Dr. Linder's Blog
The patient to the right is a 26-year-old female who was looking to enhance her breast size and shape. As you can see by the pre-op photo, both breast are small in size but nicely balanced. During her consultation, she explained her desire to increase the fullness of her breast, but also wanted to look as natural as possible. After listening to her goals, we agreed to schedule a surgery date.
During her breast augmentation surgery, we selected 325 cc moderate plus saline implants. This style of implants are mid-range with a moderate width and moderate amount of projection. This implant is also excellent to use when one is looking for that natural appearance.
The post op photo is three months out she is very happy and she has a excellent look, very natural and balanced.
During consultation, questions often arise as to which implants will be best for the patient, silicone vs. saline. Although both implants are still available, FDA has still restricted the use of silicone gel implants to women who meet specific criteria.
In the United States, both Mentor and Inamed provide FDA approved silicone gel implants for women who meet the specific criteria. This specific inclusion criteria, according to mentor’s adjunct study, is that the patient be female, that the patient be willing to follow the study requirements and that the patient must have at least one or more of the specific indications, including 1) postmastectomy for cancer reconstruction; 2) a severe deformity which can include status post traumatic or a congenital deformity, including pectus carinatum excavatum tubular breast deformity or severe asymmetry such as in Poland syndrome, or finally breast ptosis, meaning sagginess to the breast which requires some form of mastopexy or breast lift. Final criteria can include replacement or revision from either reconstruction from breast or breast augmentation in which silicone gel implants were used previously.
There are exclusion criteria as well, which can be found on the Mentor Preoperative Patient History Record. These include the patient having any history at this time of an abscess or infection anywhere in the body. If the patient is pregnant or nursing, they are excluded from the study. If the patient has any symptoms of diagnoses of lupus or scleroderma, uncontrolled diabetes, tissue that is incapable of handling the silicone gel implant, including radiated tissue or psychological reasons.
If a patient meets any of the criteria as described above and the patient has a desire to either add silicone gel implants and/or continue with them after replacement, then the patient will need to fill out with the plastic surgeon the entire informed consent.
The informed consent will include specific details which will mark out the risks and complications associated with the surgery. These will include infection, hematoma or collection of blood, serous fluid collection (seroma), capsular contracture with scar tissue formation as well as anesthetic risks. Capsular contracture can occur with either silicone or saline and may require removal of the scar tissue, referred to as a capsulectomy, or release of the scar tissue (capsulotomy) in order to allow more volume space and room for the implant to move.
Silicone implants may deflate, rupture or leak and may require replacement. They may be more difficult to detect because although there is a rupture of the intracapsular shell, it may not be detected for many years. Mammograms and even ultrasound may not detect the rupture and an MRI may be required in order to get a more definitive answer. Extracapsular silicone migration can occur as well as this may lead to free silicone which migrates to the lymph nodes under the armpit or the axillary lymph nodes or into other parts of the body. If an implant is ruptured, it should be removed as soon as possible. Increased scar tissue formation certainly may occur as well as migration of the silicone gel to different parts of the body.
Other complications associated with silicone gel implants, include silicone gel bleed. This is simply the oil of the silicone migrating through small micro pores within the shell, which may bleed through and be trapped within the scar tissue around the implant. This may increase calcifications. Mammography interference and difficulty in detecting calcifications versus cancer may also be associated with silicone gel implants, especially when placed in the retromammary pocket (above the pectoralis major muscle).
In contrast, saline implants may be more user friendly in that 1) we’re able to change the fill volumes of these implants with women who have asymmetric breasts are able to titrate the volumes of the implants to even out the breasts to make them more symmetric. Saline implants also if they shall rupture are an all or none phenomenon and within several weeks it will be quite apparent that the implant is deflated. The fluid from a saline implant when placed preoperatively in a sterile environment will be absorbed or resorbed and should yield no harmful effects to the patient.
Capsular contracture certainly can occur with saline implants, although in my practice I have found it to be less likely than silicone gel, as there is no silicone gel bleed with saline implants.
In the future, silicone gel implants may be available to the general public. At this time, it is still under FDA review and although the advisor panels have approved the silicone gel implants to be reviewed by the FDA, there is no definitive answer at this time. In general, as in any surgery, the use of silicone versus saline implants must be tailored to the needs and specifics of each individual. It is important to choose the specific implant carefully. The patient once again needs to be included within the criteria outlined by Mentor and/or Inamed Corporation in the United States of America.
