Breast Augmentation Surgery
Located in Raleigh, North Carolina
and serving patients nationwide
Seeking natural-appearing results
Patients come to this practice for breast augmentation surgery because they want to look great, to feel more confident about their appearance, to throw away their padded bras, to have more options when they are shopping for clothes or searching in their closet for what to wear to an important event - and to not look like they are obviously a plastic surgery patient.
Hundreds of thousands of women have their breasts augmented each year in the United States, and those who have had great breast augmentations don't look artificial - they look beautiful and natural, with breasts that are full but in harmony with their figure. They look great, they wear what they want to and fill out their clothes nicely, and the surgery they have had is their little secret.
When the goal of this operation is a natural-appearing breast enhancement, the results can be absolutely beautiful. However, if the goal is to create an excessively full breast profile which is out of proportion to the shoulders, waist and hips, then the results - by definition - never appear natural. These patients not infrequently end up having a series of operations to address problems related to the excessive implant volume.
A natural-appearing breast is noticeably fuller in the lower pole (below the nipple) than the upper pole. In profile (viewing from the side), the upper pole slopes gradually from where the breast begins in the upper chest down to the nipple, and the lower pole is full and rounded. For any patient considering breast augmentation, there is an implant size above which the upper pole begins to look rounded, convex, and unnaturally full. Mild to moderate upper pole fullness can look beautiful and youthful, but excessive upper pole fullness due to overly-large implants looks decidedly fake, and like what most people think of as a 'boob job'.
As a highly experienced North Carolina breast augmentation surgeon, Dr. Law takes great strides to ensure that the results of his procedures appear natural.
Read DR. LAW'S PHILOSOPHY on NATURAL-APPEARING BREAST AUGMENTATION
- Cohesive Silicone Gel vs. Saline Breast Implants
- How many cc's? - deciding on implant volume
- Incision locations
- Subpectoral vs prepectoral implant position
- Attention to detail in breast augmentation
- Breast augmentation after pregnancy
- Special considerations: asymmetry, tuberous/constricted breasts, etc
- Recovery and downtime
- Avoiding capsular contracture
- Revisional breast augmentation surgery
Cohesive silicone gel vs. saline breast implants
Women considering breast augmentation now have the luxury of deciding between two kinds of breast implants: cohesive silicone gel (approved for cosmetic use by the FDA in 1996) and saline. There are a number of pros and cons to consider with each type of implant however the most important thing to know is that patient satisfaction is very high with both. You can't really go wrong with this decision - it is merely a matter of deciding which is best for you personally.
It is also very important to understand from the outset that a cohesive silicone gel implant is a very different (and vastly superior) medical device compared to the older liquid silicone gel implants that were available for cosmetic use in the 70's and 80's, but were not approved by the FDA for cosmetic use from 1991 to 2006 (although they still could be used for breast reconstruction). The new cohesive gel implants are manufactured so that the gel material is in a solid state which means that if the implant's outer shell fails, the gel material does not easily leak out of the implant as it would with the older liquid silicone gel implants. The design and manufacturing process for the outer shell has also improved a great deal, resulting in significantly lower implant failure rates. These improvements make gel implants much more appealing as long-term medical devices, and because of the major improvements the FDA cleared them for cosmetic use in 2006.
One very important issue to consider is implant palpability, i.e. whether you can feel the implant or not when you - or someone else - feels your breast. Both silicone gel and saline implants are soft and generally breast-like. Most surgeons and patients agree, however, that silicone gel breast implants tend to feel more natural than saline breast implants. Because saline is non-viscous, it tends to allow the edges of the implant to collapse and this makes the implant edges more easily palpable. This will be quite obvious to you when you examine samples of saline and silicone gel implants during your consultation.
