|There are two basic types of implants: saline filled and silicone
gel-filled breast implants. Both types have the same basic type of outer
envelope made of a solid, rubber-like form of silicone called an
|Saline filled implants These implants are made of an elastomer
silicone envelope, which is surgically implanted under your tissues, and
then filled with sterile saline, a salt-water solution, through a valve.
|Silicone gel-filled implants These implants are made of an
elastomer envelope pre-filled (prior to surgery) with a clear, sticky,
thick jellylike form of silicone that approximates the consistency of
breast tissue. Silicone gel implants come in many sizes. The size used
depends on the amount of augmentation desired or the size the
reconstructed breast is to be.
|Presently, saline filled implants are available to all patients from
only the Mentor Corporation and McGhan Medical. Silicone gel-filled
breast implants are available to women through two FDA-approved studies,
an adjunct study and an investigational device exemptions (IDE) study. http://www.fda.gov/cdrh/breastimplants/biavail.html
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|The reasons for deciding to undergo a breast implant operation are as
varied as the number of women who have the operation. The common thread
amongst these women is a profound desire to improve their quality of
life. In 1990 the American Society of Plastic and Reconstructive
Surgeons (ASPRS) conducted a survey of women who had breast implants
indicating that the overwhelming majority of women succeeded in
improving the quality of their lives. The 592 women who completed the
survey had had their implants for an average of eight years. 65% of the
women who respond had implants for cosmetic enlargement and 35% for
92.5% said they were satisfied with their implants
82% said they would do it again without a doubt
16% said they would probably do it again
2% said they would definitely not do it again
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|Breast implant surgery for breast augmentation involves making a
single incision in or near the breast and inserting the implant either
between the breast and the chest muscle (subglandular placement) or
behind the chest muscle (submuscular placement).
|Subgladular placement this placement may make surgery and
recovery shorter, may be less painful, and may be easier to access for
re-operation than the submuscular placement. However, this placement may
result in more noticeable implants, more capsular contracture, and more
difficult imaging of the breast with mammography.
|Submuscular placement This placement may make surgery last
longer, may make recovery longer, may be more painful, and may make it
more difficult to have some re-operation procedures than the
subglandular placement. The possible benefits of this placement are that
it may result in less noticeable implants, less capsular contracture,
and easier imaging of the breast with mammography.
|Once you choose the placement of your breast implant, it is necessary
for you to determine the location of the incision site. The location of
the incision depends upon your body type and your personal preference.
You can choose to have the incision, around your nipple (periareolar
incision), underneath your breast (inframammary incision), or near your
armpit (transaxillary incision). If the incision is made under the arm,
the surgeon may use a probe fitted with a miniature camera, along with
minimally invasive (very small) instruments, to create a
"pocket" for the breast implant.
Periareolar This incision is the most concealed, but is associated
with a higher likelihood of inability to successfully breastfeed, as
compared to the other incision sites.
Inframammary This incision is less concealed than periareolar and
associated with less difficulty than the periareolar incision site when
Axillary This incision is less concealed than periareolar and
associated with less difficulty than the periareolar incision site when
|The breast implant surgery itself may be done either under local or
general anesthesia in the hospital, a surgical center, or in the
physicians office. The procedure is usually done as one-day
outpatient surgery; however, for some women an overnight stay is
recommended. The procedure takes two hours or more, depending on whether
the implant goes above or beneath the muscle.
|First, the surgeon creates a pocket-a space between the tissues-to
accommodate the implant. After inserting the implant, he or she closes
the pocket and sutures the tissues in place. Then either a surgical bra
or bandage is placed over the incision. Post surgical swelling is to be
expected, as is some pain and discomfort. Most women return to work and
resume non-strenuous activities, such as driving, about a week to ten
days after surgery.
|The following description applies to reconstruction following
mastectomy, but similar considerations apply to reconstruction following
breast trauma or for reconstruction for congenital defects.
|The procedure for breast implant reconstructive surgery differs from
that of augmentation surgery. Following your mastectomy you have a
choice, you can choose to have immediate reconstruction or delayed
reconstruction. Immediate reconstruction occasionally involves placement
of a breast implant directly after your mastectomy; however, it usually
involves placement of a tissue expander that will eventually be replaced
by an implant.
