Breast Augmentation

You might be confused by the terminology around implant placement: above the muscle, below the muscle, submuscular, subglandular, subfascial or dual plane. Different surgeons have different preferences, but it all depends on your weight, skin type and lifestyle. Dr. Demirkan will help you make the best decision for your operation.

Let's Make it Clear!

Your chest is covered by the pectoralis muscle in the upper and inner parts, with a thick membranous covering called fascia. A breast implant may be placed:

• Over the muscle — called subglandular.
• Over the muscle but below its fascia — subfascial, practically the same as subglandular.
• Under the muscle — submuscular; the muscle does not cover the implant in the lower-outer quadrant.
• Under the muscle, after separating its lower half from the breast tissue — the dual plane, which frees the lower pole as the muscle slides upward.

Which Plan is Best for You?

You may not be aware of sagging in your breasts when they are small or atrophied. Limited sagging may be treated by breast augmentation alone. A common question is whether a bigger implant removes the need for a lift; however, if there is a significant descent of the nipple or excess skin, augmentation alone may create bad results — from bigger but low-set breasts to big breasts with nipples pointing even further down.

Dr. Demirkan will carefully evaluate your breasts and discuss your aesthetic goals to help you decide whether to have a concomitant lift. The position of the nipples, skin elasticity and the sternal-notch-to-nipple distance are crucial factors.

Degrees of Ptosis

The breast augmentation incision is quite short, measuring 4.5 cm in length, and has a quick healing capacity. Several incision sites have been used in the past; however, at present the inframammary approach is the gold standard. The previously popular periareolar incision has been associated with higher capsular contracture rates, and the axillary approach was more usable with saline-filled round implants.

Simulation in breast augmentation has been available for almost two decades; however, it may still be more virtual than real. 3D imaging technologies from companies like Vectra, Crisalix, or newer 2D-to-3D techniques may stumble when estimating soft-tissue dynamics, so virtual reality is used only as an adjunct in deciding the size and shape of the implant.

Another type of simulation uses try-on sizer kits, letting you feel the weight and see the size by placing silicone cones in your bra — still a crude way to decide.

Dr. Demirkan analyzes your breast features, understands the size you wish, and chooses a range of implants that may fit. During surgery he performs a real try-on with implant sizers — sterile, disposable, one-to-one replicas of the actual implant — to find the best-fitting implant.

Perfect symmetry does not exist in the body, and breasts are no exception. You may not be aware of these asymmetries until your physician points them out: the nipples may be at different levels, one side may be larger, the inframammary folds may not match.

If the differences are minimal, it is best to leave them untouched. If there is a significant volume difference, the smaller side may receive a bigger implant, or the same implant may be used on both sides with fat injection to the smaller breast. Differences in nipple levels or sizes may need procedures that create additional scars, and tubular breast is another cause of asymmetry that needs a special approach.

Tubular breast is a congenital problem that creates a range of deformities in the form and shape of an already small breast. It may profoundly influence your psychosocial well-being and sexual life. Its correction needs expertise and sometimes reconstructive techniques; in severe forms, a two-stage operation may be required. Constricted breasts, tuberous breasts and herniated areola are other names for this problem.

It may be bilateral or unilateral, and is almost always asymmetric even in bilateral cases. It represents a congenital arrest in breast development, causing the following landmarks in varying degrees:

• Elevation or absence of the inframammary fold
• Breast base constriction — more in the lower quadrants
• Deficiency in the skin envelope — more in the lower pole
• Small breast volume
• Sometimes ptosis
• Areolar herniation

According to the degree of deformity, Dr. Demirkan offers a unique set of procedures for full correction, which may combine breast augmentation, breast scoring, breast lift, nipple reduction, nipple lift, tissue expansion and fat injection. Treatment is more difficult than plain augmentation but may have life-changing results.

Fat injection might be a way of breast augmentation by itself in a selected group of patients. Ideally, a fat-injection candidate should:

• Not be obese or very thin
• Be able to maintain a stable weight
• Expect a modest augmentation
• Have no ptosis at all
• Not have multiple breast cysts
• Not have suspicious calcifications on mammography
• Be a non-smoker

A more common indication for fat injection is to enhance the results of silicone augmentation. When used with implants, the operation is called Hybrid Breast Augmentation:

• Achieving symmetry
• Smoothing out visible implant borders
• Covering ripples
• Decreasing the distance between the breasts

Breast augmentation is an easy procedure compared to other aesthetic surgeries: it is short (minimizing the effects of general anesthesia), the incision is very short, and the operative area is restricted to the chest. The main post-operative problem may be the pain related to the expansive-compressive effect of the implants, particularly when placed sub-muscularly; subglandular augmentations are comparably less painful.

Dr. Demirkan uses special techniques for safe surgery and rapid recovery: meticulous tissue handling, precise pocket dissection that snugly fits the implant, a Keller Funnel no-touch insertion technique, drains to remove collected blood, and Exparel (a long-lasting analgesic) injected into the field before closing.

Timetable for recovery

When performed by a board-certified plastic surgeon, breast augmentation is a safe and effective procedure. The initial recovery period is very important to avoid complications. Following the 6-week healing period, there are a few more precautions you may take to increase the life span of your implants.

