Women who choose breast augmentation want to enhance the size and shape of their breasts. The goal is to create a natural-looking appearance. Women who undergo breast enhancement surgery do so to change the size, shape and contour of their breasts. The procedure can enlarge a naturally small bust, restore breast volume lost after weight reduction or pregnancy, achieve a more rounded bust shape or improve symmetry between the two breasts.

A woman’s breasts are one of the most important physical features that give a sense of femininity and sexuality, but for many women, their breasts are not as large or shapely as they would like. Breast augmentation is the best way to enhance your breast size and contour without a major operation.

• Undersized breasts which may have been present since birth or after pregnancy
• Loss of breast volume due to breastfeeding or weight loss
• Asymmetrical breasts
• Age-related droopiness

A breast lift is a cosmetic surgery procedure that raises and firms the breasts by removing excess skin and tightening the surrounding tissue to reshape and support the new contour of the breasts. This is usually performed on women who have drooping breasts due to breast-feeding, age, or weight loss. The procedure can also be used to reduce areolar size (the dark skin around your nipple).

Breast lifts are typically performed as an outpatient procedure using general anesthesia or intravenous sedation with local anesthesia. There are three common types of incisions used during this type of surgery: crescent, lollipop, or anchor (also referred to as inverted T). Incision patterns depend on how much sagging there is in your breasts.

Breast reconstruction is a surgical procedure that restores shape to your breast after mastectomy, surgery to remove the breast to treat or prevent breast cancer. One of the goals of reconstructive surgery is to match the size and shape of the other breast.

You may have several options for reconstruction. Some women choose not to have their breasts reconstructed after mastectomy, and some do not have enough tissue available for reconstruction at the time of their initial mastectomy surgery. For some women, radiation therapy after a lumpectomy will also make it difficult or impossible to perform immediate reconstruction.

If you’re considering reconstruction, there are many factors you’ll need to weigh before deciding on a course of action that’s right for you.

Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into nearby tissues or spread to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too.

In women, breast cancer commonly starts in either the lobules or ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can produce milk. The small ducts carry the milk from the lobules to a large duct that lies just beneath the nipple.

Breast cancer begins when cells at first become abnormal and then divide uncontrollably and haphazardly and go on living when other cells die (the word cancer refers to these cells’ ability to invade and destroy tissue). The result is a growth called a tumor that may extend beyond its normal boundaries if not treated promptly by surgery, radiation therapy, chemotherapy or hormone therapy (used for estrogen receptor-positive cancers).

Choosing the appropriate procedure for you is a critical part of your breast enhancement experience. Patients should have a realistic and positive attitude about their results, as well as an understanding that additional surgery may be needed to achieve their goals.

Although breast augmentation is the most popular plastic surgery procedure performed in the United States, it’s not right for everyone. You need to have good general health, realistic expectations and a specific motivation for undergoing this procedure.

To help you make an informed decision about having breast augmentation, your consultation with your surgeon should thoroughly address all aspects of the operation, including:

• Your expectations from surgery
• The kinds of implants available and their differences (saline vs silicone vs gummy bear)
• The medical risks associated with breast implants
• Your incision options

Breast augmentation continues to be one of the most popular procedures for women with almost 300,000 performed in the United States.  According to the American Society of Plastic Surgery, 72% of breast augmentations were performed with silicone gel implants versus 28% with saline implants.

Breast augmentation is a cosmetic procedure with the aim of increasing the size, changing the shape or fullness of a woman’s breasts. Breast implants are placed in the breast pocket under the breast tissue or under the muscle during the surgery.

Who is a candidate?

Any healthy woman who is able to undergo breast augmentation. Breast augmentation is available to any female over the age of 18 years old without the consent of an adult. A female’s growth should be complete and stable. If choosing silicone gel implants and you are less than 22 years of age it would be considered an off label use.

That being said, we recommend a thorough understanding of the risks, alternatives and benefits of undergoing a breast implant augmentation and possess the maturity to make the right decision.

How is it performed?

An incision is made in the fold of the (inframammary) or along the areola of the nipple (peri-areolar) most frequently. Some surgeons will also make an incision in the axilla (trans-axillary). The implant is then placed in a pocket that is dissected underneath the breast tissue (subglandular) or the pectoralis major muscle (submuscular).

Dr. Koumanis will discuss incision options with you and the advantages and disadvantages associated with the different methods. The biggest advantage of putting them under the muscle is that there is less chance of a capsular contracture (hardening of the breast capsule around the implant).

