Breast Augmentation

There are several factors to think about prior to undergoing breast augmentation. These are: the type of implant to be used (saline or silicone), the incision, the plane of the implant (above or below the chest muscle) and of course the size of the implant. A relatively new issue that has arisen is the choice a woman has in Canada to use silicone or saline (salt water) implants. Silicone implants, prior to the 90's, were the implant most often used. In the early 90's controversy began to arise about the safety of silicone implants. There were links made between silicone implants and what we call connective tissue disease such as lupus, scleroderma, pain syndromes etc. The situation deteriorated to the point that silicone implants were essentially banned and saline became the only choice. In the last few years, silicone implants have made a big comeback. The reason that this has been allowed to happen is that the excellent scientific research that was done to investigate the safety of silicone implants has found that there is NO relationship between silicone and connective tissue diseases. This is not to say that women who were complaining of being sick were not really sick, but that there was no cause and effect relationship between their silicone implants and their symptoms. What the studies found in essence was that the incidence of connective tissue disease was the same in groups of women who had and who did not have silicone implants. Unfortunately, it is human nature (and very reasonable) for a young woman who was previously healthy and then went on to develop disease to associate her new medical condition with silicone implants. What we know now is that this same woman was destined to fall into the larger group of women overall who are destined to develop the disease whether or not she had implants. Having said all of this, I by no means encourage or "push" silicone implants on my patients. I do not work for the company or get paid any royalties. In fact, I would encourage any woman struggling with the idea of putting silicone implants into her body to avoid them and use saline. Cosmetic surgery should be a positive, uplifting experience. A woman who will continuously worry about her silicone implants is still best off going with saline. The other side of the coin is that almost all plastic surgeons would agree that silicone implants are a better product in that they look and feel more like a natural breast. They are a better replica of the human breast and give a better esthetic result. At the end of the day, a woman along with her family must take all of this information into account and choose the implant type that is best for her.

Preparing for breast implants surgery involves mental preparation, a review of your current medications and vitamins, and following standard pre-operative instructions.
Mental preparation for breast implants surgery is key to a pleasant post-operative recovery. It is important to understand that you are undertaking a very commonly performed procedure and that Dr. Backstein will have screened you pre-operatively to ensure you are a safe candidate for the procedure. Furthermore, breast augmentation by its nature is a safe procedure since the surgical work is carried out in a superficial plane of the body well away from large blood vessels or major organs. The chest cavity is never entered and bleeding is minimal and easy to control.
It is equally important to understand that immediately post-operatively your breasts will look somewhat larger and less natural than they will several weeks post-op. In particular, swelling can give the appearance that the breast implants are high on the chest whereas in reality, this look is simply a result of swelling which has a tendency to accumulate in the upper portion of the breast implant pocket. This look will resolve soon after your breast augmentation surgery. Make sure you review any medications and vitamins at least two weeks prior to your surgical date. Medications such as anti-inflammatory drugs, blood thinners/anticoagulants and vitamin E products should be discontinued completely for at least two weeks prior to breast implant surgery in order to minimize the risk of extra bleeding during or after surgery. Multi-vitamins may contain vitamin E and should be stopped if vitamin E is present. Finally, be sure not to eat or drink anything at all from midnight of the day before your breast implant surgery so as to enter the operating room with an empty stomach.

Breast augmentation surgery has been performed for over a century in one form or another. Modern breast augmentation began in the 1960's with the use of silicone implants (see history of breast implants) Today, breast augmentation and implant surgery has reached it's pinnacle in terms of patient safety, technology and quality of implants. Breast augmentation surgery is usually done under general anesthesia although local anesthesia is possible in some cases. On the day of your surgery, Dr. Backstein will begin by marking your breasts using a surgical pen while you are still awake and in the standing position. This is done while you are awake since the breast anatomy and position tends to change when a woman is lying down on the operating table making marking while under anesthesia less reliable. Once marking is complete, you will gently be put under anesthesia. Dr. Backetin only employs anesthesiologists with Royal College of Canada certification in Anesthesia.
The procedure is performed by first making the smallest possible incision in the area that was agreed upon in your breast implants consultation. The major step in the breast augmentation procedure is to create a "pocket" in which to insert the breast implant. This is done by carefully separating tissue layers according to the pre-operative markings. Dr. Backstein will then irrigate and flush the breast implant pocket copiously with an anti-septic solution to ensure that it is absolutely sterile and prepared for insertion of your breast implant. The same procedure is carried out on both sides and finally the incisions are sutured closed using careful cosmetic surgery techniques and using absorbable sutures.

Choosing the correct size of the breast implants to be used in your surgery is a challenge that can lead to a fair bit of stress for women undertaking breast augmentation. Many techniques to select the correct breast implants size exist including computer imaging, rice in a bag (in which an amount of rice equivalent to the size of the implant being considered is inserted into a bra in order to replicate the look of the implant), and the use of breast implant samples during your breast augmentation consultation. Dr. Backstein strongly believes that the use of breast implant samples is the best technique by far. Using sample breast implants eliminates a great deal of the inaccuracies and guess-work associated with computer imaging and rice in a bag. Dr. Backstein has a full array of shapes and sizes of breast implants in his office at Steeles Avenue Cosmetic Surgery which can be inserted into your bra in order to gain an appreciation for how that particular implant would look if used for your surgery. It is best to do this sizing exercise with an unpadded bra and while wearing a fitted shirt. Dr. Backstein will explain how placement of the breast implants above or below the muscle influences the size of the implant and how to account for this when choosing an implant. Dr. Backstein does not insist that patients choose the final size of their implants during the consultation and this decision can be changed even up to several days prior to your scheduled breast augmentation date.
Ultimately, there is no single breast implant size that is right for any individual but a range of sizes each of which would look great. It is true to say that the vast majority of women who have second thoughts about their implant size after breast augmentation surgery will say that they may have chosen a larger implant so Dr. Backstein encourages women to keep an open mind during the breast implants consultation process.

