Breast augmentation

Dr.Aslani, Head of department of Plastic surgery of Hospital Quiron Malaga, presents case based discussions of breast enlargement cases

28 year old patient requesting breast enlargement,moderate amount of gland

After submuscular breast enlargement, round implants.

The patient requested cleavage, therefore round implants where the better option. The submuscular position gave the patient cleavage but still a antural look.

This patient requested breast augmentation but a natural look was of utmost importance to her, therefore the decision was made to use anatomical implants.

Another example of a moderate profile implant in submuscular position:

Again the round implants do not cause an overly wound shape in the submuscular position, but provide cleavage.

The moderate profile prevents too much of gap between implants

The inframmary incision is not noticable in the new inframammary fold.

The next patient requested the most natural look possible, cleavage was of less importance to her, the decision was made to use anatomical implants.

Before and after augmentation with 335 cc anatomical implants

Different patients request different options, and a solution which is desired by one patient may not be so good for another patient.

There is no precut recipe which applies to all patients, therefore we suggest to take sufficient time to discuss in depth all options between surgeon and patient.

We do mainly use implants of the Natrelle, Allergan and Polytech brands.

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www.cirumed.es

Breast enlargement without implants ?

Dr.Alexander Aslani, Specialist Plastic Surgeon and Head of the Department of Plastic, Aesthetic and Reconstructive Surgery of Hospital Quiron in Malaga, Spain, on of the  most controversial  topic in cosmetic surgery: breast enlargement without implants.

Macrolane

Is currently a very popular option with a few myths around it.

With view to the popularity of breast enlargement in Spain,I see significant numbers of patients looking for this possibility, with few of them actually being aware of the limitations in indications.

Basically Macrolane is hyaluronic acid, which is well known and a has a long history as a wrinkle filler , just used in a higher density. It is the most frequently used brand for the indication with new ones coming onto the market now.

The concept is to use this as a “filler” for the breast. The idea is very appealing and there are indeed some interesting indications for Macrolane in breast enlargement for selected patients.

Macrolane is also suitable to treat small contour deformities, especially after liposuction. I think this will be one of its prime and most widely used  indications in the future. Macrolane for breast enlaregment will play a role, of course, but patients seeking breast enlargement via this route will have to understand the limitations.

Macrolane injections have to be repeated, although required injection volumes for subsequent “touch-ups” are significantly less than for the first treatment. Macrolane can be administered using local anestetic, but macrolane injections have to take place in an operating theatre though, for the sake of patient safety.

Amongst surgeons, there is a certain range of opinion as to how much macrolane may be used in one session for breast augmentation. I prefer to restrict to about 100 cc per session. Some surgeons inject a lot more, but there are concerns whether distribuition of fluid is entirely predictable or not. To my opinion, with an injection of 100 cc one stays within a safe margin, preventing the danger of unforeseen and undesired fluid distribution.

Lumipness and adverse reactions have been observed in some cases. Patients need to be aware of this.

They problem is usually temporaray, but can last for some time.

Whilst  macrolane has already been available on the market for a couple of years, this is still a comparably short time from the surgical point of view.

Downside is furthermore  that the possible volume injection is restricted.

Case example macrolane before and after 180cc macrolane breast augmentation:

Macrolane is currently the most popular solution in non-surgical breast augmentation.

The augmentation shown does exhibit the, usually, maximum possible augmentat¡on in one session.

In this case, 80 cc macrolane were applied 20 months after the initial procedure.

This reflects the usual percentage of reabsorption.

Free microvascular tissue transfer

It is possible to apply tissue transfer techniques parallel to those used for breast cancer , also  for breast enlargement.

Therefore tissue can be taken from the buttocks or from the abdomen and transferred to the breast.

Microsurgical techniques are then used to anastomose vessels taken with the block of tissue, to donor vessels,usually in the axilla. This is an extensive operation.