The degree to which this difference is significant varies a great deal with regard to two factors: the amount of breast tissue that exists prior to augmentation, and the size of the implant that is used. A silicone gel implant's more natural feel will be much more important to patients who are slender and who fit in an A cup bra preoperatively, as they have less subcutaneous soft tissue and breast tissue to conceal the implant. In such a patient a saline implant is usually very easy to feel through the skin, and may even be visible externally - especially in the lateral aspect of the augmented breast where the tissue covering the implants is the thinnest. The difference in feel between saline and gel implants will be less noticeable to a patient who is more full-figured and whose pre-operative bra size is a full B or especially a C cup, and in some fuller-figured patients saline implants may be undetectable by palpation (meaning they feel completely natural). Saline implant palpability is primarily a matter, therefore, of how much natural tissue there is to disguise the implant.
Another important difference between gel and saline breast implants is what happens if the implant shell fails. If a saline implant ruptures, that breast will rapidly 'deflate' as the body absorbs the saline. Most patients have little tolerance for having just one augmented breast, of course, and a saline deflation thus requires a return to the operating room to replace that implant. When a gel implant fails, there is no change in the appearance or feel of the breast, as the gel material is inert and is not absorbed by the body (and with cohesive implants the vast majority of, if not all of the gel material, remains within the implant's outer shell). As there is no outward sign that the implant has failed, the only way to discover that a gel implant has ruptured is to undergo a radiologic test such as an MRI, which is the best means currently available for diagnosing silicone gel implant failure. The FDA recommends that women receiving gel implants have MRIs at certain intervals postoperatively to monitor the status of their implants (this is an FDA recommendation but not a requirement). The cost of an MRI scan (which includes the charge for performing the test as well as a charge for the test being interpreted by a radiologist) is about $1000-1200. The FDA also recommends that patients with a ruptured silicone gel breast implant have the implant removed and replaced.
Back to Top
How many cc's? - deciding on implant volume
The actual size of a breast implant, measured in cc's, is really not very descriptive of what a breast augmentation will look like, or what the cup size will be. It is all relative to the size of the breast and the size of the patient preoperatively. A tall, broad-shouldered patient with small A-cup breasts may require 450cc implants to achieve a C-cup breast volume postoperatively, while a shorter patient with medium B-cup breasts may only need a 250cc implant to achieve a C-cup breast volume.
If a natural appearance is the goal, then the way to get the size right is to 'try out' different implant volumes and profiles in the operating room. Once the implant pockets have been created, sterile sizers can be placed in the implant pockets, and the upper half of the O.R. table raised so that the resulting breast appearance can be assessed with the patient in an upright 'sitting' position (chest fully upright) while under anesthesia. These sizers are available not only for each implant size but also for each implant profile: low, moderate and high (in this practice we use high-profile implants only in rare instances). Inflatable sizers are used for saline implant augmentations, and pre-filled gel sizers are used for gel implant augmentations.
For any patient there is obviously a range of implant volumes that would be considered natural-appearing, and a volume at which the upper pole of the breast begins to look very unnatural. While one patient may seek an augmentation that is 'perfectly natural', another may be interested in a result that is more on 'the full side of natural', and many patients do ask that the largest implant volume be selected that does not produce an unnatural fullness in the upper pole. By using breast implant sizers intra-operatively to determine exactly what breast implant profile and volume produces the best breast appearance in the O.R., patients can be provided with the closest possible approximation of their preoperative goals, and can be assured of a natural-appearing result.
Read DR. LAW'S PHILOSOPHY on BREAST IMPLANT SIZE and BRA CUP SIZE
Back to Top
Three incisional approaches are commonly used for breast implant insertion: trans-axillary (underarm area), peri-areolar (from about the 4 to 8 o'clock position of the areolas), and inframammary fold (in or just above the crease below the breasts). No two patients are alike, so it is important to individualize the surgical plan for each patient's individual needs.
An advantage of the peri-areolar incision is that the color and skin texture difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely. In many patients the scar is almost undetectable after only a few weeks. This incision is commonly used in patients who have had one or more pregnancies and have a medium to large areolar diameter.
The axillary or underarm area incision is ideal for patients with very youthful-appearing breasts, especially younger women with no history of pregnancy. These patients often have a small areolar diameter, which makes the peri-areolar incision less than ideal, and smaller, perkier breasts - where the inframammary fold (and thus a scar in that location) can be easily seen.