The surgery usually takes 1.5 to 2 hours and is performed most frequently under general anesthesia but sometimes under intravenous conscious sedation where the patient does not require a breathing tube and is given medication to make them very drowsy.

Where is the incision made?

The most common place for the incision is hidden just under the breast fold. The incision is usually under 2 inches. Another common place is a small incision around the areola if the patient is a candidate. The implants are then introduced through this small space in a safe and sterile manner.

Breast lift surgery also called mastopexy is used for drooping or sagging breasts (“ptosis” in medical terms). Drooping or saggy breasts usually occur with advanced age, after breastfeeding and pregnancies. Women usually come to our practice seeking an improvement in the way their breasts look and feel.

Who is a good candidate?

All healthy women are candidates for breast lift surgery if they have sagging ptotic breasts. The following situations are seen frequently in women who desire breast lift surgery:

• sagging breasts after significant weight loss
• lifting of the breasts after aging, post-pregnancy or breast-feeding
• repositioning of nipples that have dropped to give a more perky appearance

Do you sometimes combine other procedures with breast lift surgery?

Yes, sometimes breast augmentation with an implant is needed if significant volume has been lost and need to be regained at the same procedure as a breast lift. Additionally, some women desire mommy makeover procedures which can combined breast surgery with liposuction, tummy tuck or torso lift and possibly a thigh lift. This is not an exhaustive list but a combination of any of these procedures is sometimes performed at the same time as your breast lift surgery.

How is breast lift surgery or mastopexy performed?

A circular incision around the nipple is carried out along with different patterns in order to lift the nipple-areola complex, skin, and breast tissue up. The pattern and length of the incisions are varied depending on the type of procedure needed and how much of a breast lift is required. Dr. Koumanis will go over all the options with you during your appointment and consultation.

What are the results like for breast lift surgery?

Most women are very pleased with their breast lift surgery. However, results are never guaranteed. That being said breast lift surgery is a common and frequently performed surgery with true and tried results for the most part. The results usually last for a significant period of time but again every case varies depending on age skin quality etc. Dr. Koumanis strives for all his patients to be happy with their results.

What are some of the complications?

As in any procedure complications sometimes occur. It is not common in surgery. However, infection bleeding, scarring, sensation issues have been known to occur. Dr. Koumanis prides himself on low complication rates and will discuss all of these issues during your consultation.

What is the recovery time?

Most candidates will experience some discomfort for the first few days to about a week. This is usually tolerable and pain control prescriptions are used to help with postoperative pain. The pain is not usually significant with this procedure but everyone is different.

Patients are usually okay to begin some activities within 48 hours. Walking, sitting can occur the next morning. Some light exercise can usually begin at around four weeks and unrestricted activities usually at six weeks. That being said, patients are different and so Dr. Koumanis will discuss each postoperative step in person with you.

Breast Reconstruction
Dr. Koumanis is an expert at breast reconstruction with over 14 years of experience performing advanced techniques to restore the female breast after mastectomy. In the following section, frequently asked questions involving breast reconstruction using implants and your tissue will be answered.

What is breast reconstruction?
Breast reconstruction is the use of autologous tissue (i.e., your tissue), breast implants, or a combination of the two to restore the shape of ones’ breasts.

How many surgeries does it take to achieve final results?
It takes approximately 2-3 surgeries to achieve the final results. It depends if your mastectomy surgeon will be performing a nipple-sparing approach or whether the tumor is close to the nipple ducts and therefore must be taken. The third and final step in reconstruction is to make nipple flaps. If a nipple-sparing approach is used, nipple flaps are not needed.

What happens in each step?
The first step involves the mastectomy. After the mastectomy and at the same anesthesia setting, Dr. Koumanis will first take a tissue expander, wrap it with Alloderm (cadaveric acellular dermal skin), and place it behind the pectoralis muscle of the chest or above it, covering the front/anterior surface of the tissue expander. Then two drains are put in each breast pocket to help drain fluid in the postoperative period. The drains stay in between 1-2 weeks usually.

1. Inferior Skin flap of Breast
2. Alloderm™ sling cradling the implant

Then three weeks later, expansion starts in the office. The skin is prepped with betadine and alcohol, and sterile normal saline is injected into the expander each week until you attain the desired size.

Once the expansion is complete, the second stage involves removing the tissue expander and replacing it with a permanent silicone cohesive gel implant. Some flap revisions by excision of the skin envelope are sometimes needed.
The third stage will involve the creation of nipple flaps if the nipples and areolas are excised during the mastectomy.

What is the advantage of putting the implant above the pectoralis muscle?

When does one perform a unilateral (one side) versus a bilateral (two-sided) breast reconstruction?