This makes any  implant removals in the future superflous. However it is a very expensive and long operation and will therefore remain a rather exotic indication. It may be used in cases of congenital breast deformities though, like Poland-Syndrome (failure of breast bud to develop on one side). In these cases, microsurgical free tissue transfer may be considered.

The extent and cost of this operation will leave this possibility random in the future. Some surgeons say that the extent of such surgery is disproportionate to the effort of mere breast enlargement.

I do not necessarily agree to this, but suggest that patients are entitled to decide individually after careful explanation of the implications involved.

It is a consideration in discussing breast enlargement options.

Autologous fat transplantation

The one of the dreams of Plastic surgery.

Take the patient´s own (autologous) fat from somewhere else and inject it for breast enlargement.

Unfortunately it is not that easy.

There are certain established methods to prepare fat for transfer, especially the so-called Coleman technique (centrifugation technique) and numerous preparation kits are on the market.

Success of these techniques is quite variable though.

They may, or they may not, work. The smaller the volume of fat injected, the larger the chance of “take”. Take means the percantage of fat that survuves the transplantation. This take of fat transplants is vetry variable and differs from patient to patient.

Current research is aiming at mixing free autologous fat with growth factors and even to “breed”patients own fat cells.

This may increase survival of fat tissue but there are, as I have to say, fundamented concerns that these growth factors may possibly promote growth of breast cancer.

We are still in the pioneering stages of such “tissue-engeneering” techniques.

Vacuum-assisted devices

Have received excessive marketing attention. Principle of these treatments is that continued vaccum pressure applied to te breast may assist in breast enlargement of tissues.

I personally cannot comment on possible success, since I have no experience with these.

From the strictly scientific point of view the success rates seem rather fictional. I do not see any physiological mechanism suggesting that this really works.

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Breast augmentation-above or below the muscle ?

There are ongoing debates as to whether it is more advisable to place the implants in breast augmentation on top or below the breast muscle.

As in most cases involving aesthetic surgery, there is no single right answer.
The main reason for subpectoral (under the muscle) placement is as follows:
1. The muscle covers the implant, thus capsular contracture (“breasts that feel hard”) is less common.It has become rare anyway, but the cases that I usually see are breast augmentation on top of the muscle. Another theory is that should capsular contracture occur it may be less obvious to be detected.
2. For the same reason, rippling (wrinkling) of the implant is less apparent.It is never completely evitable though.If patients will normally notice such rippling on the lower pole and side.
3. Mammograms are more accurate.
4. In very small-breasted women, the outline of the implant is less visible.As a rule of thumb, if the thickness of breast tissue is less than 2 inches, submuscular placeement is mandatory.
5. Muscle tissue is well perfused. Perfusion is the best combat tool against infection, the most dreaded risk in breast augmentation .

The argument for subglandular breast augmentation (under the breast tissue) placement is as follows:

1. If any degree of ptosis is present, a subglandular implant lifts the breasts much better.
2. Lower risk of postoperative bleeding is involved.
3. Significantly less postoperative pain occurs.
4.  Breast augmentationcan be performed with intravenous sedation and local anesthesia, which is a safer alternative to general (complete) anesthesia.

Examples from our gallery:

Breast augmentation 335cc anatomical implants submuscular before:

Breast augmentation 335cc submuscular anatomical implants after surgery:

Breast augmentation 340 cc moderate profile round implants subglandular before:

Breast augmentation 340 cc moderate profile round implants subglandular after:

There are no precut recipes for the best procedure in breast augmentation, but a lot of suitable solutions for different patients.

For more information visit our Homepage:

www.cirumed.es

Is breast augmentation combined with uplift a safe procedure ?

Breast augmentation mastopexy,which means a breast uplift combined with  breast augmentation with implants is probably, apart perhaps from rhinoplasty, the most demanding procedure in aesthetic surgery.

“There is a lot of misunderstanding around this operation,and whilst it may be extremely rewarding, patients need to understand the complexity of the operation to adequately appreciate the results “, says Dr. Alexander Aslani, who is head of department of Plastic surgery, Hospital Quiron, Malaga.
He has extensive experience with breast augmentation with mastopexy, because it is one the most frequently demanded operations within cosmetic surgery in Spain.

