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.

For more information visit our Homepage:

www.cirumed.es

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.

For more information visit our Homepage:

www.cirumed.es

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.

For more information visit our Homepage:

www.cirumed.es

Breastfeeding after breast augmentation?

Is not normally a problem after straightforward breast enlargement, since the majority of techniques does not interfere with the breat tissue itself, but works underneath the breast  muscle or the breast gland.

Exception applies to breast augmentationthrough with an incision through the nipple, which may necessitate dissection through the breast gland. breast augmentation or breast enlargement through a nipple incision is particurlarly popular in Spain

But even with this  breast augmentation technique it is not normally a problem.

For more information visit our Homepage:

www.cirumed.es

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.

For more information visit our Homepage:

www.cirumed.es

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

Scar sparing breast uplifts ?

Scar sparing breast uplifts are currently receiving a lot of attention in scientific Plastic surgical literature.

Generally, uplift procedures are advised once a certain degree of btreast ptosis (sagginess) has developed. Once the level of the nipple is located below the level of the submammary crease , literature reviews generally recommend some kind of uplifting procedure, with or without use of breast implants. Whether a breast augmentation is to be advised together with the breast uplift, will depend on the amount of available breast tissue and patient desires.

Whether or not to stage breast augmentation and breast uplift into two proedures remains a matter of controversial topic, and surgeons opinions about this vary.

Whilst it is true that rates of revisional surgery for breast uplifts is significantly higher than for both procedures individually, it is also true that a staged procedure naturally bears a 100%revision rate.

Case 1

Patient with significant volume loss following multiple pregnancies

Progressive ptosis(sagginess) with nipples below the inframammary fold

Patient asked for uplift and volume fill

Operation performed was subglandular lift

Combination with vertical scar mastopexy

Result 10 months post op

Good projection

Sufficient size

In spite of the undoubtedly significant percentage of revisional surgeries for breast augmentation with uplift, patient satisfaction is still very high. Most touch up surgeries will aim to correct nipple position and/or scars.

Opinions among surgeons regarding which technique to use generally vary considerably, but the technique with the least scarring is not necessarily the one that makes the patients most happy.

Especially among Caucasian patients much is to be said for rather considering more scarring to trade in for a favourable shape, since fair skinned patients tend to scar favourably and the scars tend  to fade over time to a degree that they are of much less concern to patients.

Bear in mind that this is a long term observatzion, scars after breast uplift may be quite red initially before gradually fading. The process of scar fading after breast uplift is not entirely in the surgeons hands, lots wil depend on personal factors also.

Within reason, one can also explain if the patient is willing to accept more scarring there is less chance of recurrence of ptosis (sagginess). Nevertheless, very shortly after a breast uplift, and regardless of the technique used, it is not unusual for the scars to be quite red and swollen, especially when absorbable suture material, which I personally recommend, is being used. Given time, these scars, nearly without exception, tend to fade significantly and do not normally concern patients then.

To promote softening and fading of these scars after breast uplift (mastomexy) we tend to use silicone stripes, which promote softening of the scars more rapidly. But as alway, time is the best healer.

For more information visit our Homepage:

www.cirumed.es

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.

For more information visit our Homepage:

www.cirumed.es

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.

For more information visit our Homepage:

www.cirumed.es