Plastic surgery of the breast usually involves breast augmentation, breast reduction, breast lift or breast reconstruction procedures. These procedures are usually performed to address asymmetry, increase or decrease size, improve contours and balance appearance.
Breast augmentation or augmentation mammoplasty, is a surgical procedure to enhance the fullness, shape, and appearance of a woman's breast. It is commonly performed with the use of a breast implant made of a silicone polymer shell. In the U.S., this shell is filled with water (saline filled) at the time of surgery, or is composed of a silicone elastomer gel (gel filled) which is pre-filled by the manufacturer at the time of surgery. All implants are made of the silicone shell which has a definitive lifespan. Women who undergo breast implant surgery should be informed by their surgeon that implants will last 12 to 15 years on average. When implants reach their lifespan or fail, the contents of the implant will leak (saline or gel) and will usually note a change in the appearance of the breast. Therefore, most women who undergo this procedure should do so with the expectation that they may need a revision or second operation for implant removal or replacement. In addition, women will be exposed to the contents (water or gel) of the implant when leakage occurs. In the U.S., gel filled implants were barred from patient use for several years pending a review case studies due to reports of a link between gel filled implants and auto-immune disease. Silicone implants remained available in other countries and no scientific link to illness has been reported. A retrospective review in the U.S. revealed no scientific evidence to support the claim that silicone gel increased the incidence of auto-immune disease in the women who filed such claims as the incidence in these women mirrored the development of such diseases in the normal population. However, it was felt by the FDA that further studies were needed in order to definitively determine if there was any greater risk on a prospective basis. Thus, silicone gel implants are available for placement by a board certified plastic surgeon. However, the physician and patient must be enrolled in an investigational study as well as meet certain criteria. In general, silicone gel filled implants have the advantage over saline filled implants in that they feel and appear more natural. In addition, in women with very thin skin or contractures from prior implants, silicone gel implants also provide an improved appearance over saline filled. Saline implants provide the benefit of adjustable sizes based on the amount of saline inserted and are less costly. There is also the peace of mind that comes from knowing that the implants are filled with water and no studies are necessary to inform you that this is safe.
Breast augmentation involves an outpatient surgical procedure in which the patient is asleep for 30 to 45 minutes while under the care of a board certified anesthesiologist. Although this procedure can be performed under local block and sedation, Dr. Coleman prefers that the patient is monitored by an anesthetist which allows him to focus on the surgery. Incisions are usually performed in the areolar area or in the lower fold of the breast tissues. In some cases, the incision can be performed in the axillae (armpit). Dr. Coleman at this time feels that reported complications from passage of implants through the umbilicus does not warrant performing this procedure through the belly button. Placement of the implant is usually below the pectoralis muscle which is cut at its inferior border. Certain patients such as competitive body builders or weight lifters are better candidates for placement above the muscle. The patient does have the option of placement of a pain catheter at the time of surgery to decrease postoperative pain. There is a healing period of 7 to 10 days in which the patient is restricted to very light activities. The first two postoperative days are the most painful. Most patients are able to return to work in some capacity in 5 to 7 days. Patients rate pain after this at 7 of 10. Patients can return to lower body and non-impact cardio activities in 10 days. Return to full activities is 6 weeks on average.
Risks associated with breast augmentation include implant failure, infection, contracture, decreased nipple sensitivity, and asymmetry. In Dr. Coleman's experience, the incidence of such major complications is extremely low. In fact, the most common reason for revisional surgery is for patient request for greater size enlargement. Elective breast augmentation is contra-indicated in woman under the age of 18, history of chronic breast pain or infections, inflammatory or immunological disorders.
Breast reduction or reduction mammoplasty, is a surgical procedure that addresses symptoms associated with enlarged breast by size reduction. Symptoms such as headaches, neck, back, and shoulder pain can be associated with enlarged breast. Some studies also suggest that pulmonary symptoms can also be associated with massively enlarged breast. Breast reduction mammoplasty can decrease many if not eliminate musculoskeletal symptoms secondary to enlarged breast. Most women feel that breast reduction also gives the appearance of significant weight loss. The procedure is performed as an outpatient under a general anesthetic. It requires the temporary placement of two drain catheters which are removed approximately one week after the surgery. Patients rate the pain 5 of 10. Patients will require 7 days of limited activity which usually includes time off work. Limitations of physical activities are required for a total of approximately 6 weeks. The procedure does result in rather extensive scars on the lower breast. Complications are rare but risks include loss of nipple sensitivity, asymmetry and inability to breast feed. In some cases, private insurance will cover the procedure if patients meet certain height to weight ratios, and have failed conservative treatment modalities such as weight loss, anti-inflammatory medications and therapy.
