Breast Augmentation: Aug. Mammoplasty Frequently Asked Questions
Q & A with Tom J. Pousti, MD
Q: How long do I need to be off of work?
A: It is recommended that you take one week off of work after breast augmentation surgery and continue to avoid strenuous activity and heavy lifting for 4 weeks after the surgery. I also ask the patients to not drive for 2 weeks after the surgery.
Q: Who is too old to get a breast augmentation?
A: Breast augmentation can be performed from an age of 18 years old on up. You are NEVER too old to improve the appearance of your breasts.
Q: Should implants be placed under the muscle or over the muscle?
A: Every patient’s anatomy is different, therefore, the only way to know which procedure would give you the best cosmetic result is by having a board certified plastic surgeon examine you and discuss your options with you.
Q: Is it necessary to wait until after having children before having breast augmentation surgery?
A: No, it is a matter of choice for each woman. More than half of patients perform the surgery before having children and the majority of them have no problems breast feeding afterwards. The incisions used are small and the surgeon attempts to minimize the amount of disruption of the glands to the nipple/areola. The underlying breast implant does not harm the breast fed baby in any way.
Q: How do I decide what size to go?
A: The size that a patient decides to achieve is a very personal decision. Often time the patient wishes to achieve a “natural look” to simply improve the proportionality of the upper and lower body. Some patients, however, want a “round” look. For these patients a “natural look” is not a priority and they are not concerned if other people know that they have had a breast augmentation. In making this decision, it helps to discuss your goals with your surgeon. Pictures are often helpful as a form of communication between the patient and the surgeon. Often times, discussing “cup size” is useful but one must be careful since “cup size” depends on the manufacturer of the bra.
Q: Do breast implants interfere with mammography?
A: Yes. Breast implants, regardless of their location in the sub-muscular or sub-glandular location, can interfere with mammography. Generally, the breast implants placed in the sub-muscular position tend to interfere with mammography less than those placed below breast tissue. Mammography centers are well accustomed to performing mammography on patients who have had breast implants (using displacement techniques).
Q: Can sensation of the nipple/areola be lost after breast augmentation surgery?
A: Yes, a small percentage (<5%) of patients have permanent nipple/areola sensation loss after breast augmentation surgery. Many patients have temporary loss or hyper-sensitivity of the nipple/areola complex. The surgeon takes great care during the operation to avoid injury to the nerve supply to the nipple/areola complex.
Q: How do I decide on the incision (approach) to be used during breast augmentation?
A: Several approaches are available to perform the breast augmentation. These include the following: an incision under the areola, under the breast (just above the infra-mammary fold), and in the axilla (arm pit). The choice of incision is a decision made by the patient and the surgeon. In general, we try to use the incision which is best hidden and therefore less visible. Often times, this decision is made based on the patient’s anatomy. For example, if the patient has some amount of excess skin under the breast, an incision can be well hidden in this area (just above the infra-mammary fold) otherwise an incision around the areola tends to heal very nicely and becomes barely visible with time.
Q: How do I decide to go over or under the muscle with the breast implant?
A: The decision to do a sub-muscular (under the muscle) or sub-glandular (under the breast tissue) breast augmentation is based on several factors. Some of these factors include the patient’s preference and the patient’s anatomy. Each type of augmentation has its pro’s and con’s. In general, however, all things being equal, I prefer to do sub-muscular breast augmentations. This type of augmentation is associated with less chance of seeing or feeling the breast implant. This operation is also associated with a decreased risk of breast implant hardening (encapsulation or scar tissue formation). Sub-muscular breast augmentation interferes with the performance of mammography less so than does sub-glandular breast augmentation.
On the other hand, sub-muscular breast augmentation is generally associated with more patient discomfort and a longer period of time to achieve the final cosmetic results compared to the sub-glandular breast augmentation. Weighing the pro’s and con’s of each type of augmentation, whenever possible, I prefer to perform a sub-muscular augmentation to achieve an end result with fewer complications and a better aesthetic result.
Q: Who should perform my breast augmentation surgery?
A: The physicians most qualified to perform breast augmentation surgeries are board certified plastic surgeons. It is important to get information regarding the surgeon’s training. Can the surgeon perform this procedure in a major hospital in your city? What do other patients say about the surgeon’ s ability to communicate and his level of care post-operatively?
Q: What do the implants feel like?
A: In general, implants feel firmer than your own breast tissue. Also, the appearance and feel of augmented breasts depends on how much breast tissue the patient had pre-operatively. In general, the more tissue the patient the patient has pre-operatively, the more natural the look and feel post-operatively.
Q: What medications should I stop before surgery?
A: It is recommended not to take any aspirin containing medication, ibuprofen containing medication or any herbs or weight loss medications for at least 2 weeks before surgery.