Unilateral breast reconstruction is performed when a one-sided mastectomy due to cancer is performed. A bilateral procedure is performed when there is cancer on both sides. A bilateral procedure is sometimes performed due to the patient’s desire to reduce her cancer risk on the opposite breast. Bilateral procedures whereby the opposite breast is removed prophylactically are common due to strong family history of breast cancer, genetic risk (BRCA1 and BRCA2 genes), in ability to properly monitor the opposite breast, or patient anxiety of having to undergo a possible future cancer procedure or mastectomy.

If one side is performed, the other breast sometimes needs a reduction or a mastopexy (i.e., lift) in a future procedure. Bilateral reconstruction procedures have one advantage; they offer better symmetry as both breasts will consist of implants. A prophylactic mastectomy slightly improves oncological risks and survival if there is no strong family history, genetic predisposition, or bilateral disease. With that being said, we perform bilateral procedures, with one side being prophylactic quite frequently.

How long does the whole process take?

As discussed above, implant breast reconstruction requires a minimum of 2 operations (tissue expander first, then an exchange of tissue expander to silicone gel implant once fully expanded). A third small operation is only needed if nipple flap reconstruction is required. If no radiation or chemotherapy is required in your breast cancer treatment plan, things go quickly. In this case, most breast reconstructions are completed within four months. If radiation and/or chemotherapy are required, the process takes longer. Please see below.

Where are the incisions made?

Incisions are made following where the tumor is located. If the mastectomy is being performed prophylactically due to BRCA1 or BRACA2 genetic predisposition, then a nipple-sparing approach can be used if the nipples are in a decent position. Then the incision is made laterally along the inferior breast fold to hide the scar as much as possible. If the nipple needs to be raised, a peri-areolar incision is used to enter the breast. A skin-sparing approach is used whereby as much of the breast skin is retained during the mastectomy.

Figure: Various incisions used in mastectomy and breast reconstruction surgery

1. Inframammary incision (hidden scar *NS approach)
2. Inferior peri-areolar incision (*NS with lateral extension if needed)
3. Superior peri-areolar incision (*NS with lateral extension if needed)
4. Classical elliptical incision (horizontal across breast when closed)
*NS=nipple-sparing

What if I need radiation or chemotherapy?

If you require chemotherapy and/or radiation, this is usually done after the first surgery (i.e., mastectomy and tissue expander). By the time you begin your therapy, which is generally within six weeks of surgery, we will usually have you fully expanded. Needing chemotherapy and radiation will delay the completion of your breast reconstruction. With chemotherapy only, the second stage surgery can commence within 4-6 weeks after your last treatment to allow for your immune system to return to its normal state.

If you require radiotherapy, the tissue expander exchange to the silicone gel implant will take place six months after your final radiotherapy session. The tissues need time to heal from the radiation damage and fibrosis. Sometimes Dr. Koumanis will perform a fat grafting procedure three months after radiation to help heal the radiated tissue around the implant, soften the tissues, and decrease the effects of radiation fibrosis.
Radiotherapy can cause loss of the implant through infection or extrusion.

If this occurs, then an autologous reconstruction (i.e your own tissue from elsewhere) may be needed. A latissimus muscle flap with a new implant or a DIEP flap (i.e., skin and fat tissue from the abdomen) may be required for a successful outcome.

Are silicone implants safe?

Silicone gel implants are safe. They have been FDA-approved in breast augmentation or breast reconstruction settings. They do not cause cancer, and there is no evidence that they cause any autoimmune disorders. Almost all of our patients tolerate them very well. The recent issue of BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma) is associated with breast implants. BIA-ALCL is a rare but treatable type of lymphoma that has been linked to certain breast implants. It is more frequently associated with older textured implants.

Dr. Koumanis generally uses smooth gel implants except in certain circumstances. Dr. Koumanis, to this date, has not experienced BIA-ALCL in any of his patients. He will discuss the symptoms in detail during your consultation. Symptoms usually include an enlarged breast with seroma fluid within the breast pocket. Not all enlarged breasts with fluid after implant reconstruction are due to BIA-ALCL, so a fluid sample is usually taken to rule out the diagnosis

How long do the silicone implants last?

Although we have seen many last even longer, silicone cohesive gel implants generally last approximately ten years.

Do I need frequent follow-up and monitoring?

It is best to be followed up yearly for the first few years then bi-yearly after that. If a rupture does occur, this is not life-threatening. If a rupture of an implant is suspected, an ultrasound is the first line to detect the rupture. If this is inconclusive, an MRI will be ordered which is more sensitive to detecting a rupture.