Indication for a breast uplift is breast ptosis (sagginess) of the breast, most commonly following weight loss and pregnancy.

This results in an empty skin envelope with no appropriate filling. The concept of the operation is to tackle the problem from two sides: firstly to tighten the skin envelope and secondly to fill it appropriately with a breast implant.
“The change can be very impressive and patient satisfaction is very high, however, depending on the degree of sagginess, a certain amount of scarring will be necessary,” says Dr.Aslani.”I normally advise patients that shape of the breast is much more important to patients than scarring in the long run, but scarring will be involved.
To what degree does very much depend on your skin type, the fairer the skin the better the result.”
There are still surgeons promoting a two-stage approach, which means doing the mastopexy in one go and then the implant placement in the next.
“The advantage of this is that the tissue reaction is more predictable” so Dr. Aslani.”On the other hand patients always need two operations. In my experience, although I completely agree that the overall revision and complication rate of combined breast implants and uplift is significantly higher than in a plain breast augmentation , it is safe and preferable to do the operation in one go.
There is a higher incidence of infection, wound healing problems, scar revision, that is true, but this is clearly outweighed by the benefit arising to the patient from a one-stage procedure.

My experience is that given that patients are aware of the complexity of such a breast augmentation and breast uplift procudure, they are usually very happy with the fairly impressive change achievable.

There is however a certain chance that both surgeon and patient agree on performing a touch-up procedure like a scar revision, often around the nipple, after about a year has passed.Whilst these are mainly minor procedures that can be done under local anesthetic, scientific literature reports incidence of such requests being as high as 15%.
Especially for UK residents coming to Spain for cosmetic surgery this has to be discussed and born in mind.
The most common misunderstanding within this procedure is the expected change of breast size.
“Uplift and implants combined do not necessarily increase cup size, but rather a preexisting cup-size is filled by proper breast volume than just by an empty skin envelope. It is about changing the shape of breast, not primarily about increasing the size. There must be a good understanding between patient and surgeon beforehand, I always say the patients with breast augmentation with uplift need to be selected very carefully.Especially patients rather wishing bigger breasts need to be advised that there is unfortunately no way to get around gravity in the long term.”
The change in breast shape is quite dramatic and patient satisfaction with the operation generally very high.
However, patient understanding regarding the procedure must be kept very clear.
Whilst scarring, implant positioning and staging were and will remain a controversial topic among Plastic surgeons for a while, the combination of breast implants with breast uplift can,on the other hand, be one of the most rewarding surgeries of all.

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Which breast augmentation incision is best?

There is no one best incision, since it depends on factors like what kind of breast implants you are getting, your anatomy, your lifestyle, what size implants you are getting, and your surgeon’s preferences.

To some extent, it is up to the patient. In Spain, for instance, we observe many patients favouring  breast augmentation via a periareolar (nipple) incision, for a variety of reasons.

There is no single best incision, but lots of pros and cons.
There are surgeons who will insist that one is better than the other, and each type of incision has undoubtedly got advantages.
It all depends upon your needs. Remember, you will end up with bigger breasts no matter what incision is used, but some will give you less scarring than others. Always think long-term because implants may, one day, have to be replaced.

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Choosing implant size in breast augmentation