The infra-mammary fold incision works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts. As full breasts conceal the infra-mammary fold very well, the scar is usually not visible when standing or sitting upright. Ideally this scar is placed just above the inframammary fold on the lower pole of the breast, so that it faces down and therefore tends to be less noticeable.
Breast implants can be inserted through a limited incision in the belly button area, however there are a number of problems with this approach and it therefore is not widely used. Approaching the surgery from such a remote location does not lend itself to the creation of a precisely-defined implant pocket, or the creation of a natural-appearing result.
Back to Top
Sub-pectoral vs. pre-pectoral implant position
This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.
The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.
Read DR. LAW'S PHILOSOPHY on BREAST IMPLANT POSITION FOR BODY BUILDING, FITNESS AND FIGURE COMPETITION
Back to Top
Attention to detail in breast augmentation
In many breast augmentation patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola. Ideally the implant should be centered directly behind the nipple-areola complex (NAC). In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that a breast implant sits below the skin. In addition, inadequate release of the inferior origin of the pectoralis major will allow the muscle to hold the implant in too high a position, and may even cause the implant to displace upwards (as high as the collar bone in some patients) when the muscle contracts. Patients with this problem require reoperation to release the inferior origin of the pec major and/or the inframammary fold.
Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance, and one that requires surgical correction: repair of the inframammary fold(s).
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. The result may (or may not) be tolerable in the upright standing or sitting position, but when the patient lays down in supine position (on one's back) the implants may fall far to the side and produce little to no anterior breast projection in this position. Patients with the problem almost always want it corrected, and the treatment once again is surgical: a lateral repair of the implant space, to restrain the implants from falling off to the side.
Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. It is lateral projection of the breasts beyond the lateral border of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure'. While one does not want to over dissect the lateral extent of an implant pocket, careful attention must also be paid to ensure that lateral breast projection is not inadequate.
Breast implant base diameter is also of crucial importance. The base diameter (the side-to-side dimension of the implant) must be ideal for the existing horizontal dimension of the breasts preoperatively, as well as the breadth of the anterior chest in general. Obviously, a given implant volume and base diameter that works well for a small-framed patient that is 5'3" will be completely inadequate for a broad-chested patient who is 5'10". One wants to increase cleavage area fullness and lateral breast projection in most cases, and an implant of inadequate base diameter may accomplish only one of those goals, while too wide an implant will be overprojecting in both directions. Careful evaluation of all of these breast and implant dimension issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.
Back to Top
Breast augmentation after pregnancy
Quite a number of the breast augmentation patients in this practice are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some 'stretching out' of the breast skin. In many of these patients, a breast implant of moderate size will restore a very pleasing breast contour. These patients are not looking to raise eyebrows at work or around the neighborhood - they just want to throw their padded bras away, to have more options with clothing, and to feel better about their appearance in private.
When there is mild to moderate laxity of breast skin and/or loss of breast volume that makes the breasts appear somewhat droopy or 'deflated', the addition of a breast implant can 'fill up' the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or 'mastopexy'). This situation often exists after pregnancy and lactation, but there are also quite a number of patients with significant breast skin laxity who have never been pregnant.
In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the breast augmentation surgery to tighten the skin envelope around the implants, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. An augmentation mastopexy is required when the surgeon's preoperative assessment is that without a lift, the likely postoperative appearance is that of a breast drooping off of an implant - which is a distinctly unnatural and unappealing breast profile.
Read DR. LAW'S PHILOSOPHY on AUGMENTATION ALONE vs. AUGMENTATION MASTOPEXY
Back to Top
Special considerations: asymmetry, tuberous/constricted breasts, etc
Many patients considering breast augmentation are seeking to not only enhance the volume of their breasts, but to also enhance the shape and/or improve the symmetry of their breasts. Essentially all breast shape and symmetry issues can be improved during breast augmentation, and with most of them it is possible to make significant improvements and produce an aesthetically desirable breast profile. Accurate preoperative evaluation, appropriate surgical planning and attention to detail during the surgery are all crucial elements in achieving this goal.
