In an average year, over 300,000 new breast augmentation procedures are performed in the United States. Saline and silicone gel breast implants are now available to the general public and are FDA approved. Both Natrelle ® and Mentor ® Corporation have approved devices of both saline and silicone, which are used by Dr. Linder each and every week. The new Natrelle silicone gel implants have a more cohesive viscosity, which means that the silicone inside the implant acts more like a soft solid than a liquid. All breast implant manufacturers currently have a consistent testing standard for silicone cohesiveness, which is recommended by the FDA.
Dr. Linder performs both saline and silicone gel augmentations every week and the specifics of the implant depend upon the patient's anatomy. Las Vegas breast implant surgeon Dr. Linder will help you choose which implant is best for your specific needs, as well as the placement of the implant. All patients should have a careful medical history and physical examination prior to the surgery. Preoperative mammograms are recommended for all patients over the age of 35 or any patient with a significant family history of breast cancer. The ideal size of the final outcome of the breast augmentation procedure is specifically related both to the patient's personal desires as well as the surgeon's experience in order to reduce future risks and complications.
During the initial consultation at his Las Vegas practice, size, profile, saline versus silicone and positioning of the implant should all be determined. In addition, base diameter of the inframammary fold will be measured. The degree of ptosis or the amount of sagginess (positioning of the nipple to the inframammary fold) should be determined as well. A breast lift may be required concurrently with the breast augmentation in order to achieve the most acceptable results. In other words, if a patient has a significant amount of sagginess with skin laxity, then a breast lift procedure should be performed in order to achieve an excellent final result. Using a larger implant usually will not lead to a satisfactory long-term result in that the implant will sag further with time and the addressing of skin laxity will not have been performed.
Postoperative care of our breast augmentation patients can be categorized in the acute perioperative period, the first six weeks and the future or delayed perioperative period, after six to eight weeks. Acutely over the first six weeks postoperatively Dr. Linder instructs his patients not to do any heavy lifting of items over five pounds. The arms should remain below the level of the shoulder and the upper arm should not be elevated above the shoulder level. This helps, in his practice, to reduce bleeding, hematomas and tearing of small arterial branches and blood vessels, including axillary arterial perforating vessels from the axillary artery. To prevent hematomas and bleeding as a result, Dr. Linder instructs his patients not to do any heavy lifting whatsoever of the upper arm region as well as the chest area for six to eight weeks, depending upon each individual female's anatomy. Secondarily, aspirin, Advil, Motrin, Excedrin, Ibuprofen, products that may reduce clotting, should also not be taken by the patients within 14 days of surgery and four weeks postoperatively. These are Dr. Linder's specific instructions and they may vary with other physicians or Board Certified Plastic Surgeons.
A secondary acute complication to avoid is infections. Infections may be associated with staphylococcus epidermis, staphylococcus aureus which can be associated with skin infection, cellulitis or even an abscess. In the operating room our patients are given 1 gram of Ancef or cephazolin. If they have an allergy to penicillin, they may be given Ciprofloxacin 400 mg IV piggyback 30 minutes prior to induction of the anesthetic. Prevention of infection is critical for breast augmentation patients who have prosthetic devices. Acutely during the first six weeks postoperatively, the patients are instructed to take their oral antibiotics for seven days. We normally use Keflex 500 mg, four times a day for seven days or if they are penicillin allergic, we will go with Ciprofloxacin 500 mg twice a day for 7 to 10 days.
Delayed complications can include, most commonly, capsular contracture associated with scar tissue and hardening around the breast implant. This is associated with a Baker classification. A Baker I classification is no hardening or palpable scar tissue capsule. The breasts remain soft and there is no scar tissue contracture or disfigurement. Grade 2 ptosis is a palpable contracture; however, there is no visible distortion. Grade 3, shows moderate hardening with both palpable and visual distortion. Baker 4 capsular contracture occurs when the breasts are hard, tender and cold, which are often very disfigured, may have a double-bubble deformity or superior retropositioning of the implant and there may be pain with mild to moderate palpation of the implant.
Scar tissue contracture is one of the most common and serious complications of augmentation mammoplasty procedures. We see patients weekly from around the entire world who have scar tissue hardening and Baker 4 capsular contractures requiring open capsulectomies (removing scar tissue) or circumferential capsulotomies (releasing and scoring the scar tissue around the implants to allow more room for the bag).