Q: How do I reduce nausea post-operatively?
A: Unfortunately, nausea is a common problem after many surgical procedures. Many medications can be used intra-operatively in an attempt to reduce this problem. Post-operatively, nausea can be reduced by minimizing the use of narcotics and taking the medication with a small amount of food in the stomach. If nausea is not relieved by these measures, anti-nausea medication may be prescribed.
Q: How do I know if I need a breast lift?
A: A breast lift (mastopexy) is an operation used to treat ptotic (sagging) breasts. A consultation with a well qualified plastic surgeon can help answer this question for you. In general, evaluating the position of the nipple/areola complex in relation to the fold under the breast (infra-mammary fold) will help determine the need for lifting. Different types of breast lifting operations are available depending on the severity of the sagging. Reviewing pictures of patients with similar situations may be helpful in deciding how to proceed.
Q: What can I expect post-operatively?
A: Unfortunately, most patients experience a moderate to significant discomfort post-operatively. This seems to be increased with sub-muscular breast augmentation compared to sub-glandular breast augmentation. Many patients are unable to sleep because they are not used to sleeping on their backs. Soreness of the back and neck may be related to this difficulty finding a comfortable position. Some patients choose to use 2 pillows and sleep in a reclined position.
Q: What is symmastia?
A: This is when the two breasts communicate in the midline (cleavage area). This may be done to “increase cleavage” by dividing the soft tissue or muscle fibers at the medial edges of the breast. This can be seen with implants placed over or under the muscle. It is a correctable problem.
Q: What is the difference between textured and smooth implants?
A: Texturing refers to the surface of the breast implant. Textured implants have a rough surface in an attempt to prevent contracture formation (especially when the implants are placed above the muscle). This does not appear to be relevant in the sub-muscular position. Textured implants may be associated with rippling more than smooth implants.
Q: What is a “Tuberous Breast”?
A: Tuberous Breasts, otherwise known as constricted breasts, are associated with some breast tissue deficiency especially medially (around the cleavage area). The appearance of the breasts can vary greatly from a very severe deficiency of breast tissue to mild deficiency. Often times, the patient will have different size and shape between the right and left breast. This is a correctable condition. Of ten, implants can be used to improve the size, shape and symmetry of the breasts.
Q: When do the stitches come out?
A: The stitches usually come out 5-7 days after surgery.
Q: When can one shower after this procedure?
A: After the stitches are removed, the patient is allowed to shower.
Q: If I have to have the surgery redone later in life, will the incision be made in the same place as the original?
A: Usually, yes, the incision would be made in the same area.
Q: Will I need expanders to achieve the size I want?
A: Usually, expanders are not necessary.
Q: Do you use sizers during surgery to best determine size?
A: Yes, I always use sizers.
Q: How many different sizes of implants do you take into the OR?
A: I always have all breast implant sizes available in the OR.
Q: Do you make over-sized pockets?
A: Pockets are slightly larger than the implants used. This will allow for some movement of the implants so as to resemble natural breasts as much as possible.
Q: If I develop a capsule and the implants have to be removed, will I be able to have them put back again?
A: Most of the time, patients wish to have implants replaced after removal of capsules (capsulotomy).
Q: What guarantees are offered with the implants?
A: Currently, the implants are warrantied for life by the implant manufactorer. They also provide a stipend to return to the OR if an implant leak occures within the first 10 years.
Q: What is the best way for me to determine the size implant I will need to go from where I am to where I want to be?
A: Often, by looking at pictures, we can ascertain your goals of size and shape of breast desired.
Q: Will I be able to sleep on my stomach?
A: In general, approximately 2-3 months after surgery, one is able to sleep on their stomach.
Q: Who prescribes the painkillers and can we collect them prior to surgery?
A: All necessary prescriptions will be prescribed by the doctor several weeks prior to surgery (at the pre-op appointment).
Q: How long will I have to wear this special bra?
A: Normally, the bra will need to be worn for 2-4 weeks. There are reasons why the bra is important and following San Diego Cosmetic Surgeon’s, Dr. Pousti, directions will give you the best possible results. Each patient is different and so the recovery will also be different.
Q: What are the risks of breast augmentation / lifting performed at the same time vs. doing them separately?
A:Breast augmentation / mastopexy (breast lifting) surgery is one of the most commonly requested breast contouring surgeries performed. Patients who seek to have this operation done generally wish to improve the contour of the breast by lifting the nipple-areola complex by tightening up the “skin envelope” and achieve increased fullness of the breasts especially superiorly and along the cleavage area. The combination breast augmentation / mastopexy surgery differs from breast augmentation surgery alone in that it carries increased risk compared to either breast augmentation or mastopexy surgery performed separately. Furthermore, the potential need for revisionary surgery is increase with breast augmentation / mastopexy surgery done at the same time. Revision mastopexy may also be necessary if the patient gains or loses weight or becomes pregnant. Loss of breast skin elasticity may contribute to the earlier need for revisionary surgery (repeat lifting) as well.
