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.

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.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.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.

Read more about  breast augmentation here.

Dr.Alexander Amir Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
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.

Read more about  breast augmentation here.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
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.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
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.

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.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Breast enlargement FAQ

Breast enlargement: Planning, costs, sense and nonsense, fact and fiction about Plastic surgery´s most popular procedure.

The most frequent questions regarding breast enlargement /breast augmentation by Dr.Alexander Aslani, Director and Chief Consultant Plastic surgeon of Cirumed Clinic Marbella.

Question:What is better in breast augmentation, locating the breast implant on top or behind the breast muscle ?

Dr.Aslani,Marbella: Generally the indication depends on the amount of breast tissue the patient has The less breast tissue, the more favourable it is to go behind the muscle.

Question: Is it possible to do a breast augmentation as a day case ?

Dr.Aslani,Marbella: Yes, this is possible. Requests for that are frequent to save hospital costs for the breast enlargement, be careful with submuscular augmentations who may require substantiative pain relief. In planning a breast augmentation, this has to be taken into account.

Question: What is the most common complication following breast enlargement ?

Dr.Aslani,Marbella: Infection. Occurrence depends very much on the access used. Incidence will be between 2-3 %. This is in the nature of surgery with a foreign body.

Question: Do I have to exchange implants every 10 years ?

Dr.Aslani, Marbella: No. This is outdated. There is no preset implant removal times any more, as long as you haven´t got problems, they can be left in.

Question: What is capsular contracture ?

Dr.Aslani, Marbella: A normal foreign body reaction against the implant. This is only problematic once exceeding a certain degree.

Question: Will a an anatomical implant give me a more natural result ?

Dr.Aslani, Marbella: Generally speaking yes. Beware of emptiness on top though, in the breast that is full in the lower pole and flat on top, it may not be the wisest solution.Different women expect different results from a breast augmentation. Some find the look a little bit to natural afterwards.

Question: What recovery time has to be expected ?

Dr.Aslani,Marbella:This depends very much on where the implant is positioned. Positioning behind the muscle heralds a longer recovery time, which can well take a few days.

To mitigate that, I routinely inject a long acting local anesthetic before finishing the breast enlargement. This anaestetic is naturally injected before the implant is put into position, to avoid accidentally piercing the implant.

This injection does considerably alleviate the pain caused by positioning of the implant behind the muscle.

Question:What is the difference between smooth and textured implants ?

Dr.Aslani:Smooth surface implants are suspected to increase the risk of capsular contracture in breast enlargment, which seems to be much lower with textured implants.

Question:I have heard that should one have breast enlargement, there is a high chance to end with the necessity for an uplift later in life ?

Dr.Aslani:Generally speaking, this is not true. It depends on implant and soft tissue development.In selected cases of breast enlargements, however, that might very well be the case. This is a problem of gravity and not a problem of the implants as such.

Question: Which is incision is best for a breast enlargement ?

Dr.Aslani:The three most common and popular accesses are the armpit, the nipple and the fold underneath. There are differences in preference from the side of the surgeon as well as the patient.

Question: Can I breastfeed after a breast enlargement ?

Dr.Aslani:Generally yes. This will depend a little bit on the incision used for the breast enlargement. If introducing the breast from underneath the fold or from the armpit, there should be no problems with breast feeding, Even the periareolar access (cut from the nipple) should not normally present problems, but there is a potential for it.

Question: How high is the risk of hardening of the implants ?

Dr.Aslani:The breast implantsthemselves do not harden….what you refer to is most likely capsular contracture. Every patient will get capsular contracture at some stage, the question is just to what degree. More than mild degreees can be seen in about 5% of cases, with occurrence of the problem being more common if the breaqst enlargement is carried out with positioning of the breast implants on top of the muscle.

However, occurrence of capsular contracture is still a possibility after breast augmentation, although getting increasingly rare.

