Northern Virginia- Fairfax and Manassas
By: George Bitar, M.D. and Larry Lickstein, M.D.
Board Certified Plastic Surgeons
When Should a Breast lift with an Augmentation Be Performed Simultaneously?
If a woman desires bigger breasts and feels that her breasts are sagging, then she may be a candidate for a breast lift and augmentation. Depending on the degree of lift desired, skin will have to be removed from the breast to achieve the lift. Although a lift will reposition the breast to a more elevated and youthful position, nevertheless, the breast may lose about 10%-15% of its volume because of skin removal. In this situation, you have a choice to try on implants and see whether you would like an implant to be done at the same time as the lift, or have the procedures done separately. An augmentation/ lift procedure is a more involved procedure than either a lift or an augmentation alone. It also carries a higher risk of complications, but it is usually an extremely satisfactory surgery.
Very rarely are a woman’s breasts perfectly even, or symmetrical. Sometimes, the lack of symmetry can cause a woman to be distressed, adding prosthetic implants in her bra to achieve symmetry. This is a common situation that women do not like to discuss. The solution is straight-forward. If a woman with uneven breasts seeks a breast augmentation, it is simple to fill one breast implant more than the other to make the breasts as symmetrical as possible. Sometimes a breast augmentation is performed on one breast and a breast augmentation and lift, or a breast lift alone, or even a breast reduction is performed on the opposite breast simultaneously. The treatment plan is agreed upon during the consultation.
Preparing for Surgery
An initial consultation is set-up where we will discuss the breast lift and augmentation procedure and to decide whether you are a good candidate for the surgery. At this stage we will also have an additional discussion regarding selection of your implants. Your medical history is reviewed and you will be asked to see your medical doctor for a physical check-up and a few labs to make sure you can undergo the surgery safely. You are given the opportunity to be seen by your own doctor to give the green light for surgery. You are asked to stop smoking, if you are a smoker, two weeks before and two weeks after surgery, for the surgery to be performed safely, and for you to have optimal results. You are given the opportunity to talk to patients who have had the same surgery you are considering. We will see you shortly after the surgery (in a day or two usually). You are seen regularly after your surgery. You are always welcome to come back for follow-up, even years after your surgery, free of charge.
Breast Augmentation / Lift Procedure
We perform a breast augmentation/lift procedure by combining both a breast augmentation procedure and a breast lift procedure. First we perform the breast augmentation from an under-arm approach or through the mastopexy incision site/inframammary. The procedure is relatively simple and straightforward. A patient, who is deemed a good candidate for this operation, is taken to the operating room. They are given antibiotics, and anesthetized. The breasts are injected with tumescent solution to give some pain relief and decrease the bleeding during surgery. A pocket is created behind the muscle. An implant sizer – think of it as a disposable implant- is placed in the pocket and inflated to the volume desired by the patient. The patient is sat up in the operating room and the breasts are inspected. When a very nice result is achieved, the patient has the sizer removed and the true implant placed in the correct location.
Next we perform a breast lift. The breast lift technique depends on the amount of lifting needed:
1. Minor Lift: A periareolar, Benelli, or “donut” lift is performed where a “donut” shaped segment of skin is removed from around the areola and the scar is only around the areola.
2. Moderate Lift: A “lollipop” lift is performed where skin around the areola and from the lower aspect of the breast is removed with the resulting scar being around the areola and a vertical extension from the areola to the bottom of the breast at the midline, shaped like a lollipop.
3. Major lift: A “wise pattern” lift is performed with an anchor incision. Skin is removed from around the areola and a significant portion of the lower half of the breast leaving a scar that is shaped like a lollipop plus horizontal scars extending part or the total lower crease of the breast forming a scar that looks like an anchor.
Benefits of the Breast Lift with Augmentation
There are many different ways of doing a breast implant and lift procedure. This is one of our preferred approaches because the breast muscle is not cut, the healing process is faster, and the pain is less. Admittedly, this technique of inserting the implant from the under arm incision and performing the breast lift by removing skin around the nipple and areola is a variation on the common approach. The advantages are as follows:
1. The muscle is left intact, thus decreasing inflammation and pain, and also preserving intact muscle coverage for the implant, in case of an infection of the incision.
2. The option to adjust the implant size easily from a different site (from the underarm location) exists without difficulty, by inflating or deflating the sizer implants to achieve the desirable breast volume, before committing to the final implant size.
3. There is no suturing near the implant, so risk of infection, and puncturing the implant is minimized and time is saved
Our next most commonly used approach is to combine the breast lift and breast augmentation through and inframammary approach or through the mastopexy incision. The advantages to this approach are as follows:
1. The scar is about 1-2 inches long and heals very nicely or the existing mastopexy incisions can be used in some situations
2. The incision is hidden in the natural fold of the breast making it inconspicuous in swim suits or without clothing
3. Precise definition of the submuscular pocket and control of bleeding can easily be achieved
4. Pre filled silicone implants can be safely positioned
5. In revisionary or removal and replacement cases, this approach allows for precise capsule removal, pocket shaping and implant repositioning
How We Minimize Complications of Breast Lift with Augmentation:
At the Bitar Cosmetic Surgery Institute, we take pride in making sure we provide for our patients the best surgical experience possible. This is a process that includes the pre-operative preparation, the actual surgery, and the after care.
General complications can occur with any surgery. Cosmetic surgery is usually a safe surgery performed on healthy patients and, as all surgeries go, is with low risk. What we do to even lower the risk of complications is to operate at a first class hospital, with board certified anesthesiologists and nurses. To avoid post-operative complications, we advocate early mobilization –patients seen in our office one or two days after surgery- and active participation in their own post-operative care. When we create a partnership, the results invariably improve.
