Putting It All Together
Making Your Selections
“After doing your homework, make your choices in the following order: your surgeon, pocket location, type and size of implant, and incision.”
You’ve now completed all of your surgeon consultations and compiled your notes from those visits. It’s time to select your surgeon.
What to Decide First? Does It Matter?
Yes, it matters. If you make the right choice of surgeon, the rest is easier. The best surgeon should always present you with options and should discuss the trade-offs of each option or set of options, as well as discussing factors that are not controllable and what an augmentation won’t change about your breasts. Together, you’ll make team decisions. You’ll need to decide the following things, in order:
- Who is my surgeon?
- Dr. X
- Dr. Y
- Dr. Z
- What pocket location?
(This choice is critical becauseit determines how much tissue will cover your implant for your lifetime!)- Retromammary (behind breast tissue only)
- Partial retropectoral (behind the pectoralis muscle)
- Dual plane (behind muscle above, behind breast tissue below)
- Total muscle coverage (behind pectoralis and serratus muscles)
- What type and size implant?
- Smooth
- Textured
- Round
- Anatomic
- Filler material
- Size
- Which incision location?
- Inframammary
- Periareolar
- Axillary
- Umbilical
Picking Your Surgeon
If you’ve done your homework, picking your surgeon is usually easy.
Chances are good that you already know who you want to be your surgeon. One surgeon will often clearly stand out above the others, but if you are fortunate enough to have more than one surgeon who meets most of the guidelines we’ve given you, read on.
If you’re making a choice of surgeon based primarily on price, you need not read any further.
In fact, you probably haven’t even read this far, but if you have, you’re likely to get exactly what you’re paying for, and nothing you read is going to help you unless you prioritize quality over price. Amazingly but often predictably, you’ll be the first to point fingers when something doesn’t go right following surgery. Patients who prioritize price over quality rarely look in the mirror when pointing fingers.
How Do You Know Who’s Right? The Comfort Level
First, review your checklists from chapter 11. If you evaluated each surgeon objectively using the criteria in the checklists, one surgeon will usually meet several criteria that other surgeons don’t meet. If a surgeon clearly meets more criteria, go with that surgeon. But if you’ve found two or more surgeons who meet all of the objective criteria, it’s time to go with your gut feeling.
Select your surgeon based on objective criteria from your homework.
Who makes you most comfortable? Never place comfort above qualifications!
Which surgeon listened to you best? Which do you feel best understands what you want? Which surgeon presented you the most options with the best explanation of trade-offs? Which surgeon emphasized reconciling your wishes with your tissues and demonstrated tissue limitations? Which surgeon seemed to care the most? Which was most thorough? We’ve mentioned all of these criteria before, but these are the ones that should weigh heavily on your gut feelings.
Which surgeon told you what you didn’t want to hear? What are the factors you and the surgeon can’t control? What characteristics of your breasts won’t be changed following your augmentation? Truth based on knowledge and experience sometimes isn’t pleasant, but it’s still truth.
If you’re still not sure, make a second visit to each surgeon you’re still considering. Focus on which surgeon pays the most attention to detail. Look for distinguishing points to help with the final decision. Always focus on substance.
In the following sections, place a check mark beside your choices.
Picking the Pocket Location
- Retromammary (behind breast tissue only or subfascial)
This choice is logical only if you have more than 2 cm. of pinch thickness of the tissues higher on your chest above your breast tissue. If your surgeon doesn’t measure tissue pinch thickness, how do you know? A visual guess isn’t as good as a measurement, and this has a lot to do with whether you’ll see the edges of your implant. Fewer than one-fifth of patients we see have adequate tissue thickness to make this a logical, safe choice. - Subfascial coverage (behind the breast tissue and behind a very thin, less than 1 mm thick layer of fascia)
This location has not been proved to add any significant coverage or have any benefits compared to a properly performed dual plane procedure and does not provide one-tenth of the coverage that dual plane allows. It is more of a surgeon gimmick than a pocket location that really adds tissue coverage. - Partial retropectoral (behind the pectoralis muscle)
If you don’t have more than 2 cm. of pinch thickness, put the implant partially behind the pectoral muscle regardless of the trade-offs. You may have some distortion of the breast when the muscle contracts (that’s not often), and the distance between the breasts may widen slightly over time, but both of these trade-offs are better than putting an implant under tissues that are too thin! - Dual plane (behind the pectoralis muscle in the upper breast, behind breast tissue in the lower breast)
If you don’t have more than 2 cm. of pinch thickness, and you need muscle coverage in the upper breast but would like to reduce the trade-offs of traditional muscle coverage, the dual-plane location offers that option. The best of both worlds is a very good option for most, but not all, first-time augmentation patients. It is not necessarily the best approach if you are very, very thin (less than 0.5 cm pinch thickness immediately at the fold under your breast). - Total muscle coverage (behind pectoralis and serratus muscles)
This is not usually a good choice for augmentation because it has too many trade-offs that affect the lower, outer shape of the breast and the shape and position of the fold beneath the breast. It is sometimes useful in reconstruction cases.
