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Dr. Kuruvilla (00:11):
Welcome back to Behind the Double Doors. I'm Dr. Shannon Kuruvilla. I'm a plastic surgeon at Basu Aesthetics and Plastic Surgery in Houston, Texas. Today we're talking about breast augmentation. This is the most common procedure performed in the country and the one that I get the most questions about. Which implant, what size, how many CCs over or under the muscle? What about fat transfer? What does recovery feel like? So this episode is a top to bottom walkthrough of every decision you'll make on the way to surgery and what life looks like after. Why is breast augmentation the most performed cosmetic surgery in the United States? And the reasons women seek this is very personal. So contrary to stereotypes, most patients are not asking for a traumatic change in a huge balloon sitting on their chest. They're usually seeking volume restoration after pregnancy or weight loss, correction of an asymmetry.
(01:00):
Asymmetries are very common in breasts, better proportion with their frame, or creating shape and fullness that they may have never naturally had. So usually what I hear most commonly is not, I want bigger breasts. It's that I want to feel more balanced or I want my clothes to fit better or the way that they used to. So it really is mostly and primarily about harmony and confidence. The first decision that we make when moving forward with breast augmentation is what type of implants, saline versus silicone. So these implants differ in their fill material, what actually fills the implants, the feel of the implants, what happens if the implant ruptures and then also age eligibility. So your saline implants also kind of known as saltwater implants. So that is when the silicone shell or the outside of the implant is filled with sterile salt water. Saline implants are FDA approved for patients aged 18 years and older and then rupture is immediately noticeable because obviously the implant deflates and your body will absorb that salt water.
(02:05):
Silicone filled implants are filled with a cohesive silicone gel, meaning that it is a gel that holds its form kind of like a gummy bear. When you cut a gummy bear open, the inside of it holds its form. So silicone implants are FDA approved for 22 years and older for cosmetic augmentation and rupture can be silent. So meaning the implant ruptures that form stable implant filling holds its structure so you don't necessarily notice it immediately. And that is why screening matters, which we'll get into later on in terms of screening for this silent rupture. Neither is universally better. The right choice depends on anatomy priorities and goals. So saline implants are less and less placed in patients these days. Frequently it's used in like tissue expanders for reconstruction, but from a cosmetic standpoint, most patients and most surgeons will choose silicone implants. And that reason is because they tend to feel a little bit closer to natural breast tissue, particularly in thinner patients or women who have less native breast tissue coverage.
(03:10):
Modern cohesive gel implants are different from earlier generations. So they are very cohesive form stable. They hold their form. They feel softer. They move more naturally with your breast tissue and they have that improved upper pole shaper tension. So you can imagine a saline implant. When the patient goes to stand up, all that salt water is going to fall to the bottom and maybe give the breast a very bottom heavy appearance. You'll lose some of that fullness in the upper pole, whereas silicone fill implants are designed to maintain the upper pole fill. Do patients care about what brand they get? Not often. So usually patients may have seen something in social media about a new in brand being used in breast implants. I think that all implant brands offered in the United States are excellent options. Which one is offered to you will depend on the shape that you're going for, your tissue, some of your health history as well.
(04:05):
But for just the interest of time and today's discussion, we're going to focus more on procedural level walkthrough. There is an episode where I go into Motiva implants, which are kind of your sixth generation, newest generation implants, and that'll kind of cover those distinctions in detail. Okay. So let's go over the sizing conversation and why CCs are the wrong starting point. So I love information that we can gather from the internet. I love that social media has provided so much more clarity for patients who are seeking surgical procedures, but frequently patients come in and already have this kind of CC in mind for what they want. I kind of enjoy debunking that when patients come in with that preconceived idea and that's because I really prove to the patient that I'm making this decision based off of their particular anatomy and your body proportions and your existing breast tissue.
(04:57):
So CCs are actually kind of the least useful place to begin when choosing a breast implant. The real conversation in your consult will be about your body proportion, your chest with, your tissue envelope, your skin characteristics, your lifestyle, and then of course what you're looking for in yourself. So the same implant volume will look very different on two different women just based off of how wide their breast footprint is, how much tissue they already have that exists and how tall, how big they are. I usually will start off the conversation by going over some before afters that the patients have found that they really like and kind of really emulate what their goal is. I do like for the patient that they're showing me to have a similar starting anatomy just to have a more predictable result. So we'll use some wish pictures as I call them.