Bleeding after breast implants/ lift can be traumatic to a patient. It usually happens in the hours ensuing the breast augmentation, and usually happens on one side. Sometimes, a small amount of bleeding can be observed, but if the bleeding in a breast after a breast augmentation becomes significant, then the patient needs to have the bleeding removed in the operating room in a usually straight-forward procedure. The rate of hematomas, or bleeding after a breast augmentation is reported to be about 2%. Before surgery, our patients are tested to make sure they don’t have any common bleeding disorders by their own physicians, and by lab tests. We use tumescent solution, similar to that used in liposuction, before starting a breast augmentation procedure to decrease the amount of bleeding. That technique plus minimal dissection, handling of the muscle during the procedure and creating the appropriate pocket size for the implant are all techniques that decrease the chances of post-operative bleeding. In our practice the rate of hematomas in breast augmentation/lift is less than 1%.
Breast implant infections occur in general in about 1-2% of cases. The most important step in avoiding infections, in our opinion, is to perform the surgery at a first-rate surgical facility with board certified anesthesiologists and nurses. Patients are given the appropriate intravenous antibiotics coverage throughout the actual surgery. During the surgery, the skin surface of the patient is cleaned properly. Next, the doctor changes gloves multiple times during the operation, and he is the only one who handles the implant in the operating room to ensure total sterility and avoidance of infection. After the procedure, our patients are prescribed a one-week course of antibiotics to minimize infection. As a result of these extra precautions, our implant infection rate is significantly lower than the national average at less than 1%.
Capsular contracture is the hardening of the scar tissue around the implant, and occurs in 10%-15% of women with breast implants. It can also be a factor of time elapsed since the implant placement. Every implant will have scar tissue around it; that is totally natural. What is undesirable is for the scar tissue to harden and cause the patient pain or unnaturally-looking breasts. The theories behind the cause of capsular contractures vary. Capsular contractures may be caused by a sub-clinical infection, by significant bleeding during the operation, or by time alone. In the previous section, we discussed how to minimize the risk of infection. In order to minimize the risk of bleeding, we inject the breasts with a tumescent solution, similar to that used in liposuction. The reason for the tumescent solution is to decrease the bleeding during and after the operation and to provide for local anesthesia to decrease post-operative pain. As a result, our rate of capsular contracture has been less than 1%.
Rippling is the formation of small waves or folds of the breast surface due to a breast implant. Sometimes rippling is visible, other times it is palpable, or both. In the case of breast augmentations, especially with saline implants, this potential result can lead to patient dissatisfaction in up to 10% of breast augmentation patients. In order to avoid rippling, one must understand what causes it. The chest muscle, or pectoralis major, does not cover the chest totally; the lateral edge of the breast is not covered by that muscle, which is used as coverage for a breast implant. Rippling can be avoided or minimized by giving the breast implant maximum coverage with breast tissue and muscle. For that specific reason, rippling is minimized by placing an implant under the pectoralis major muscle and by selecting an implant size that would be covered almost completely by the muscle. As a result, the implant cannot be felt from the lateral edge of the breast. Because of these two guidelines, the rate of rippling among our patients is less than 2%.
Deflation or Rupture
Breast implants are devices. Their lifespan of “looking good” varies between different types, the patient’s conditions, and the technique used, but that lifetime is not indefinite. The younger the age of a woman seeking breast implants, the higher the probability that they may have to be adjusted or replaced at some point in the future. The good news is that newer breast implants are made of better material than the old ones and have a longer lifespan, with fewer complications. It is difficult to quote rates of breast implant rupture or deflation because it is a function of time. The best way to minimize this risk is by paying attention to each step in the pre-operative evaluation of a patient, the actual surgical procedure, and the follow-up care. If an implant ruptures or deflates, it needs to be exchanged. Saline implants ruptures are easier to diagnose, but silicone implant ruptures may need MRI imaging to make that diagnosis.
Ability to Breastfeed
Women are sometimes concerned that if they get a breast augmentation, they will not be able to breastfeed afterwards. The likelihood of losing the ability to breastfeed after a breast augmentation is very small, since the dissection occurs away from where the milk ducts are located. With the breast augmentation operation described above, inability to breastfeed after a breast augmentation that we have performed has not occurred with any of our patients to our knowledge.
Loss of Nipple Sensation or nipple / Areolar skin
Similar to what has been said about ability to breastfeed, loss of nipple sensation is a potential complication that due to the technique with which we perform this procedure is a minimal complication, with less than 1% occurrence. However, there is theoretically a higher chance of losing the nipple in a breast lift/ augmentation procedure than in either a lift or an augmentation alone due to changes in blood supply to the nipple. Temporary loss of sensation from a “stunned” nerve or a bruised nerve may occur in the time period after surgery, but sensation in the vast majority of cases returns within a few weeks.
Smoking is an absolute contraindication in breast lift with augmentation. The carbon monoxide and nicotine in cigarette smoke causes severe reduction in blood supply to the skin and breast tissue during healing. This results in delayed wound healing, wound separation, death of the skin, loss of nipple tissue, and a higher risk of infection. Cotinine testing is performed in patients with a smoking history to ensure that they are safe when having this procedure.
For more information about this procedure call our office and speak to our friendly staff member 703-206-0506.
Information on this web site is for information only. Do not use the information to diagnose or treat your plastic surgery or cosmetic surgery problems. Please contact your plastic surgeon with all questions and concerns.