When breast augmentation / mastopexy surgery is performed, an implant is used below or on top of the pectoralis muscle. The breast tissue and skin is then elevated lifted) to cover the breast implant. This “lifting” often involves skin excision, the areola, vertically and sometimes horizontally. This skin excision serves to tighten the “skin envelope”. By doing so, a lifted appearance of the breast is achieved and the loose-saggy appearance and feel of breast tissue is eliminated. Herein lies the competition and the potential risks and complications: the mastopexy procedure by definition involves reducing the skin envelope allowing for repositioning of the nipple-areola (and reshaping the breast). Breast augmentation by definition enlarges the breast and expands the skin envelope. Also, placement of an implant necessitates dissection of a “pocket” that reduces blood flow. The blood flow is further compromised by incisions used to reduce the skin envelope.
Because of these factors, while breast augmentation OR mastopexy surgery is relatively simple and complication free, breast augmentation / mastopexy surgery done together carries increased chances of complications and need for further surgery. For example, there is an increased risk of infection, implant exposure, breast asymmetry, loss of nipple-areola sensation, inability to breast feed, mal-positioning of the nipple-areola complex, mal-position of the implants, wound healing problems, tissue necrosis, loss of blood supply to the nipple-areola complexes. Any of these complications may require further surgery, therefore, increasing the likelihood of revisionary surgery. It is important that the patient understands the principles behind any planned procedure of any breast augmentation / mastopexy surgery. An understanding of the procedure will facilitate an understanding of the potential risks and complications when they occur. A well-informed patient may decide to stage the procedures (for example, perform the breast lifting operation initially followed by breast augmentation at a later date). A well informed patient who decides to proceed with single stage breast augmentation / mastopexy procedure should understand the nature of the procedure, the increased potential risks and complication so the combined procedures (compared to the procedures performed individually), and the higher likelihood of revisionary surgery to correct imperfections that arise from the combined procedures. This revisionary surgery may impose additional discomfort, recovery time, time off of work and cost to the patient.
To summarize, single staged breast augmentation / mastopexy surgery carries increased risk compared to either of the procedures done separately. In order for the patient to make a well informed decision, it is necessary for her to understand the potential increased risks and complications as well as the potential need for further surgery when the single staged procedure is performed. This will allow the patient an opportunity to proceed with two staged procedures (procedures done separately) or proceed with the single staged procedure with the increased risk of potential risk and complications and need for further surgery.
Q: How long do I have to wear the bandeau?
A: The amount of time that the bandeau needs to be worn depends on your specific situation. On average, the bandeau will be worn for 2-4 weeks after the procedure by our cosmetic surgery patients.
Q: When can I start to exercise?
A: Dr. Pousti does not recommend heavy weight lifting or strenuous exercise until 6 weeks after the procedure. Patients may walk and do leg exercises soon after the procedure.
Q: How long is the recovery?
A: Every San Diego Cosmetic Surgery Patient is different in their recovery. Most patient’s are able to resume the majority of their normal activities 4-6 weeks after the procedure.
Dear Dr. Pousti,
I was a bit hesitant initially to proceed with this type of elective surgery. It was after hearing you at the seminar describe procedures with their benefits and potential risks that I felt a bit more at ease about selecting you as my doctor. Upon my consultation with you, I was then convinced that you were most qualified and that I would enjoy having you see me through this process. In part, it was your sense of humor that placed me at ease. That has helped to sustain me through each subsequent visit. In preparation for each visit, my husband and I would discuss my progress and decide on the questions we should ask each time. Because of that sense of humor, we would inevitably come up with a set of serious questions but quickly move on to some fun ones. As a result, we have come up with a set of top 10 questions, a la David Letterman style, questions about things that most of your patients might want to know regarding breast augmentation (but might be too embarrassed to ask):
10 Do you have any suggestions as to what to do with my extensive collection of padded bras?
9 Will my new décolletage reduce my possibility of speeding tickets?
8 Since my implants are filled with salt water, will they rise and fall with the tides?
7 Should my “coming out” party for my new breasts be a formal or casual?
6 Please tell me that you didn’t get the water from the Dead Sea!
5 Since I live in the desert, should I be concerned that my implants will evaporate and my breasts shrivel up like California raisins?
4 My husband and I are having trouble naming our new friends. Any suggestions?
3 Will my new implants affect my predisposition to sea sickness?
2 Is there any correlation between breast implants and bead accrual during Mardi Gras?
And #1 Will I float?
Thanks for a job well done and for keeping a sense of humor.
A satisfied patient and a very happy husband!