Choice of size is a difficult, but important factor in breast/breast enlargement surgery. 
To my experience, it can go two ways, but from a practitioners point of view it is much more frequent to see patients asking for bigger implants than having it the other way round.
I think a contributing factor is especially that many patients orientate on “celebrity”-examples of patients who have had more than one breast augmentation and in that case tend to look “over”operated indeed.
It is impossible to try a breast implant on like a shirt. You dont get this opportunity in breast augmentation. Several factors need to be considered.
1. Dissatisfaction with breast size is the number one cause for re-operation in breast augmentation surgery. Nevertheless, it is not a revision for a surgical complication because everything may have gone very well.
2. You cannot plan a cup size,a cup size is just a letter. It is more important to gather together photographs of your likes and dislikes when it comes to breast size, shape and form. Different brands of manufacturers will have different cup sizes for the same breast.
3. Sizing implants slipped into your bra can give you a relative estimate of breast implant volume.The tend to look a bit “stuck-on”. Most surgeons, who frequently perform this operation will have a set of sizing implants available for you to examine and place in a bra.
Go for the feeling in size and not for the look.
4.Remember that in breast augmentation there are factors that cannot be changed, like for instance the width of your sternum. Breast enlargement gives you a bigger breast and a certain
Change in shape. However, you cannot buy a breast “of the shelf”
5.The choice of projection and implant shape, be it teardrop or round, will depend on the shape of your breast before the operation and position on the implant. I frequently observe that patients translate a solution from a friend they might know and who has had a breast augmentation to themselves.This does not work this way. Every body is different and everybody is individual.

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Is mammography necessary before aesthetic breast surgery ?

The decision depends also on the preference of the individual surgeon; it is not absolute necessary.

In our Cirumed specialist group , we solved the question in the way that a highly qualified gynecologist furnishes patients before breast enlargement, breast uplift or a breast reduction with a so-called 4-D- ultrasound.

Dr.Ramin Pakzad, extremely experienced in the field of  breast disease and especially in the area of the breast cancer treatment and is our partner in these cases and since I can absolutely depend on the accuracy of his assessments, I prefer the ultrasound diagnostics done by him.

That provides me and my patient the security of a thorough preoperative diagnostics and saves young patients partly extensive -x-ray exposure.

A possible history of breast cancer within the family will also endorse the indication for preoperative breast screening. There are different approaches to breast screening before aesthetic surgery like breast augmentation, but we regard this one as best. Suspective findings in the age group seeking for breast augmentation are lessthan 0.5%, but nevertheless they occur.

Although the chance of a positive finding is very low especially in young patients, who are the majority of patients requesting breast augmentation, it still merits the effort. “If we are able to spot 1:1000 breast cancer cases just by the coincidence of screening for a breast augmentation operation, it was totally worth it”, says Dr.Pakzad, who teams up with Dr.Aslani and two oncologists forming a breats cancer unit in the Malaga area.

The 4-D-ultrasound technique does also play a significant role in spotting ruptured implants after breast augmentation.

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Dr.Ramin Pakzad Pakzad, Consultant gynecologist , Director, Clinica Banus, Marbella, Malaga Spain, Clinica GynBanus Marbella

Choosing implant size in breast augmentation

Choice of right implant size is most decisive in breast augmentation surgery.

Although generally it is a procedure heralds an extremely high degree of patient satisfaction, many patients tell me that that if they did the procedure again they would go to a larger size.

To request a smaller size is very unusual.

Most patients tell me the like the swollen look directly after the operation, and are a bit disappointed with the size decrease once the swelling goes. Dissatisfaction with breast size remains the number one cause for re-operation in breast augmentation.

I tell every patient not to go into breast augmentation requesting a specific breast size and cup size because fixation on a ceratin cup size, which differentiates from the final size, can lead to dissatisfaction with your final result.

I routinely show patients pictures of the effects certain implant sizes have on certain breasts,making clear that the result of a breast enlargement cannot be bought “off-the-shelf”

I avoid the use of sizing implants, except for special request. since the look distracts from the final result.

Cup size measurement is extremelyinaccurate but as a rule of thumb every 150-200 cc’s of volume you will go up a cup size. Bear in mind that is a rough estimate.

Remember that breast augmentation cannot or only moderately alter anatomical fix points such as distance between nipples and gap between breasts, these things can be influenced, but not on a “you-wish-I–deliver”basis. Some anatomical variables have to be taken into account.

I personally regard breast augmentation as one of the operations with the highest degree of patient satisfaction, and as long as abovementioned considerations are taken into account, I intend to keep it that way.

