1. How are the breast implants put in?

Breast implants can be inserted through a variety of incisions: a. In the fold under the breast (inframammary) b. Around the areola (periareolar) c. Through the areola and around the nipple (transareolar) d. Through the armpit (trans-axillary) e. Via the belly button (trans-umbilical)

Inframammary fold (IMF) incisions preserve the function of the breast, namely breastfeeding and pleasure. I use this incision most commonly for breast augmentation surgery. When an incision is made in the fold under the breast, the scar lies in a natural crease and does not tend to stretch or be raised, as can happen in other areas. All structures leading to the nipple and areola (milk ducts, nerves, blood vessels) remain intact. In addition, once an implant is inserted, it is probable during a woman' s lifetime that another surgery may be required (to change the implant, remove it later in life, perform a breast lift with drooping, etc.). Therefore, the scar is already present and this can be used again as an incision in the future. Many other incisions used for breast augmentation are only a one-time option. The IMF scar is hidden in bras and even triangle-top string bikinis, and will only be visible up close when the breasts are lifted.

Peri-areolar incisions are usually around the bottom of the areola, the pigmented circle that surrounds the nipple. There are bacteria that live in this area, and vital milk ducts and nerves are in this region. By definition, some of these structures will be divided (cut) during surgery, resulting in a higher risk of complications (infection, numbness, inability to breast feed, etc.). In addition, if a woman makes raised scars, they may be visible beneath a tight shirt or through a bathing suit.

Trans-areolar incisions also cut through breast tissue and/or ducts, blood vessels or nerves. Nipple retraction can also result from scar tissue that normally forms after surgery. For these reasons, I would not recommend this for most women.

Trans-axillary breast augmentation makes an incision in the armpit, or axillary area. This is often a one-time incision, that creates a scar in the area where most women shave, and is also a site of normal bacterial growth (hence deodorant use!). The incidence of infection can potentially be higher, and this incision cannot be re-used in the future for other surgery.

Trans-umbilical breast augmentation (TUBA) is more of a gimmick than routine approach. A long tube and scope with a camera must be tunneled beneath the skin of the belly button all the way to the area under the breast. If there are any complications during surgery such as bleeding, or if the surgeon cannot adequately visualize what they are doing, a second incision must be made in the IMF. Only a tightly rolled up saline-filled breast implant can be used (not silicone implants), it is also a one-time incision, and a long band of scar tissue beneath the skin is possibly visible after surgery - a permanent deformity. I would never recommend this option to any of my patients.


2. What is a"drain" and when is one used?

A drain is a thin, soft, silicone tube that is inserted into the area of the breast pocket (where the implant is placed) at the time of surgery, that exits through the skin and whose purpose is to remove wound fluid during healing. It is attached to a small suction bulb, often in the shape of a grenade (known as a JP, or Jackson-Pratt bulb), that when compressed, applies very gentle suction to the drain tube, and slowly removes fluid from the area of surgery. See [website link] for a picture of a drain.

Initially, the drain fluid appears thick and red, as there is minor bleeding with any surgical procedure. With time (over days to a week), there are less red blood cells in the wound fluid and the fluid becomes more clear and less red. The color changes from dark to light red, pink, orange and finally clear light yellow (known as serous fluid). It is at this point that the drains are ready to be removed.

Just as when you scrape your knee and it initially bleeds and then weeps fluid for a time, wounds inside the body also make wound fluid. This is a normal part of healing. However, wounds outside the body that are exposed to air eventually dry out and form a scab. Wounds that are inside the body, such as around a breast implant, or in the area of a tummy tuck, continue to create wound fluid until the body is healed. Bacteria love to grow in wound fluid - this is why Plastic Surgeons usually use drains to remove this fluid as it forms - to decrease the risk of infection and capsular contracture (contraction of scar tissue around a breast implant).

Drains are not painful, and do not hurt when they are removed in the office, usually 3-10 days after surgery. They are held in place by a small stitch (suture) that is cut, and the drain is easily pulled out. I usually recommend that my patients avoid showering while their drains are in place, also to decrease the risk of infection. They may sponge-bathe, shower only the lower half of their body, and either wash their hair in the sink or go to the salon for a wash and blow-dry (and splurge on a mani-pedi while they are there!).


3. What about doing other operations at the same time?

Breast augmentation usually takes 1 to 2 hours, and is usually performed under general anesthesia, where you are completely asleep. It is common and safe to perform surgery on additional areas of the body at the same time. This is common as part of the "mommy makeover" spectrum of procedures. Complimentary procedures include surgery on the abdomen (tummy tuck or liposuction), flanks, hips, buttocks, or inner and outer thighs. Breast and body surgery is often done together, as the results compliment each other and only one anesthetic, one recovery period and downtime is needed.

I do not recommend any more than 6-8 hours of surgery at any one time. After this long under surgery, the risk of complications increases and tends to potentially outweigh the benefits.

The main risk of any surgery under general anesthesia that lasts longer than one hour are blood clots in the legs (known as DVT, or deep venous thrombosis), or blood clots that break off from the legs and travel to the lungs (PE, or pulmonary embolus). If these events were to occur, you would need to be put on a blood thinner for up to six months, and potentially come into hospital for monitoring for a short time.

