1. How does the shape of the ribs affect augmentation decisions?

The shape of the rib cage forms the foundation of breast augmentation. The flatter the ribs are in the front, the more forwards the implants sit. Alternatively, if the ribs angle off to the sides the implants will tend to fall more to the sides. This is not something that can be changed, but it is important to discuss with your board certified plastic surgeon prior to breast augmentation.


2. What is minimally-invasive surgery?

Minimally invasive surgery is surgery performed through smaller incisions as a way to speed recovery associated with the traditional approach. Sometimes this requires a camera, a robot, or specialized equipment. By its nature, this type of surgery limits the surgeon' s access to and control of the operative field. For procedures like endoscopic brow lifts, it is clearly advantageous in carefully selected cases.

I am a big fan of being minimally invasive, whenever it is appropriate. For example, laparoscopic gallbladder surgery has helped many patients. In most cases it can do what the traditional surgery can do (remove the gallbladder), but without the traditional incision. Since the incision is what causes the majority of the pain in traditional gallbladder surgery, eliminating the incision leads to significantly less pain and a quicker recovery (a few days verses a few weeks). The smaller scars are its nicer too.

Breast augmentation (without a lift) is minimally invasive. An incision is made just large enough to introduce the implant and specialized instruments are used to allow the surgeon to view the pocket created. Where to place the incision has become more controversial with the introduction of incisions placed off the breasts.The incisions placed on the breast are the best (http://www.drmele.com/html/breast-augmentation.html incision-location) They allow maximum exposure, predictability, safety, ease of insertion, and revision surgery can use the same incision in the vast majority of cases. With the periareolar or inframammary incisions, the surgeon can feel bands in the breast pocket that may not be appreciable via the axillary or umbilical incisions off the breast. While all the approaches give scars, they tend to heal well. The scars on the breast are better hidden in clothing.

Silicone gel filled implants should not be inserted via the belly-button (TUBA approach) or the armpit. These small remote incisions are likely to lead to damaged breast implants and deflation. Since saline implants can be inflated after insertion, it is possible to insert the implants without damaging them. Carefully selected patients can have implants inserted in this fashion; however, there is an increased risk of malposition, and most revisions require a new scar on the breasts. Since most the discomfort from breast augmentation comes from the area around the implant and not from the incision, there is no significant benefit to pain control or recovery.


3. Will the veins on the breast skin become more noticeable?

Sometimes. Pale thin skin shows veins more. Breast augmentation tends to stretch the skin (same skin covering a bigger volume) and compress the veins closer to the surface.


4. What is the difference between implants in-front-of vs behind the pectoral muscle?

The difference is where the implant is placed with respect to the pectoralis major muscle. Implants placed behind the muscle tend to give a more natural teardrop shape, make it easier to perform mammography, have the additional support of the muscle and tend to have fewer capsular contractures. The downside, implants can sometimes move when the muscle is strongly flexed.

Implants in front of the muscle can fill the skin better, improve the appearance of tubular breasts, and do not move as much with muscle flexion. The downside, implants in this position are more obvious, especially along the upper edge. More information, and pictures relating to implant placement can be found on my web site: http://www.drmele.com/html/breast-augmentation.html implant-location.


5. Can you explain about textured vs smooth implants?

Textured breast implants were originally designed to decrease capsular contracture seen with the original (pre 1985) silicone gel filled implants. Silicone gel filled implants have evolved since then, and so has the indications for textured implants. Silicone breast implants manufactured after 1994 have a more durable shell and less gel bleed. As a primary investigator for Allergan and Mentor, I am working with many other Board Certified Plastic Surgeons in the United States to determine how much better these implants are. If you decide to get silicone filled breast implants, please ask your surgeon about participating in the breast implant follow-up studies.

Today, the primary reason a textured implant is used is to keep shaped implants from rotating. Round implants can spin within the breast pocket without changing the shape of the breast. For teardrop shaped implants, however, it is important that the big end stays at the bottom. Texturing allows the implant to adhere to its capsule like Velcro. This is meant to prevent the implant from rotating, but still allows easy removal when necessary. More information is available on my breast augmentation page: http://www.drmele.com/html/breast-augmentation.html implant

And help in choosing size, type (saline vs silicone) and implant shape/diameter can be found on my blog: http://www.sanfranciscoplasticsurgeryblog.com/category/breast-augmentation/breast-implant-options/


6. What is meant by wrinkling or rippling of implants?

Breasts are meant to be soft, and so are breast implants. Because breast implants are manufactured with soft outer shells, these shells can fold. If the wrinkles can be felt or seen through the skin, this is termed rippling. Rippling is more common with saline filled breast implants. The larger the implant and the less breast tissue covering the implant, the greater the chance of rippling. Saline implants tend to be more palpable. That is to say, they can be felt more frequently when compared to silicon gel filled implants. As a result it is very common to be able to feel wrinkles with saline filled breast implants, especially along the outer breast, where the muscle does not provide full coverage. If it is not seen, it is not usually treated.

Treatment options vary depending on the cause. Sometimes the implant is replaced with a silicone gel filled implants, sometimes the capsule is modified. More comparisons between saline and saline filled breast implants are explored here: http://www.sanfranciscoplasticsurgeryblog.com/how-to-choose-the-correct-breast-