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Incision placement in breast enlargement

What is the perfect incision placement for breast augmentation ?

Well, there is none. There is different options, the most popular ones being

1.The armpit. This is a very elegant approach, implying the the breast implant is brought in through an incision in the armpit. I personally have used it for quite a while and on very special patient request I still do, but a few points have to be taken into account. Firstly, the skin of the armpit can impossibly be made sterile, so there is a higher risk of infection, secondly, I have had patients who, after axilar breast enlargement, reported certain restrictions in movement to me. This has to be taken into account.

2.The nipple. In planning breast enlargement, I guess half of the patient is very keen to have their incision through the nipple and half are terrified just by the thought of that. there are really very different views on that. Since I personally only use cohesive gel implants, a certain size of the nipple is necessar. This does not have to be excessive but should be sufficient to accommodate a 3cm cut along the lower nipple border.The scar will fade with any of the three incisions mentioned, but probably quickest here.

3.The inframammary crease. Great advantage of this incision in breast enlargement is that it heralds the smallest risk of infection, and the inframammary fold can be planned very accurately.Length of incision is normally around 3-4 cm.

Case example from our practice:

Patient with very little breast tissue and small nipple

Athletic, desire for substantial augmentation

Patient requested cohesive gel implants

Therefore nipple no suitable option

Post op result

Inframmary, submuscular augmentation

300cc moderate profile round coheisve gel implants

6 months post op inframmary incision not visible

Preoperative A cup, postoperative C-cup

There are some exotic variations like endoscopic approaches through the  bellybutton just to name one example, who I feel make restricted sense from the physiological point of view since when placing a foreign body large dissection pathes make the procedure somewhat more risky.

In Spain, breast augmentation remains the most popular aesthetic surgical procedure.

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Breast enlargement-what implant to take ?

“There is no easy answer to this question, because not every breast is the same”, says Dr.Alexander Aslani, who is head Consultant Plastic Surgeon of the Cirumed Clinic Marbella and Consultant Plastic Surgeon in London´s Highgate Hospital.

“It depends very much on the breast and , more importantly, on patients preference. Different patients prefer different looks, and this has to be taken into account when planning the procedure.
Generally, The question is where fullness is required….if it is on the upper pole, a round implant may be the better option, especially if the implant is positioned behind the breast muscle, choice of breast implant,but this depends very much on the case.I prefer to show patients pictures with relevant examples, and then we make a choice together .Breast surgery is not just a “boob job” but a very individual and every breast is different and therefore requires different solutions,” says Dr Aslani.

Round implants or anatomical ? Again this this depends, says Dr.Aslani. People perceive that breast enlargement with anatomical implants as more natural.

“Anaomical implants behind the muscle can occasionally look a bit flat on top, if the breast is fairly flat on top in the first place and the muscle rather strong,” so Dr.Alexander.Aslani.

Generally breast augmentation is one of the operations with he highest degree of patient satisfaction, which tends to give patients an enormous boost in self confidence.

Materials used are, without exception, cohesive silicone-gel filled implants.

Breast augmentation/breast enlargment in Cirumed Clinic Marbella continues to be one of the most popular procedures for patients from abroad seeking cosmetic surgery in Spain, the backbone of medical tourism in Marbella.

There is a couple of other procedures breast enlargement can safely be combined with, says Aslani, depending on the nature of the request.

A frequently asked question is….can Breast enlargement be done as a day case ? Yes, it can says Dr.Aslani, but he suggest for patients not to enter without a “plan B” to possibly stay overnight.

How long do breast implants last ?

“At present, we don’t know”, says Dr.Alexander Aslani.”We presume that patients can enjoy the effects of a breast enlargement for as long as there are no problems. Should problems occur, action might naturally have to be taken and the breast implants exchanged”.

Dr.Alexander Aslani, Cirumed Clinic Marbella, Marbella, Malaga, Spain, www.cirumed.es, www.alexanderaslani.com