In order to prevent these complications, I ensure each one of my patients wears both compression stockings while asleep (known often as TED hose, or TEDS), AND sequential compression devices (SCDs or IPCs). These take over the function of the muscles of the calves and legs, as you normally flex your muscles and move around while you are awake, and even during sleep! Under general anesthesia, you do not move your legs; TEDS and SCDs take over this function for you and prevent complications.

Most patients are completely safe during surgery. Be sure to ask your surgeon which prevention methods will be taken to avoid these types of complications (for any surgical procedure, no matter how short!)


4. Why must I have an adult stay with me the first night?

Most surgeries are done under general anesthesia, or at the minimum under strong intravenous sedation. These medications cause drowsiness, sometimes nausea, and dizziness. You will likely have some discomfort after your surgery and be taking pain medication with a narcotic that can also cause drowsiness or an altered level of consciousness. This is why you cannot drive immediately after surgery and it is recommended that you have an adult be with you at least the first night after surgery to ensure that you are safe and to assist you with activities such as dressing, bathing, preparing food, going to the bathroom, etc. Anesthetic drugs are generally cleared from your system within 24-48 hours. You may still be taking pain medications for 1-2 weeks after surgery. It is wise to make sure you have a friend or family member within close driving distance to come over and help you if needed for the first days after surgery.


5. What measures can be taken to prevent capsular contracture?

Capsular contracture is a complication of breast augmentation that we do our best to avoid! It involves contraction of scar tissue around the implant, which can cause a change of shape of the implant, distortion of the breast, or if severe, pain. In order to prevent capsular contracture (CC), I always use drains! Drains remove wound fluid during healing, prevent against bacterial infection or blood around the implant (both of which can increase the incidence of CC).

Other methods to prevent CC include the use of preventative antibiotics (both at the time of surgery and afterward, until the drains are removed), and teaching implant massage. Massaging the implants functions to move the implant around within its space, known as the pocket. By massaging the implant, a large pocket is created so that the implant can move around within its space. This creates a natural breast augmentation, so the implants subtly move forward when bending forward, to the sides when lying flat, just like a normal breast!

Implant massage is most important during the first few months following breast augmentation. However, just like scars outside the body, which take a year to mature and become soft, flat and mobile, it takes up to a year until the natural scar of the breast implant pocket is completely mature. Therefore, I counsel my patients to massage their implants each day for the rest of their life! Implant massage also functions as a breast self-exam. If a lump in the breast were ever to form, a woman who was massaging regularly would find it immediately. It is also a good idea to "get to know your breasts" so that you know where you are dense and if you form cysts at certain times of your menstrual cycle. This will help you to know when something is new or abnormal in the future.

Lastly, some surgeons routinely place their patients on medications that have anecdotal evidence only to help to prevent CC, or to lessen it when it occurs. Names of these medications include Pavabid (papaverine) or Accolate (an antihistamine). Use of these drugs to treat CC is completely "off-label" (not FDA-approved) and has not been confirmed to work 100% of the time. They are also quite expensive and not readily available at all pharmacies.

The best plan of action for CC is prevention, using drains, antibiotics, and implant massage. Once a capsule has formed, if it is causing deformity or pain, it will likely require an additional surgical procedure to remove scar tissue, with the above preventative measures instituted immediately after surgery.


6. What is the "Band" or "Strap" that everyone talks about wearing after operation?

A "bandeau" is a strap or band that goes across the top of the breasts after breast augmentation to help push the implants down and achieve a more natural result. Typically, it is placed by the surgeon over the dressing at the time of surgery or a few days afterward and is worn most of the time for a few weeks. It is most commonly used following a submuscular (or subpectoral) breast augmentation, where the implants are placed either totally or partially under the muscle of the chest wall. The muscle often pulls the implants upwards and outwards, and the bandeau helps to counteract this permanent location of the implants.

I tend to place implants most commonly under the breast tissue itself, known as the "subglandular" method. This technique often gives the most natural result, it avoids implant distortion with pectoralis major muscle motion, and gives the most lasting and reliable results over time.


7. What is meant by the Rapid Recovery method? How much swelling is there after operation?

The "rapid recovery" method is a term used very infrequently, likely as a marketing term to "sell" surgery to women who would not normally seek an invasive procedure. Just like lingo such as "short scar" (breast reductions, facelifts), "mini" (abdominoplasty), and "mommy makeover", these terms are meant to make surgery less scary and friendlier to potential patients.

Often the extent of surgery and pain, downtime and recovery is quite similar between the "full" or "standard" procedure and a "mini" or "rapid recovery" procedure. Allow your Plastic Surgeon to determine which procedure fits you best and to decide what details of surgery will achieve your specific goals.

Recovery after a breast augmentation will naturally be more rapid if the implants are placed beneath the breast tissue only (subglandular rather than submuscular), if activity of the arms and chest is kept to a minimum for 1-2 weeks after surgery, if mild compression is used (such as a bra or ACE wrap), and if drains are used.