|There are two potential advantages to immediate reconstruction: your
breast reconstruction starts at the time of your mastectomy, and there
may be cost savings in combining the mastectomy procedure with the first
stage of reconstruction. There are, however, some disadvantages. There
may be a higher risk of complications such as deflation with immediate
reconstruction, and your initial operative time and recuperative time
may be longer.
|The advantage to delayed reconstruction is that you can delay your
reconstruction decision and surgery until other treatments; such as
radiation therapy and chemotherapy are completed. Delayed reconstruction
may be advisable if your surgeon anticipates healing problems with your
mastectomy, or if you simply need more time to consider your options.
|During a mastectomy, the surgeon often removes skin as well as breast
tissue, leaving the chest tissues flat and tight. To create a space for
the breast implant, a tissue expander is placed under the remaining
chest tissues. The tissue expander, like an implant, has a rubber
silicone outer shell. Generally, the tissue expander is surgically
inserted through a small incision in the mastectomy scar. Over the
course of several months, the surgeon adds small amounts of saline
through a special tube. The expander gradually inflates, gently expanding
the skin and muscle by stimulating the growth of healthy new tissue,
much as a baby gradually expands a mother's stomach. This procedure
creates a more natural appearance and may reduce the risk of capsular
|When sufficient tissue has been created, the temporary expander is
surgically removed and a more permanent implant is inserted. The surgery
to replace the tissue expander with a breast implant is usually done
under general anesthesia in an operating room. It may require a brief
hospital stay or be done on an outpatient basis.
|Breast reconstruction may be achieved without any implants at all by
surgically moving a section of skin, fat and muscle from one area of
your body to another. The section of tissue may be taken from such areas
as your abdomen, upper back, upper hip, or buttocks. The tissue flap may
be left attached to the blood supply and moved to the breast area
through a tunnel under the skin (a pedicled flap), or it may be removed
completely and reattached to the breast area by microsurgical techniques
(a free flap). Operating time is generally longer with free flaps,
because of the microsurgical requirements.
|Flap surgery has both advantages and disadvantages. Flap surgery
creates breasts with a more natural shape and feel, and allows
reconstruction in women who have so little skin or such tight,
irradiated skin that reconstruction would otherwise be impossible or
unsatisfactory. However, flap surgery requires a hospital stay of
several days and generally a longer recovery time than implant
reconstruction. Flap surgery also creates scars at the site where the
flap was taken and possibly on the reconstructed breast. Flap surgery is a major operation, and
it is more extensive than your mastectomy operation.
It requires good general health and strong emotional motivation. If you
are very overweight, have uncontrolled cancer, or have other severe
medical problems, this surgery may be too risky for you. Also, if you are
very thin, you may not have enough tissue in your abdomen or back to
create a breast mound with this method.
|The two most common types of tissue flaps are the TRAM (transverse
rectus abdominus musculocutaneous flap, from the abdomen) and the
Latissimus dorsi flap (which uses tissue from the upper back).
TRAM flap In this procedure, the surgeon creates a flap using
skin, fat, and one or both of the rectus abdominis (abdomen) muscles.
This pair of muscles extends the length of the front of the stomach and
flexes the spinal column, tenses the stomach and intestine walls, and
helps press the contents of the stomach and intestines. There are two
types of TRAM flap procedures, pedicle and free flap. In the pedicle
TRAM flap procedure, the flap remains attached to the original blood
supply and is tunneled through the abdomen up to the breast area. In the
free-flap procedure, the tissue is detached from the abdominal blood
supply and reconnected to the blood vessels in the armpit using microvascular surgery. The pedicle TRAM flap procedure typically takes
three to six hours of surgery under general anesthesia; a free TRAM flap
procedure generally takes longer. Typically, the hospital stay is two to
five days. You can generally resume normal activity after six to eight
weeks. You may have temporary or permanent muscle weakness in the
abdominal area. If you are considering a pregnancy after your
reconstruction, you should discuss this with your surgeon.
Latissimus dorsi flap In this procedure, the surgeon moves a
section of tissue from your back to your chest to reconstruct the
breast. The surgeon creates a flap from your skin, fat, and the
latissimus dorsi muscle - the broad, flat, triangular-shaped back muscle
that moves the arm, draws the shoulder back and down, and helps draw the
body up when climbing. The flap is then tunneled inside the body from
the back to the front of the chest. The skin and muscle remain partly
attached to the blood and nerve supply. The tissue flap is then set into
the mastectomy site and sutured in place. The Latissimus Dorsi flap is
usually thinner and smaller than the TRAM flap, and therefore this
procedure may be more appropriate for reconstructing a smaller breast.