Breast asymmetry is extremely common, and in fact essentially all breasts have some identifiable and measurable asymmetry. So the goal of surgery is not really perfect symmetry, as that does not exist in nature, but rather to produce the closest approximation of symmetry that is possible. In some cases it is possible to improve size asymmetry by using implants of different volumes and/or profiles. To do so one must patiently evaluate a wide variety of implant sizers intra-operatively with the patient in the upright sitting position. In some cases the breasts appear to be similar in volume, but asymmetries in the projection of the chest wall may mandate the use of different size implants in order to produce the closest approximation of symmetry.
For some patients it is actually quite important to reduce the volume of the larger breast (hence the somewhat confusing term 'reduction augmentation'), which in turn allows the surgeon to use implants of the same or similar size. If there is a significant difference in breast volume, and one attempts to address that difference solely by using implants of different size, then the result may be acceptable early on but as time passes the breasts will age very differently. The smaller breast with the larger implant will tend to remain youthful and perky-appearing, while the larger breast with the smaller implant will gradually become droopy-appearing and may eventually assume the appearance of a breast hanging off of a small implant. Not a pretty picture.
Other shape issues are quite common, including one known as 'tuberous breast'. Tuberous breasts tend to be narrow at the base and are overly projecting for their size, and this phenomenon may occur on one or both sides. In its mildest form, the lower pole of the breast is underdeveloped or may even appear constricted - sometimes referred to as a 'constricted lower pole'. In severe cases the breast is conical in shape and is sometimes described by the patient as looking like a 'torpedo' or a 'Snoopy dog'. Regardless of the degree of tuberosity, it is possible to dramatically improve the appearance of the tuberous breast during augmentation surgery using a number of specialized surgical techniques.
Many patients with severely tuberous breasts have said that they have never removed their bra in an intimate setting. Careful patient assessment, thoughtful planning and attention to detail during the surgical procedure can produce a dramatic and life-changing improvement for most patients with tuberous breasts.
Back to Top
Recovery and downtime
The recovery from subpectoral breast augmentation used to be a rather unpleasant experience, but it no longer has to be. A space for the implant must be developed behind the pectoralis major, and a portion of the muscle's inferior origin must be released. Surgery on a muscle in most cases produces significant postoperative pain, and that is certainly true for breast augmentation. However, by using a local anesthetic infusion device (the On-Q 'Pain Buster') for the first two to three days after surgery, the pain associated with this procedure can be reduced quite dramatically.
While breast augmentation patients in this practice receive a prescription for a mild narcotic pain medication for use after surgery (just in case), most of them never take it. Most patients report little to no pain in the evening following surgery, and perhaps some mild discomfort on Postop day one and two. Patients can resume all normal, non-strenuous activities of daily living immediately after surgery, and can begin pec major range of motion exercises on the evening of their procedure.
Patients are seen in the office the day after surgery, and again on Friday for removal of the Go-Pump catheters (which is painless). Working patients usually return to work the Monday following the surgery; stay-at-home moms may need some help with toddlers for the first two to three days after surgery. Exercise is limited to walking only for the first two weeks; in weeks three and four some light exercise is permissible. Patients can gradually increase their exercise/workout level in the second month (weeks five through eight), however it is a full eight weeks before patients are allowed to return to activities that require forceful, repetitive, sustained pec major contraction - such as pushups and heavy weight lifting. It is important to ensure that the breasts are well supported in snug fitting sports bra (or two) when returning to impact exercise such as running or aerobics.
Read DR. LAW'S PHILOSOPHY on PROTECTING IMPLANT POSITION after BREAST AUGMENATION
Back to Top
Avoiding capsular contracture
You may have heard of someone's breast implants 'turning hard'. It is not the implants themselves that turn hard, of course; what has really happened is that the fibrous capsule around the implants has tightened and thickened, making the implants less mobile and causing them to feel firm (and eventually, in some cases, even 'hard'). The medical term for this phenomenon is 'capsular contracture'. It is a problem that is best managed by avoiding it altogether, and fortunately there are a number of things that can be done on the day of surgery to guard against it.