Important measures during recovery

• Avoid sleeping on your side or front for 4 weeks — the implants need to stabilize in their pockets.
• If you had a submuscular or dual-plane implant, avoid lifting heavy objects with your arms for 6 weeks (3 weeks for subglandular).
• Use the medical bra given by your physician — it fixes the implants in the desired position; avoid sports bras (push implants up) and wired bras (disturb the incision).

Precautions in daily life

• Support your breasts — they are bigger and heavier and prone to sagging, especially during jogging and jumping; a sports bra is essential during exercise.
• Protect your breasts from excessive movement during sexual activity, which can detach the implant from its adhesions and make it mobile.
• Avoid large weight fluctuations, which increase the chance of sagging.

Bra manufacturers use four different sizing systems depending on the geographic location: UK, Europe, Russia and Australia/New Zealand. But all use 'band size' and 'cup size' measurements, as shown in the table below.

This table is based on bra measurements in the UK.

Nipple sensation is erogenic and conveyed by a special nerve with a complicated anatomy — the 4th intercostal nerve, which sends branches to the nipple from both the inner and outer parts of the breast. These branches may be pulled during dissection or stretched by the implant, and postoperative oedema has a compressive effect as well. Dr. Demirkan uses a preoperative steroid injection and postoperative cooling to limit nerve injury.

Nerve injury may happen in about 5% of cases, and its occurrence is not related to the incision or implant-placement site. Larger-volume implants have been associated with nerve injury in some studies but not all. When changes occur, they usually recover over time.

You may breast-feed your baby even if you have had a breast augmentation. Only in cases where the incision was placed in the peri-areolar region might there be some obstruction of milk channels due to scar tissue. Loss of nipple sensation may be another cause of difficulty, as the hormones responsible for milk production are triggered by feeling the baby suckling.

Numerous studies have examined the transfer of silicone from mother to fetus and its presence in breast milk, and found no toxicity during or after pregnancy; any minute silicone levels in breast milk are more likely related to nutritional or environmental sources. There may be more discomfort during lactation in moms with implants, particularly with some capsular contraction.

Most studies do not show a significant change in breast sagging postpartum; however, pregnancy weight gain, genetics, the length of breast-feeding and the number of pregnancies all play a role. A planned pregnancy is not a contraindication for augmentation, but it is better to wait until full healing (about 2 months) before conception.

The longevity of breast implants is a question in almost every patient's mind. However, everything has a life span, and you should not expect to keep your implants for an entire lifetime — about a quarter of recipients have removed or changed them in the second decade.

Reasons to remove or change implants include:

• Capsular contracture
• Implant rupture
• Rippling
• Implant malposition
• Change to a larger or smaller size
• Implant change during a lifting procedure
• Personal reasons to remove

Many women do not need to change their implants even after 20 years — including the first-ever recipient, Mrs. Timmie Jean Lindsey, who wore hers for more than 50 years. Newer-generation implants have much longer durability. The FDA advises a control MRI 5-6 years after implantation to detect any rupture, repeated every 2-3 years thereafter. Most companies in Turkey provide a lifetime warranty for rupture due to production faults.

Introducing any foreign material into your body always induces the formation of a surrounding capsule, which aims to wall the foreign body off from your living cells. Breast silicones are no exception. In some cases this capsule thickens and starts to contract around the implant — this is capsular contracture, a gradual process that may halt at any stage, so a staging system is used.

Baker's classification system

• Grade I — no capsular contracture
• Grade II — some clinical contracture only your physician can detect
• Grade III — you notice the contracture due to hardening of the breast
• Grade IV — others can see the problem: overt deformity with hardness, pain and distortion

The cause is not known exactly, but studies suggest a role for the immune system. A strong theory is the formation of a 'biofilm' around the implant from skin bacteria introduced during insertion, creating a chronic low-grade inflammation; hematomas ease biofilm formation. Surface characteristics also play a role — textured surfaces are less associated with contracture, and a polyurethane-coated type has the lowest rate.

Capsular contracture may occur any time after surgery, but most cases appear within the first two years; the incidence is around 4-5%. Having Grade II does not mean it will inevitably advance. It is treatable: light cases may need only medical treatment, while significant distortion or pain needs implant replacement.

To prevent capsular contracture, Dr. Demirkan takes several precautions

• Textured implants are preferred.
• Before insertion, the surgical site is prepped again, gloves are changed and the pocket is flushed with a triple antibiotic solution.
• A Keller Funnel is used to prevent contamination during pocket insertion.
• Drains are used in every case to prevent hematoma.
• A massage program is encouraged during recovery.

ALCL is another risk associated with silicone breast implants. It is a fairly recent type of complication and may be the only tumor associated with breast augmentation. It is thought to be related to the factors associated with capsular contracture and the surface characteristics of some implants.

It is quite rare and confined to the implant capsule, hence has a good prognosis, with the majority achieving complete remission — early diagnosis is important. It usually manifests as a mass or effusion in the capsule. Symptoms may include discomfort, tightness in the chest, enlargement of a breast, a mass on self-examination, skin rashes and lymph-node enlargement in the armpits. The treatment is surgical: removal of the implants and their capsules with the tumor.