The Latissimus Dorsi flap procedure typically takes two to four hours of
surgery under general anesthesia. Generally, the hospital stay is two to
three days. You can resume daily activity after two to three weeks. You
may have some temporary or permanent muscle weakness and difficulty with
movement in your back and shoulder. You will have a scar on your back,
which can usually be hidden in the bra line. You may also have
additional scars on your reconstructed breast.
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|During capsular contracture, the scar tissue or capsule that normally
forms around the implant tightens and squeezes. Capsular contracture is
generally more common following infection, hematoma, and seroma. It is
also more common amongst women who have chosen to have subglandular
placement. Symptoms range from firmness and mild discomfort, to pain,
distortion, palpability of the implant, and/or displacement of the
|Additional surgery is needed in cases where pain and /or firmness is
severe. This surgery ranges from removal of the implant capsule tissue
to removal and possible replacement of the implant itself.
|In some cases, capsular contracture may happen again after these
|As far as the ability to successfully breast feed after receiving
breast implants, one study reported that 64% of women with implants with
were unable to breast feed compared to 7% without implants. It is
thought that the periareolar incision site may significantly reduce the
ability to successfully breast feed.
|There is a high likelihood that women who have received breast
implant surgery will need to have additional surgery at some point to
replace or remove their implants. Problems such as deflation, capsular
contracture, infection, shifting, and calcium deposits can require
removal of the implants. Most women choose to have their implants
replaced. For those who do not, cosmetically unacceptable dimpling
and/or puckering of the breast may result.
Dissatisfaction with Cosmetic Results
|Dissatisfying results such as wrinkling, asymmetrical implant
displacement (shifting), incorrect size, unanticipated shape, implant
palpability, scar deformity, hypertrophic (irregular, raised scar)
scarring, and/or sloshing may occur. Careful surgical planning and
technique minimize, but do not always prevent results such as these.
|Pain of varying intensity and duration may occur and persist
following breast implant surgery. In addition, improper size, placement,
surgical technique, or capsular contracture may result in pain
associated with nerve entrapment or interference with muscle motion. You
should tell your doctor about severe pain.
|As with any surgery, infection can occur during or after the breast
implant operation. Infections with an implant present are harder to
treat than infections in normal body tissues. If an infection does not
respond to antibiotics, the implant may have to be removed. In this
event you can choose to have another implant surgery once your infection
has been eliminated.
Interference with mammography
|Breast implants may delay or hinder the early detection of breast
cancer either by hiding suspicious wounds, injuries, or tumors or by
making it more difficult to include them in the mammogram image.
Implants increase the difficulty of both taking and reading mammograms.
Mammography requires breast compression that could contribute to implant
|For these reasons you may wish to undergo a preoperative mammogram
and another mammogram six months to one year after implantation to establish a
baseline. It is essential that you tell your mammography technologist
that you have an implant before the procedure. The technologist can use
special techniques to minimize the possibility of rupture and to get the
best possible views of your breast tissue. These special techniques
require more x-ray views, therefore exposing you to more radiation. The
benefit of the mammogram in finding cancer outweighs the risk of the
|In rare instances, Toxic Shock Syndrome has been noted in women after
breast implant surgery. Toxic Shock Syndrome is a life-threatening
condition. Symptoms include sudden fever, vomiting, diarrhea, fainting,
dizziness, and/or sunburn-like rash. In this event, you should see a
doctor immediately for diagnosis and treatment.
|A hematoma is a collection of blood inside a body cavity. A seroma is
a collection of the watery portion of the blood (in this case, around
the implant or around the incision). Postoperative hematoma and seroma
may contribute to infection and/or capsular contracture. Swelling, pain,
and bruising may result. If a hematoma occurs, it will usually be soon
after surgery. However, a hematoma may also occur at any time after
injury to the breast. While the body absorbs small hematomas and seromas,
larger ones will require the placement of surgical drains for proper
healing. A small scar may result from surgical draining. Implant
deflation/rupture can occur from surgical draining if damage to the
implant occurs during the draining procedure.