(05:49):
I will then jump to my measurements and go based off of the breast footprint with how much tissue the patient already has and then we will also use sizers. So at the patient's preoperative
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appointment, we will give you a sizing bra incisors and you'll try different sizes of implants with a form fitting shirt and that'll help give me a range of like what you are going for. So the goal is not choosing the biggest implant, it's choosing the right implant. I think the sizing process is very fun for patients. I try to give like a range for what to allow them to try on just what I think is going to fit their body well. I do have some patients that will go a litle bit outside that range and try to get in a little bit bigger and we have to have a conversation on why I feel like that may not be safe or might not be proportional, but I do think it gives the patients a litle bit of ownership in this decision making and also helps them understand better what CCs will look like on their body.
(06:45):
Thanks to Kylie Jenner, patients now are very well aware of this partially under the muscle and that is only one place that we might elect to put an implant. I make that decision preoperatively. So usually in the consultation based off of your exercise level, if you're a big bodybuilder, if you do a lot of upper extremity exercises, I base it off of how much breast tissue you have if I feel like you have good coverage for that implant and then also kind of based off of your goals too. So there are four main planes that we talk about in plastic surgery for where to place implants. The first one is what's called subglandular. This is also known as over the muscle and underneath the breast tissue and the muscle I'm talking about here is your pectoralis major muscle. Placing an implant here kind of has slightly quicker recovery because we're not adjusting any of your muscle insertions.
(07:36):
You're not going to have what's called animation deformity where when you go to flex your pec muscle, you notice the implants moving, but this does require that the patient have adequate tissue coverage, so have some amount of breast tissue to hide that implant and camouflage it. The next layer deep to that would be something called subfascial. So this is still on top of the pectoralis muscle, but I use the fascia over that muscle as an extra layer. So again, you are not getting animation deformity where every time you flex your muscles, the implant moves, but it adds another layer of camouflage. This works best in carefully selected patients. So patients that naturally have good, strong breast tissue coverage that's going to hide any sort of what's called rippling of that implant. So just kind of irregularities in the implant. Athletes may or may not elect to have it on top of their muscle if they have very large pectoralis muscles.
(08:27):
And then patients, women who just prefer to avoid muscle manipulation, you can go on top of the muscle or subglandular. They're the same thing. And then you have under the muscle. There's kind of your most extreme, which is called total submuscular where the entire implant is covered by muscle. You get more upper pull camouflage, you reduce any sort of risk of visibility of the implant edges, but more likely to have the animation deformity. And then your dual plane that this is kind of the most common historically in cosmetic breast surgery. This is also you're partially under the muscle where we use your pecturalis muscle to cover the top part of that implant and then we use your breast tissue to cover the lower part of that implant. So it's a very specific decision. It has to do with patient's lifestyle goals and then what I feel like is going to be safe and kind of reduce any sort of risk of implant visibility.
(09:17):
So fat transfer I think is becoming increasingly popular and so obviously deserves some good discussion in the conversation regarding breast augmentation. So fat transfer to the breast can be used as a standalone procedure or combined with implants for kind of refinement. Benefits of fat transfer is we're using your own tissue. In patients who know that they want to have liposuction, we're not wasting that fat, we're putting it to good use. It's very soft. It can offer a natural enhancement particularly to cleavage and then that upper pole, it can help kind of blend and hide an implant or just like, like I said, better shape that upper pole. Limitations for fat transfer. So your volume increase is pretty modest. I would not recommend jumping several cup sizes with just fat. It's not as form stable. Not all of that fat will survive and I do counsel patients about that.