Much is written about the issue of breast implant placement, namely submuscular (under the muscle) or subglandular (above the muscle and below the breast tissue) placement. What is being talked about is where the pocket is created to put the implant into. During breast implant surgery, a pocket is created to house the newly inserted breast implant. Prior to surgery, tissue layers are stuck together like a sticker to its backing and only during the breast augmentation surgery are the tissue layers separated so as to accomodate the implant. This pocket can be made either above the pectoralis (chest) muscle or below the pectoralis muscle. The advantages of placing the implants below the muscle are that the final result may have a slightly more natural look and the rate of certain complications such as capsular contracture and downward migration ("bottoming-out") of the implant may be reduced. As such, Dr. Backstein suggests submuscular implants to most patients. In certain cases, the pre-existing breast anatomy and position will indicate that subglandular (above the muscle) placement of the breast implants is advisable. In particular, a woman with a substantially sized breast that has become deflated and droopy or pendulous, usually as a result of pregnancy and breat-feeding, will usually benefit from placing the breast implants above the muscle since this allows the volume of the implant to better "perk-up" the loose, hanging breast tissue.

In general, breast implants surgery will not affect a woman's ability to breast feed. A closer look at how the procedure is done helps to explain why this is.
When the pocket is created during breast implant augmentation the breast mound itself is not violated. This is true whether the implants are placed submuscular (below the muscle) or subglandular (above the muscle, below the breast). The implant is never actually placed into the substance of the breast where the milk glands and ducts leading from the gland to the nipple are located but instead is always placed beneath the breast tissue leaving all the structures important to breast feeding intact and untouched. The only exception is if a woman chooses to have breast implant surgery performed using a peri-areolar (around the areola) incision. In these cases, the incision itself and the associated scar tissue or mastitis may lead to interference with breast feeding in some cases. The important message is that if breast feeding is important to you, avoid the use of the areolar incision in your breast augmentation surgery.

There are several complications of breast augmentation/implants that need to be understood:

Infection, while very rare (less than 1% of cases), has consequences that can be difficult. An infected breast implants would present itself as a swollen, red breast with increased pain and possible fever and general unwellness. Unfortunately, if this rare complication is to occur, it will almost certainly require the implant on the infected side to be removed. Furthermore, after the implant is removed, it cannot be safely replaced for at least several months. This delay in replacing the implant helps to ensure that once the implant is replaced, the infection does not recur. Dr. Backstein uses intravenous antibiotics during the surgical procedure as well as a full week prescription of oral antibiotic pills to minimize the chance of this problem. In summary, infection is very rare but needs to be understood by patients due to the significance of this complication on the breast augmentation experience.

Hematoma is a complication that generally occurs within the first 24 hours after surgery and involves leakage of blood into the same space (pocket) that the implant is occupying. It is generally caused by a small blood vessel that was encountered during the surgery starting to bleed in the first while after surgery. It is important to note that this is not life-threatening bleeding but rather a slow leak of blood that stops on its own. The reason it is significant is that if the amount of blood in the pocket is more than just a small amount, leaving the blood there can lead to distortion of the breast or infection. In such cases, the patient would be brought back to the operating room to clean out the leaked blood. Unlike with infection, the implant is put right back and after surgery, and the breasts are "back to square one".

Capsular Contracture is a relatively common complication with some studies showing a rate of up to 10% of cases. Dr. Backstein's experience is that this complication occurs in about 3% of his cases, Capsular contracture is typically a delayed complication in that it takes weeks or months to develop. Capuslar Contracture refers to a situation in which the body's normal and healthy response to a foreign material (the implant) which is the isolation of the foreign material from the surounding tissues by a thin layer of scar tissue is over-done. In such cases, the normal thin, pliable layer of scar tissue becomes progressively thicker and heavier to a point where the affected breast can begin to look contracted, tight and even raised on the chest compared to the other side. The problem nearly always occurs on only one side and many studies have tried but failed failed to identify the exact cause of this complication. A patient that develops this complication may need to be brought back for surgery called a Capsulotomy in which the scar tissue surrounding the implant is scored and released to allow the breast to relax and take on a normal shape and feel.

It should be noted that the treatements required for the complications mentioned above are all OHIP-covered and will not require additional payments.

A general rule with breast augmentation is that the final result will amount to an enlargement of the pre-operative breast shape and structure. That is to say that breast augmentation enlarges the breast you have, it does not create an entirely new form. This is why it's not advisable to find photos from magazines or other sources to act as the basis for what you want or expect from the surgery. For example, a patient with a particularly wide cleavage before breast augmentation will also have a relatively wide cleavage after breast implant surgery. The cleavage can be accentuated somewhat through breast augmentation but not dramatically. This is because placing the implants very close together on the chest wall, which is what is technically needed in order to accentuate the cleavage, will lead to other unacceptable problems. In particular, by placing the implants centrally on the chest, the nipples will end up on the outer portion of the breast mound and this will not look right. A basic surgical principle with breast augmentation is that the implant must be placed so that it is centred behind the nipple/areola and this takes precedence over creating increased cleavage.