Alteration of Nipple and Breast Sensation
|The feeling in your nipple and breast may change following breast
implant surgery. Your feeling can range from intense sensitivity to no
feeling at all. These changes may be temporary or permanent. They may
affect your ability to nurse a baby as well as your sexual response.
|Extrusion (when the breast implant comes through the skin) may result
from unstable or compromised tissue covering and/or interruption of
Calcium Deposits in the Tissue Around the Implant
|Deposits of calcium may be seen on mammograms and can be mistaken for
cancer. In this event, it may be necessary to undergo additional surgery
such as biopsy and/or removal of the implant to distinguish the calcium
deposits from cancer.
|Necrosis, the formation of dead tissue around the implant, may
prevent wound healing and require surgical correction and/or implant
removal. Permanent scar deformity may occur following necrosis. Factors
associated with increased necrosis include infection, use of steroids in
the surgical pocket, smoking, chemotherapy/radiation, and excessive heat
or cold therapy. If you are a smoker, it is recommended that you do not
smoke during the few months preceding and following your surgery.
Breast Tissue Atrophy/Chest Wall Deformity -
|The pressure of the breast implant may cause the breast tissue to
thin and shrink. This can occur while implants are still in place or
following implant removal without replacement.
|In addition to these complications, there have been concerns
associating breast implantation with certain systemic diseases:
Connective Tissue Disease
|A recent study conducted by the FDA
indicates that women whose implants have ruptured and have extracapsular
silicone gel (silicone outside the fibrous scar around the implant) were
2.8 times more likely than women whose breast implants havent
ruptured to report that they had the soft tissue syndrome, fibromyalgia.
Fibromyalgia is a syndrome characterized by widespread pain, fatigue,
and sleep disturbance. The study did not show cause and effect, but a
statistical association between extracapsular silicone and fibromyalgia.
The study also indicated that patients with extracapsular silicone gel
are not more likely than other women to have "other connective
tissue disease" such as dermatomyositis, polymositis, and mixed
connective tissue disease.
|Published studies indicate that breast cancer is no more common in
women with implants than those without implants.
Second Generation Effects
|There have been concerns raised regarding potential damaging effects
on children born of mothers with implants. A review of published
literature on this issue suggests that the information is insufficient
to draw definitive conclusions.
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|Silicone is a synthetic plastic, or polymer, that was first developed
in the 1930s. It contains silicon, a naturally abundant material,
combined with carbon, hydrogen, and oxygen that have been polymerized, a
process in which simple molecules are combined to form more complex
molecules. Silicone can be processed into three forms: a fluid, a gel,
and a solid, rubber-like compound known as an elastomer. Silicone has
been used in all its different forms, for medical purposes such as
pacemakers, hypodermic needles, penile implants, eye lenses, and
|Silicone breast implants became available in the early 1960s. They
were vastly superior to the previous breast implants, which were made of
polyurethane foam, paraffin, steel, and grafts of human tissue. The
first silicone implants were firm and therefore required several large
surgical incisions, leading to prominent scars. Over time the procedure
has improved drastically leading to improved feel, more natural look,
and much smaller incisions during surgery.
|Breast implants are not regarded as lifetime devices. It is likely
that you will undergo implant removal at some point over the course of
your life. At this point you have the option of replacing your implant
or removing your implant altogether.
|The FDA recommends that you do not have your implants removed if you
are having no physical problems. The following are the main physical
problems that necessitate removal: a rupturing or leaking of your
implant leading to deflation, silicone gel escaping from the implant
envelope and scar capsule that is detectable in your breast or elsewhere
in your body, or having a spherical capsular contraction that is hard,
painful, and deforms the breast.
|No, breast implants are not subject to strain or rupture while
traveling in aircraft.
|The pain associated with breast implant surgery depends upon which
specific surgery you choose to undertake, whether you choose submuscular
or subgladular placement, and your individual reaction to the surgery.
In general, post surgical swelling is to be expected, as is some pain
|Most women return to work and resume non-strenuous activities, such
as driving, about a week to ten days after surgery.
|Most insurance does cover your first breast reconstruction operation.
Insurance coverage for re-operation procedures or additional doctors
visits following reconstruction may not be covered, depending upon your
policy. Insurance does not cover breast augmentation and may not cover
re-operation and additional doctors visits following augmentation.
|Women who have existing malignant or pre-malignant cancer of the
breast without adequate treatment and women with active infection
anywhere in the body are not eligible for breast implants. Breast
implants are also contraindicated for pregnant or nursing women seeking
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