The patient presented is 28 years old and was looking to revise a previous breast augmentation. During her examination, I could see that her right breast had a downward elevation of the nipple-areola and a lower inframammary fold due to bottoming out. The left breast had scar tissue, also known as capsular contracture, which had formed around the implant. After listening to her expectations and agreeing on her goals to regain her breast appearance, we scheduled a surgery date.
As you can see by the patient photo to the right, she is now four weeks post-surgery, and she has balanced symmetry and nice volume in both breasts.
Tubular breast deformities are not all that uncommon. By definition, it is associated with herniation of breast tissue into the nipple areolar complex, constriction along the lower pole of the breast causing a poorly defined inframammary fold. Often the nipple areolar complexes are also lowered causing some degree of sagginess or ptosis.
Repair of the tubular breast can be performed by placing saline or silicone breast implants either through the subglandular or under the muscle with a dual plane technique. In the past implants were usually placed above the muscle in the subglandular pocket. However, presently Dr. Linder places the implant most commonly in the dual plane, two-thirds under and one-third over the muscle, depending upon the degree of the tubular breast deformity. If there is a very thick amount of glandular tissue subglandular retromammary placement may be preferable in order to allow some upper pole fullness along the medial sternal area (towards the middle of the chest cleavage area). If, however, the tubular breast is associated with minimal amounts of breast tissue, then Dr. Linder places the implants usually under the muscle medially in order to reduce visibility palpability of the implant edge.
Reconstruction of a tubular breast includes breast augmentation with saline or silicone implants, releasing the inframammary fold, the crease line underneath the breast, to a proper position and scoring of the lower pole of the breast in order to evaginate it outward, allowing it to become more rounded in shape. If there is a significant degree of sagginess, then a breast lift may also be required with a reduction of the size of the areolar.
Postoperatively, a tubular breast should be treated with an upper pole compression band which will allow relaxation of the upper portion of the breast, allow the implant to be inferiorly displaced and allow for the lower pole of the breast to become more rounded and less flattened in shape. The bands can sometimes be worn up to six to eight weeks, depending upon the length and time it takes to lower the implant to regain a normal rounded shape. Tubular breast deformity reconstruction is a challenging operation, but in the hands of a Board Certified Plastic Surgeon, can be a wonderful operation with a very satisfied patient.
The female patient presented is 26 years old and was looking to improve her breast appearance by increasing her breast volume and position. However, her thoughts about having a breast lift were concerning because of the potential scarring. During her examination, she showed a mild degree of breast sagging, and based on her expectations, a lift would be needed. After examining and listening to her goals, we agreed to schedule a primary augmentation and lift.
During her surgery, I placed 400 cc saline high profile breast implants. I overfilled the right implant to 440 cc and the left side to 455 cc to create fullness and symmetry. Because the implant alone would not elevate the breast enough and knowing her concern about scarring, I performed an incision type called the Benelli Lift to raise the nipples slightly.
As you can see, the patient is only four weeks post-surgery, but she has nice volume and symmetry, and she has a more youthful appearance.
I evaluated a 28-year-old female that was wanting to have a breast enhancement as well as address her stomach area concerns. After losing over 120 pounds, her breasts were deflated, and her abdomen had excess loose skin. After her examination and listening to her goals, we agreed on the expectation and scheduled her for surgery.
During her surgery, I performed a breast augmentation using high-profile 350 cc saline breast implants along with a formal mastopexy (breast lift). Regarding the stomach area, I performed an abdominoplasty (tummy tuck) to remove and tighten the skin. Performing these procedures after massive weight loss is very gratifying, especially when someone is only 28 years old.
The post-op photo is three months out, and her transformation is well on its way. She is extremely excited about her appearance and looks forward to this summer.
I evaluated an African American female wanting to have a breast augmentation. During her consultation and examination, she expressed her desire to regain her fullness and projection. After listening to her goals, we agreed to use Allergan 425cc high-profile saline breast implants for the primary augmentation. During her surgery, I over filled the 425cc implants to 465cc to increase her anterior/posterior projection.
Her post-op photo is two years out, and she is extremely happy with her fullness, size, and cleavage when wearing certain types of clothing.
Stuart. A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.
Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery (ABPS).