants have several options for placement. They can be put under the muscle or under the breast tissue (over the muscle). Generally, we recommend them to be placed under the muscle so that better quality mammograms may be obtained. If the surface of the implant has creases or ripples, these will be less visible when the implant is under the muscle. Muscle does not cover the entire implant, generally the upper two thirds. In addition, if the implants become firm, this may be less noticeable under the muscle. There is more of a covering over the implant when the implants are placed under the muscle, rather than just a thin layer of breast tissue. The disadvantages to placing them under muscle include: more postoperative pain for the first 48 hours, and a longer time for the implants to settle.
When the implants are placed under the muscle and because the muscle attaches to the breastbone (sternum), there can be a gap in the cleavage. If you start with more cleavage, and have a narrow breastbone, this will not be noticeable. Placing the implants under the muscle detaches only a few of the muscle fibers that insert into the ribs. It does not detach the majority of the muscle that goes from the clavicle to the sternum and should not affect the strength of the muscle. When placing them under the muscle it is much preferable to undergo general anesthesia.
Implants can be placed under the breast tissue (above the muscle). This may be preferable in some cases when there is droop or an unusual shape to the chest. The implants may be more noticeable and mammograms may be more difficult to obtain. Many physicians feel the rates of implants becoming firm are significantly higher. There also is less pain and this can be done under local anesthesia with an incision underneath the breast.
The implants can be place partially under the muscle (biplanar), with the top part covered by muscle, and the lower portion underneath the breast. This allows the implant to fill up more droop or deflation after pregnancy. This biplanar placement is done with the infra¬mammary incision and can correct more droop without a breast lift when combined with a shaped implant. It is a natural mature looking breast but avoids the extra incisions of a lift.
Incisions
Incisions can be placed around the nipple, underneath the breasts, or through the armpit. The around the nipple incision may be used in conjunction with a breast lift. Under the breast incision is the easiest for the surgeon to perform and also may be used if there are shape problems or if the implants are to be placed above the muscle. Both these incisions do leave a scar on the breast. A third option is to place a small (usually ¾ of an inch) scar inside the armpit. We find this fades the best of the three incisions and is the least visible and leaves no scar on the breast. Some implants can be placed through an incision in the navel, however the disadvantage to this approach we believe far outweigh its advantages.
Risks
The risks of implants can be largely divided into two classes: those related to having a surgical procedure and those related to implants.
Those related to any surgical procedure include scars, hematomas (bleeding), infections, numbness, asymmetry or poor results. Any of these complications can result in additional costs to you as a patient. There can be additional facility, anesthesia or implant costs. We do not charge a surgeon’s fee to take care of complication in the first three months, when they are corrected by us.
Hematoma is bleeding that occurs underneath the muscle. It is generally not life threatening, but would result in a severe swelling of the breasts and require a return trip to the operating room to wash out the blood. This occurs in 1% of the operations. Infections also occur in 1% of the operations. Bacteria live on our skin and despite careful cleansing and antibiotics, infections can occur. Unfortunately, when an implant becomes infected it acts as a foreign body and generally the implant has to be removed for the infection to resolve. The implant is left out for approximately three months before a new one is inserted. Bleeding and infection may result in additional facility, anesthesia, and implant fees (there is no additional surgeon’s fee). Smoking increases the risk of infection due to healing complications. These complications seem to occur less often when the implant is placed through the armpit incision.
Scars occur with any operation and take time to fade, and rarely patients will form hypertrophic or ugly scars.
Asymmetry (unequal size or shape) occurs in 2% to 4% of patients. Minor asymmetry occurs more frequently than that. Many patients are asymmetric before surgery and one nipple or fold of the breast is in a higher or lower position than the other, and this cannot always be corrected. Sometimes this is not as noticeable until the breast has been enlarged. One breast may have tighter or looser skin than the other side, and this affects the position of the implant. One side of the chest may be wider, or the breast shaped differently, which also will remain different and not changed by implants. However, the implant may heal in a higher or lower position on one side or the other. Some of this asymmetry can be corrected postoperatively by either wearing a bra or a breast band that either pushes one or both the implants down. Many times after placement of the implants under the muscle the muscle will go into a spasm in the first several days, pulling the implants into a higher position. About 2% of the time it requires another procedure to correct.
The operation may also result in changes in sensation in the breast or nipple, including numbness 1% of the time.
The risks of implants also include deflation or rupture of the implants, capsular contracture around the implants, and perhaps more difficulties with mammograms. First of all, the breast implants do not cause breast cancer. In fact, several studies have shown that women with breast implants have lower rates of breast cancer than non¬implanted women. This is not to imply that breast implants have this beneficial effect but may show a relationship between statistics and actual cause and effect.
Capsular contracture or firmness of the implant is due to scar tissue around the implant. The body forms scar tissue after any operation. The body will put scar tissue around any implant. In the case of a hip or knee implant, this may benefit, as it helps hold it firmly in place. Unfortunately, in the case of a breast implant, this may make it feel too firm, hard, or unnatural. Thin patients without much scar tissue may see or feel rippling of the skin over the implant, usually in the lower portion not covered by muscle.
The saline implants can deflate. The implant moves with your body and since they have a silicone shell, this shell will also move multiple times and could develop a stress fracture. They can also be punctured. Routine activities will not cause deflation. The deflation rates are currently about 1% per year or less. It can happen the first year, ten years later, or never happen. There is no "life expectancy" of the implant.
Gel implants do not deflate, but they can rupture. The gel is thick and is enclosed by the scar tissue that forms around the implant. MRI examinations are recommended in the United States at 3 years and then every 2 years to look for rupture. The United States recommendation is to remove a ruptured gel implant and replace it when that occurs. You must be 22 years of age or older for a gel implant.
The implant might interfere with the quality of mammograms. Techniques that can be done to correct this include placing the implants under the muscle or obtaining an additional view on mammogram. If you have a strong family history of breast cancer, this should be discussed with the physician.