Breast Lift or mastopexy is a surgical procedure performed to lift the nipple/areolar complex and/or lower breast tissue. This is the procedure that is needed if it appears that the nipples are "heading south." The procedure is frequently performed in women who have excessive laxity of the skin as of a result of pregnancy or weight loss. The procedure is very effective in transposing the areola and lower breast to a higher position but does not necessarily provide the appearance of increased fullness. It is therefore often combined with an augmentation for those who necessitate elevation of the nipple but also desire increased fullness. The procedure is also effective in reducing the size of the enlarged areola. Mastopexy usually results in one of three different scars depending on the degree of elevation necessary. All scars are concealed with clothing that doesn't expose the areola or lower portion of the breast. Therefore these scars are not visible when wearing standard bras or bikini tops. A "crescent" or peri-areolar mastopexy involves the least scaring and results in a scar within the natural contours of the upper areolar border. Although it results in a scar that's often very difficult to discern, it may distort the areola. It is used most often in conjunction with an augmentation in which the nipples necessitate elevation by 2-3 cm. The vertical scar mastopexy is performed with a scar around the entire areola which extends to the fold of the breast. It results in a more visible scar but is effective in lifting the nipple 4-6 cm and can reduce the size of the areolar if desired. The full mastopexy is able to lift the nipple from 6 to 15 cm and reduce the areolar size but does necessitate the longest scar. The scar is similar to the inverted "T" or "anchor scar" used for breast reductions. Mastopexy carries the risk of unfavorable scars, asymmetry, areolar enlargement, and decreased nipple sensitivity.
Reconstruction of the breast is most commonly performed to replace soft tissue defects after mastectomy for breast cancer. In such cases, the reconstructive surgery is secondary to surgical treatment of the cancer. However it may be coordinating in many instances to be performed immediately after the mastectomy during the same procedure. Current treatment options for breast reconstruction are divided into those procedures using soft tissue obtained from other areas of the body and those using implants to enhance the residual skin surrounding the breast. Procedures using natural soft tissues (autogenous) require that ample tissue be available from other areas. This is most commonly obtained from the abdomen, (TRAM flap), but in some cases can be harvested from the back (latissimus flap) or buttock (gluteal flap) areas. TRAM flaps result in a more aesthetic donor site closure which is similar to that of an abdominoplasty. Other donor flaps will leave a more noticeable scar. Standard TRAM flaps involve harvest of a portion of the abdominal wall muscle. It provides a predictable method of breast reconstruction but because it requires resection of a portion of the rectus muscle there is resultant weakness of the trunk muscles and risk of hernia. Current microsurgical techniques allows plastic surgeons to perform TRAM flaps with minimum (free TRAM) to no (DIEP TRAM) muscle resection. These procedures have a significantly lower incidence of donor site morbidity such as truncal weakness and hernia, but may carry higher risk of flap loss in some patients. All procedures involving autogenous breast reconstruction require a 3-5 day hospitalization to monitor the flaps. A secondary procedure is required to reconstruct the nipple and areola. Most breast reconstruction procedures are covered by private insurance.
Methods to reconstruction breast using implants may involve the use of muscle as well in some cases (latissimus flap), but generally have the advantage of no donor site morbidity when implants alone are used (tissue expanders). Tissue expansion is the surgical technique of using temporary expansile breast implants to stretch the surrounding skin after mastectomy. The expanders are placed at the time of the mastectomy in most instances. Expansion of the expanders are performed in the office on a weekly basis beginning two weeks after placement. Expansion usually requires 8 to 10 weeks at which point the patient is returned to the operating room for exchange of the temporary expanders with breast implants similar to those used in breast augmentation. The obvious advantages over autogenous reconstruction is that there is no need to obtain tissue from another area. Tissue expansion does involve the risks of breast augmentation such as less natural feel compared to autogenous reconstruction and implant failure. Most surgeons feel that symmetry is also more difficult to obtain when reconstructing a unilateral defect by tissue expansion.
Inverted nipples may be either secondary to congenital causes or as a result of prior surgery. Treatment may be performed in the office under a local anesthetic or in a surgical suite under general anesthetic. Success of the operation depends on several factors including the degree of retraction and etiology. In general, severe congenital cases are the least predictable in terms of success. In addition, many of the methods of treatment, even when successful at reversing the nipple retraction, may interfere with the ability to breast feed.
Male Breast Reduction (Gynecomastia)
Surgical treatment of male breast enlargement is tailored to address the severity of
the problem. In general, males who are morbidly obese should first seek treatment for weight loss prior to considering surgery as this will dramatically improve the condition. Patients must also be made aware that marijuana use and certain medications for heartburn and hair loss may increase the incidence of gynecomastia. Treatment is most commonly performed with a combination of liposuction in addition to a small incision around the areolar. In rare cases where a significant amount of excess skin exits, longer scars may be necessary. The 30 minute procedure is performed under IV sedation or general anesthetic and is rated a 3 out of 10 on the pain scale. Patients are required to wear a compression garment for six weeks after the procedure and final results will not be noted for approximately 12 weeks. Risks include infection, areolar depression, asymmetry, and decreased sensation of the nipple area.