 Breast enhancement can be performed using many different incisions; this includes placing the incision underneath the breast, along the border of the areola (periareolar), or in the armpit, transabdominal (TABA), or transumbilical (TUBA).
Each incision has its advantages and disadvantages:
1) Inframammary incision (underneath the breast) – Advantages – It is the easiest approach for the surgeon. It provides very good access to visualize the pocket and to treat bleeding points. Saline or silicone gel implants can be placed through this incision. Disadvantages - The scar can be more noticeable because of stretching. Tattooing may be required to camouflage the scar. There is a slightly higher tendency for the inframammary fold to be undermined and create a deformity of the fold (“double bubble”).
2) Periareolar incision - Advantages - The final scar usually blends in well with the change in color from the areola pigment to the native breast skin. This approach gives good visualization of the pocket. Many breast deformities and asymmetries can be treated through this approach. There is usually good visualization to design the pocket and to treat bleeding points, to divide the pectoralis muscle if placing implants in a subpectoral pocket or creating a subglandular pocket. Less likely, to undermine the breast fold and create a deformity of the fold (“double bubble”). Disadvantages - Sometimes the scar is noticeable and may require tattooing to better camouflage the incision. If the areola is too small it may not be of adequate size to allow for placement of a saline or silicone gel implant. Saline implants can be placed through a smaller areola than silicone gel implants.
3) Axillary incision (armpit) – Advantages - The incision is not on the breast. Disadvantages - The scar can be noticeable when the patient raises her arm. This approach is found to have a higher breast implant malposition rate (especially when performed bluntly without endoscopic visualization). Sometimes it is difficult to gain control of potential bleeding sources from this remote access. It can be very difficult to use this incision for placing silicone gel implants. Tattooing of the scar may be necessary to camouflage it better.
4) Transabdominal breast augmentation (TABA) - Advantages – There are no incisions on or near the breast. There is usually good visualization of the pocket and bleeding points. Because an adequate sized tunnel from the upper abdomen to the chest is created, saline or silicone gel implants can be placed through this incision. Disadvantages – It is only performed in women without significant ptosis (drooping) of the breast and who also desire a full tummy tuck.
5) Transumbilical breast augmentation (TUBA) – Advantages – There are no incisions on or near the breast. Disadvantages - It is difficult to visualize the breast implant pocket. If there is any bleeding, an inframammary or periareolar incision needs to be performed to gain access for treatment. Saline implants are the only type of implants that can be placed through this incision; therefore, silicone gel implants cannot be placed through this incision.
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Textured vs. Smooth Implants
There are many different varieties of implants. There are smooth outer shell implants and textured outer shell implants. Textured implants were created to minimize the risk of capsular contractures that can develop after breast implant placement. The plastic surgery literature has conflicting reports about the efficacy of textured implants. In fact with regards to capsular contracture rates, many plastic surgeons feel that there is no difference between textured and smooth implants. Some surgeons have reported that textured implants are more prone to develop noticeable ridging when implanted.
Round vs. Anatomical (Biodimensional)
Breast implants come in two shapes. Round implants are obviously round with no polarity (meaning no “up or down” position). Anatomical, sometimes referred to as biodimensional, have a “teardrop” shape to the implant. The anatomical implants were created to give a “more natural look” to the breasts, giving some upper pole fullness as well as a full lower pole. These implants have to be placed precisely in the breast pocket. This type of implant does have a polarity (an “up or down” position), and unfortunately has been known to turn. When the implant turns, it can make for a very unusual looking breast.
Subglandular vs. subpectoral pocket
In general, there are two breast implant pocket locations. The implants can be placed in a subglandular pocket, which is the space between the breast tissue and the underlying pectoralis muscle. The subpectoral pocket is located below both the breast tissue and the pectoralis muscle. Usually, in positioning breast implants in the subpectoral pocket, the inferior and lower medial portion of the pectoralis muscle is detached. So, actually the implant is not completely covered by the muscle. Usually the muscle ends up covering approximately 50-80% of the implant with the remaining breast tissue covering the lower 20-50% of the implant. A recommendation for implant pocket positioning often depends upon the individual patient anatomy. For the majority of patients that have very little breast tissue, a subpectoral pocket is usually recommended. This is because the implant is usually more palpable without adequate soft tissue coverage. The muscle adds another layer of soft tissue to camouflage the implant. Furthermore, the subpectoral pocket is often favored, because it is believed that the capsular contracture rate may be lower than a subglandular location. A subglandular pocket location is often preferred when there is adequate breast tissue volume.
Implant Shape and Size
There are many different shapes and sizes of implants, which allows for proper selection of the implant to match for the varying shapes and sizes of the patient’s chest. Chest wall base diameter varies; this along with patient cup size volume will impact the choice of implant chosen for a given patient. That is why the manufacturers of the breast implants have moderate profile implants, moderate plus implants, and high profile implants.
Gel vs. Saline Implants
With the recent FDA approval for silicone gel implants, Dr. Wallach is now offering silicone gel implants along with saline-filled implants to all his breast augmentation patients. Dr. Wallach was also a principal investigator in the recent FDA approved study to use silicone gel-filled breast implants under specific criteria. He is also an active participant in the post-approval study for gel implants. Saline and silicone implants are very safe devices. If a saline implant ruptures, the sterile salt water will be absorbed by the patient’s body and the breast will appear flatter. One major disadvantage of the saline implant is that it is more palpable than a silicone implant. The silicone gel implant feels more natural than a saline implant. This more natural feel permits a greater number of silicone gel implants to be placed in a subglandular pocket, more so than the saline implants. However, if a silicone gel implant ruptures, the gel has to be removed along with the ruptured implant.
A breast augmentation procedure usually takes between 1-2 hours with a recuperation of about 1 week. Patients are instructed to avoid aerobic exercise for 3 weeks and heavy lifting or strenuous exercise for 6 weeks. This is to minimize the risk of early problems with the implants such as hematoma (blood collection) formation. Dr. Wallach has presented his findings and has written several papers on the subject of breast augmentation and limited access surgery in several peer-reviewed plastic surgery journals. Dr. Wallach has also given an instructional course to fellow plastic surgeons on his preferred techniques of breast augmentation at the American Society of Aesthetic Plastic Surgery (ASAPS) national meeting.
If you would like more information about Dr. Wallach and his success with New York City Breast Augmentation procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 861-6400, by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028, or using our contact form to request additional details.
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