Know about it, but don´t worry about it too much generally breast enlargement is an operation with an enormous degree of patient satsfaction, whatever problem occurs, we are here to manage it.

Question: What is the operating time for a breast augmentation ?

Dr.Aslani:Roughly one hour.Again, depends on the case.

Question:If my breasts are very saggy, can I combine a breast uplift with breast implants ?

Dr.Aslani:Yes, breast uplift and implants can of course be combined. However you need to undrestand that this makes the procedure a lot more complex and scarring will be involved, to what degree depends on the case. Nevertheless, my overall experience with combining breast uplifts with implants is very positive. It can be a very rewarding operation.But patients have to be aware that revision rates for breast augmentation with implants are generally afre higher than for breast enlargement alone

Question: Do you use saline breast implants ?

Dr.Aslani: No, i personally don’t. I think that the long term advantages of cohesive gel implants are so overwhelming that in breast augmentation that I do not see any space for saline implants.That is of course y personal opinion.

Question: What is the meaning of high profile vs.low profile implants in breast augmentation?

Dr.Aslani: The profile describes the relation of diameter vs projection of the implants. High profile implants in breast enlargement create a lot of projection. Many women find  the sound of this appealing, however, I feel it tends to look rather fake, the bigger problem is that after the breat enlargement the breast can have a fairly large gap. Low profile implants do not induce a lot of projection, so for most breast I suggest moderate high profile implants, which tend to give the most pleasing results in breast enlargement.

Regarding the texture, smooth and textured breast implants are used in breast augmentation.

I personally do not use smooth surface implants, because the herald a higher risk of capsular contracture.

Question; Is there alternative methods for breast enlargement ?

Dr.Aslani: Well, recently there has been a lot of attention for macrolane, which is basically filling the breast volume with hyaluronic acid. This can be a very attractive option for patients dreading a surgical breast augmentation, however, indications are somewhat limited as well as the possible amount of augmentation. A very spectacular variation is aesthetic breast augmentation with autologious tissue, which can be harvested from the buttock or the abdomen as a so-called”free-flap”. I have had patients showing interests in that because in makes the use of actual breast implants unnecessary, but it is a very extensive operation, and i think the cases where the extensice theatre time and surgical distress for the patient  is justified in relation to the relatively straightforward breast enlargement with breast implants is fairly limited.

Question: Is a fat transplant for breast enlargement feasible ?

Dr.Aslani: Feasible yes, although success rates are very variable.Free fat transplants, so called fat grafts, have a very variable survival rate. Percentage of revascularisation seems to be very variable. if patients are happy to accept the risk of that happening and especially if they want fat removal (liposuction) elsewhere in the body, it may well be an interesting option. However, the results of fat grafting remain difficult to predict and I guess that this is a problem we are not likely to solve short-term.

Question: How long do breast implants afetr a breast augmentation last ?

Dr.Aslani: With the last generation cohesive gel implants, this is very difficult to say. There is no preset timespan for removal/replacement of breast implants any more.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Macrolane

Macrolane is an identical substance to the one used for wrinkle treatment which as a different indication can be used to augment breasts without implants. It does not make “classic” breast augmentation superflous, but is an addition to the Plastic surgeons possibilities for certain indications, mainly patients seeking for breast augmentation who are scared to have an opeartion, want a limited amount of breast enlargement and are not shy to repeat treatments ergularly.

It is not suitable for every breast but certain breasts can be very effectively augmented without the need for a substantiative operation. There are certain limitations as to the amount of substance to be injected, which I personally limit between 100-150 cc. Responses and reabsorption are very different from patient to patient, I would expect having top repeat treatments after about 18 months, although it is usually not necessary to reinject the same amount of substance.

There is a couple of other interesting indications for Macrolane in the field of corrective procedures after liposuction.

Dr.Alexander Aslani, Chief Consultant Plastic Surgeon, Cirumed Clinic Marbella, Malaga, Spain