A reasonably common complication delayed, includes implant deflation or rupture of the implant. If it is saline implants, these can be detected clinically with simply leakage of the salt water causing complete deflation of the breast. This is usually noticeable within six to eight weeks of a ruptured bag. Implants can be ruptured through a crack in the shell or within the fill-tube valve area in which a one-way valve becomes bidirectional. The MRIs are useful for patients with silicone gel implants in order to determine the integrity of the shell of the implants and should be performed every two to three years on women with silicone gel implants. A Linguini sign is consistent with a ruptured silicone implant with loss of integrity of the shell of the implant. Patients with ruptured saline or silicone implants should be taken to the operating room as soon as possible in order to prevent increased scar tissue contracture and collapse of the pocket around the implant.
Postoperative care and management of our augmented patients acutely for the first six weeks are put into athletic sports bras on postop day number one, dry gauze is placed and an upper pole compression band is placed if there is upper pole fullness due to muscle tightening. This is most commonly seen in younger patients who have not had settling of the breast or weight fluctuation associated with lactation, pregnancy or breastfeeding. This is often seen with patients with more endomorphic build, with thicker chest muscles or barrel chest deformities as well as tubular breast deformity. After seven days, the dressings are normally changed twice a day for the next seven days. Sutures are then removed by the surgeon on day 14 to day 17, depending upon the dryness of the periareolar incision. On day 14, the Steri-strips are removed. The long subcuticular 5-0 Prolene sutures are removed and if appropriate, the small simple sutures will also be taken out. The upper pole compression band is worn by the patient for as long a period as necessary for the patient and the surgeon to be happy with the lowering and the normal gravitational positioning of the implants. This decision is both the surgeon's and ultimately the patient's final desires.
Future care of your augmented breasts should include support of your implants and breasts at all times. As a result, Las Vegas specialist Dr. Linder instructs his patients to wear athletic sports bras for the remainder of their lives, especially during the sleep period or to maintain position and prevent malposition of the implants during the sleep phase of a woman's life. During the day, an underwire supportive brassiere is useful and will help to maintain the inframammary fold and prevent bottoming out of the implants over time. Women who have had children, who have breastfed, who have poor skin integrity or poor collagen content to the skin may end up with a bottoming out which could occur leading to gravitational inferior descent of the implant and a severe bottoming out deformity which may be very difficult to fix. Our patients are instructed once they are happy with the position and other implants, to wear athletic brassieres at night and underwire supportive brassieres every day. Patients are also instructed to take vitamin E orally every day. It is an antioxidant that does help to reduce encapsulation and scar tissue formation around the implants and has been shown to be helpful in Dr. Linder's breast augmented and breast revision patients.
*** Device Identification Card (keep for your records)
Keeping this card will be important if needed for possible future information and surgeries. This may be the only record of the implanted device so the card should be kept in a secure and accessible place.
Week One, day 1 to day 7. Patients must refrain from lifting whatsoever in order to prevent tearing of the muscle and bleeding, as well as to reduce constriction and contracture causing upper pole retropositioning of implants. Patients should avoid heavy lifting any type of pushing or pulling motion. The muscles are normally quite tight and compressing the implants posteriorly. The breasts may appear to be tight and somewhat flat. This should round out with time.
Week Two to week three, day 7 to 21. Our patients are instructed to continue to refrain from heavy lifting for the first three weeks. After seven days, dressings will be removed and replaced with 4x4 gauze. On day 14 to 17, sutures are removed. The subcuticular stitches are removed by the surgeon and dressings are replaced. The patient may or may not continue with the upper pole compression band and usually antibiotics are terminated on day 7. Patients normally will return to work after 5-7 days
Week 4 through 8. Swelling is now beginning to diminish. There is decreased edema over the next two weeks. As long as patients have had no untoward results of bleeding or infection, they may be able to resume aerobic and anaerobic exercises. Athletic brassieres should be worn during all exercise routines. Incisions are now suture-free and some form of scar cream, either Kelo-cote, Mederma or Vitamin E may be useful.
Third Month. By the third month usually the implants have settled quite nicely. Ninety-five percent of swelling is diminished and normally there is tissue expansion exercises over the next three months if there is any tightening occurring in one or both breasts.
Fourth Month to One Year. Normally the results are quite clear. The breasts should remain soft. No evidence of encapsulation or scar tissue, sensitivity of the nipples are most often intact. There may be sharp shooting pains in either or both breasts which are associated with new nerve formation or regeneration of nerves. Nipple sensitivity can be the same, increased or decreased in individual women.