(10:07):
There are things we do from a technique standpoint to optimize how much fat survives, but you usually cannot create a dramatic enlargement in just one session. All right, moving on to more of the decisions that we make when planning a breast augmentation and that is incision placement. And of course, scars are very important for patients to understand when choosing to have a surgery. All surgery requires some scar. So where are we going to place that scar? There are three main places that we will use on your breast to place an implant. The first one and the one that I tend to use most often is in the inframammary fold. So in that breast crease right underneath your breast where your breast meets your chest wall, this is an incision that is under very low tension. It's hidden in the breast crease. We have great exposure from a surgical standpoint of underneath the breast tissue and it has a lower rate of something called capsular contracture, which is when you can form scar tissue around your implant.
(11:08):
Your next option is going to be what's called periareolar. So usually along the inferior or lower edge of your areola. And this is a good option for patients just to conceal it within a natural kind pigmentation contrast on the body. And then a third very common location that patients will ask about is transaxillary. So that is usually through the armpit so you're not having any scars on the breast. I feel like there's slightly more limited acces for that. And
again, the best decision placement will be based off of anatomy and surgical goals. I'm a broken record. So in terms of your surgical day for breast augmentation, here's what you can expect. All of our surgeries are performed at our state licensed ambulatory surgical center. So our surgical center meets hospital grade standards for quality and safety as determined by the Texas Department of Health. We have a dedicated MD, board certified anesthesiologist that will be with you the entire time.
(12:03):
We have a dedicated perioperative staff, so they are trained in taking care of surgical patients before and afterwards in recovery and then we have continuous monitoring after surgery. We'll walk patients through arrival, pre-op preparation. I'm going to mark you in our pre-op area and explain all of my markings to you. I'll go over again the surgical plan. We're going to go over recovery and then once you are awake and up and walking and talking and eating, we will send you home. The procedure itself takes anywhere from one to two hours. Our team will be updating your care partner that entire time and then we'll instruct you on what to eat when you get home. I'll call to check in on you that evening. So I think that the entire day you don't feel like you're being rushed into the surgery room, you're understanding every single step and what goes on behind the scenes.
(12:54):
What does that day look like when you get home? You're probably a little bit drowsy from anesthesia, although usually patients wake up pretty quickly. You'll start to feel some swelling. So in any patients who have ever breastfed, they often describe it as engorgement. And then your stomach may or may not feel a little bit upset. We always talk to you about eating something very bland after anesthesia just to ease into that digestion, but you're taking it easy when you get home, pick out a good show to watch, but of course get up and take a lap around the house and keep your blood pumping. Okay. So what is the drop and fluff? Yes, this is very real and it is most common when an implant is placed to some extent under the muscle. So whether it's partially under the muscle or completely under the muscle.
(13:38):
The most important thing that patients should understand is that breasts do not look final immediately after surgery, especially at your one week appointment when you're swollen and that muscle is holding that implant up high. So early on after having a breast augmentation, implants often will a fear high, very tight and very firm and that is just that muscle that is kind of holding onto those implants. And then over the course of the next two to six months, the muscles will relax, the tissues will relax and the implants will settle. So that's what people refer to as the drop and fluff. It's very normal and it does require a good amount of patients to understand what your final result's going to look like. It is less dramatic and less common when going over the muscle,
but again, both results are going to be beautiful and proportional and very natural.
(14:23):
Will both implants drop and fluff at the same time? Most often, yes. However, I have seen some muscles hold onto that implant a little bit longer. Maybe the patient's dominant hand is the right side or that muscle is just a little bit stronger for whatever reason. So again, patients and of course information and understanding are very important to know that this is all a very expected and normal process in healing. So if something's looking funny, you should contact our nursing team. We have an on- call team and we have an email for all patients where I can get direct contact with you for any questions or concerns. My preference would not be for an immediate jump to online Googling or Facebook group questioning and more so just to come in and let me assess you and I can go over whatever concern you're having. So temporary sensation changes are very common.
(15:19):
I always talk to patients about the risk of nipple change sensitivity as a possibility. That is usually never permanent. It can be due to maybe that nerve feeling a little bit stretched and it can be either reduced sensitivity or numbness or heightened sensitivity or most commonly is kind of some tingling either of the breast skin or that nipple area. The vast majority of these will return to normal over time. Some can be longer lasting or permanent and it does require a straightforward discussion when you're signing up for this surgery as a possibility, but it is very rare for it to be permanent. So what do we know about breast implants and breastfeeding? So breast implants do not automatically prevent breastfeeding. Many patients will successfully breastfeed after augmentation. Outcomes usually are determined by your native anatomy, your glandular tissue, so how much breast gland you naturally have to be able to produce that milk, surgical technique, and then of course incision location.