Any time a foreign object is implanted in the body, whether it is a pacemaker or a breast implant or an orthopedic device or anything else, the body responds by forming a thin, wispy, fibrous membrane around it. In most cases this membrane or 'capsule' stays thin and wispy, but in some cases over time the capsule may tighten around the implant and thicken, making the implant feel firm or even hard. In advanced stages the contracted capsule can even distort the shape and position of a breast implant. Capsular contracture can be treated, but it is a surgical treatment, so avoiding capsular contracture is all about avoiding another trip to the operating room.
Capsular contracture can occur on one or both sides, and while it can develop early (weeks) or late (years) after a breast augmentation surgery, in the vast majority of cases it is evident fairly early following the procedure. So the good news is that once you are six to 12 months out from your surgery, if your augmented breasts are soft and supple then they are likely to stay that way for the long term.
It is believed that capsular contracture is primarily a response to the presence of low-virulence or non-virulent bacteria (i.e. not the kind that generally produce an actual infection, with redness/tenderness/fever etc) that adhere to the implant surface on the day of surgery, and which over weeks and months following surgery stimulate the cells that make collagen (called fibroblasts) to make more collagen - thickening the capsule and stimulating it to contract and tighten around the implant. It is not an actual infection; there are no symptoms that this is going on, and taking antibiotics will not prevent the process or reverse it. The source of these non-virulent bacteria is thought to be the patient's skin, or the ductal systems of the breast that lead to the nipple, as both are normally colonized with bacteria.
Because plastic surgeons now have an understanding of some of the reasons why capsular contracture occurs, there are a number of measures that can be taken to significantly reduce the likelihood that it will happen following breast augmentation surgery. Several of these techniques are discussed in the adjacent section describing 'Dr. Law's philosophy on preventing capsular contracture'.
Read DR. LAW'S PHILOSOPHY on PREVENTING CAPSULAR CONTRACTURE
Back to Top
Revisional breast augmentation surgery
There are a number of factors that can lead to a patient being dissatisfied with the results of their breast augmentation. One of the most common is capsular contracture, which is addressed in detail in a section above. Another is implant position, which can be related to a number of issues: the dimensions of the implant pockets may not be ideal or symmetrical, the pectoralis major muscle may be inadequately released and thus holds the implants too high (and can cause them to 'jump' up towards the collarbone when the muscle contracts), one or both implants may even shift in position over time which results in positional asymmetry.
If the implant pockets are dissected too far laterally, the implants look too far apart on the chest wall, and usually fall off the side of the chest when a patient lies down on her back. If the pockets are not dissected far enough laterally, the implants appear too close together and do not project enough to the side to create the upper third of an 'hourglass figure'. Over-dissection in the area of the inframammary fold can result in implants that are too full in lower pole and a 'bottomed out' appearance.
Some patients feel that their implants are too big and make them feel very self-conscious, while others feel that their implants are too small and that their expectations for a more shapely figure have not been met. This practice treats a significant number of patients who schedule a consultation because they are dissatisfied in some way with the results of a breast augmentation they have had in the past. If you are one of these patients, the good news is that the results of your surgery can almost always be improved, and in most cases quite dramatically.
Read DR. LAW'S PHILOSOPHY on BREAST AUGMENTATION REVISION SURGERY
Back to Top
For more information about breast augmentation or breast implants or if you would like to schedule a breast augmentation or breast lift consultation, please contact the Raleigh, North Carolina office of Dr. Michael Law Today!
Dr. Law is a Breast Implant expert on RealSelf.com
For more information, please click the link below:
The Big News in Breast Implants is Small
Raleigh Breast augmentation specialist Dr. Michael Law discusses natural breast augmentation and breast augmentation in Raleigh.
For more information about breast augmentation or breast implants or if you would like to schedule a
breast augmentation consultation, please contact the Raleigh, North Carolina office of Dr. Michael Law today!