(16:14):
I try not to disrupt any of your breast tissue or interrupt any of that glandular or ductal tissue so patients usually can breastfeed as they would have been able to before augmentation. That being said, breastfeeding has so many different variables that contribute to successful journey and success looks different to every patient, every person in terms of breastfeeding. I do mention breastfeeding as a potentially at risk in any sort of breast surgery, but in breast augmentation surgery, it's very low. Another decision and very important one that we'll make in your consultation is whether or not you would benefit from also a breast lift at the time of your augmentation. The way I determine if you would benefit from a breast lift is where your nipple is sitting and your areola in relation to your breast tissue and then kind of how far I think your breast tissue has fallen.
(17:08):
Usually if your breast tissue has fallen significantly, adding an implant alone will not restore that youthful breast shape. So that's when I do mention a lift. I totally respect and appreciate that adding a lift is adding scars to the breast that you may or may not have been mentally preparing for when you thought you just needed breast augmentation. So I do take my time in explaining why I would feel like these scars would be necessary and how I tried to camouflage and hide those scars as best as possible. So breast augmentation is not necessarily one surgery forever. I do tell patients, especially younger patients who maybe haven't had children yet, that the likelihood of them wanting some sort of reficient in the future is not zero. Implants are very durable, but they're not lifetime devices. So long-term ownership includes monitoring those implants for that silent rupture that can be done by periodic ultrasound or MRI per the FDA for silicone implants and I can perform that ultrasound here in our office.
(18:07):
I want patients to monitor and be aware of any sort of changes to their breasts, both in terms of the breast implant shape, watching out for something called capsular contracture, but also breast tissue and we have to be cognizant that there is breast tissue there and breast cancer screening is very important. You should still continue to get your mammograms. There are displacement techniques that radiologists can do to protect your breast implant to get a good visualization of your breast tissue and then just future planning. So understanding that if you do like to have children, if you have some sort of significant weight fluctuation, your skin is going to change and the shape of your breasts might change and you will likely want some sort of revision procedure in the future. That being said, the old recommendation of saying that implants have like this 10-year lifetime and you need to get them taken out every 10 years and changed out is not really the standard teaching anymore because implants technology has come so far that I tell my patients, unless there's an issue or cosmetically there's something that you're not liking, we should not put you under a surgery for no reason.
(19:12):
So patients might like to choose revision for aesthetic or implant related or just general health related reasons. So if you are ready to come talk to me about having breast implants, first step will be consultation. So consultations.education is not about pressure. It's not committing you to surgery. It's you gathering information about what your goals really are and then also what your anatomy might dictate in terms of a very proportional result. So bring questions to your consults, bring inspiration photos and then bring any sort of goals and concerns as well as I'm going to ask you a lot of lifestyle questions as well just about your exercise routine, your family life, your home life and your support system. So we will discuss your anatomy. We'll go over implant options in terms of brand, shape, fill. I'll go over how I'm going to size you for those implants placements.
(20:06):
So if I am going to put this under your muscle or on top of your muscle, what recovery is going to look like I'll go over risks of surgery and then weather augmentation is truly the right fit for you. So some patients think they need a breast augmentation, but they have really good volume. It's just fallen and they would be greatly served by just having a breast lift. So it's just information gathering. I try to keep it very low pressure and more of like a conversation with my patients. In terms of financing, sadly, we cannot perform breast augmentation for free, but we do have financing options available. Our website gives ranges of what you can expect. It is very easy to find out if you qualify for financing through PatientFi and when you call our care coordinators to set up that consultation, they'll also be able to give you a pretty specific price range so that way you can be very informed, understand that this is an investment and how to factor that into your life in a low stress way.
Announcer (21:04):
Basu Plastic Surgery and Aesthetics is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's B-A-S-U Plastic Surgery. Behind the Double Doors is a production of The Axis, T-H-E-A-X-I-S.io.