Picking the Implant
What Type and Size Implant?
- Size
If your envelope has been stretched by pregnancy, you’ll need enough to fill the envelope adequately for the best result. If you’ve not been pregnant, a good rule of thumb is to think about enlarging the breast the amount it would enlarge during pregnancy—about a cup size. If you want an especially large breast, you must accept the inevitable consequences of your decisions. The larger the implant (especially above 350 cc) and the thinner your tissues, the greater your risks of complications, additional surgery, visible implant edges, rippling, and possible shrinkage (atrophy) of your existing breast tissue. You need to consider what you want and balance that with what will happen to your tissues as you age, especially with a larger implant. Best choice? Ask your surgeon to enlarge your breast proportionate to your figure, filling the breast only enough to create an aesthetic result, not too large—and don’t ever discuss ccs. You’ll definitely be happier ten years or more later. Don’t be too concerned when you hear many women say they want to be larger. They aren’t thinking about the long-term consequences. - Smooth
Do you prefer a smooth-surface implant? Why? Hopefully it isn’t because smooth implants are cheaper. Don’t make this choice believing that you’ll be less able to feel the implant because it isn’t so. Tissue coverage is the main issue that affects whether you can feel an implant. The fact that a smooth-wall implant can move around more than a textured is a positive and a negative. The main worry is whether smooth implants really are as good at preventing capsular contracture and how the smooth wall implant may affect tissues long term. - Textured
Most surgeons believe that textured surface implants offer a decreased risk of capsular contracture (more so with silicone-gel filled implants compared to saline-filled implants). With anatomic or shaped implants, a textured surface helps maintain optimal position of the implant. If you choose a smooth wall implant and subsequently develop a capsular contracture, will you look back and wonder, “What if I had chosen a textured surface implant?” - Round
Easier to use than an anatomic; hence, preferred by many surgeons. The main question is how to deal with the fill issues with current round, saline-filled implants. If you fill it to manufacturer’s recommendations, the shell folds and risks visible rippling and shell failure. If you overfill, you currently are not assured in writing that the manufacturers will warranty the implant. If you’re choosing a round implant because a surgeon has told you that “anatomic implants malposition,” hopefully you asked exactly how many anatomic implants the surgeon had placed. The fact is that both round and anatomic implants can malposition, and published data1,2,3,4 suggest that the incidence of reoperations with properly used anatomic implants is less than one-half of 1 percent. - Anatomic
Looks more like a breast. More demanding of the surgeon. Offers better long-term control of upper-breast fill and breast shape. Best in first-time augmentations until a surgeon has plenty of experience, then okay for reoperations. Fill volumes are defined differently by the manufacturer, depending on the specific type of shaped or anatomic implant. (You must check.) Remember that all anatomic implants are not the same: some are full height and some are reduced height, and adequate fill to reduce risks of upper shell folding or collapse depends on the implant’s passing the tilt test outside your body. - Saline Filled
A better choice for any patient who, despite scientific evidence, has any concerns whatever about the safety or potentially higher capsular contracture rates with silicone gel filled implants. The primary tradeoff of all saline filled implants is that they are likely to have a shorter shell life compared to silicone gel implants, and therefore potentially require more replacements during a patient’s lifetime. Saline implants are also currently less expensive compared to silicone gel filled implants. - Silicone Filled
Silicone gel filled implants have been shown in FDA studies to have a longer shell life (lower failure rate) compared to saline implants. Form stable silicone gel filled implants (the newest, anatomic implants that maintain their shape when upright, without shell collapse or folding) have a substantially lower shell failure rate compared to conventional silicone gel filled implants. All silicone gel filled implants except form stable silicone gel implants have been shown in FDA PMA studies to have a higher rate of capsular contracture compared to saline implants. These rates also relate to how a surgeon performs your surgery—the less trauma and bleeding, the faster the recovery and the lower the capsular contracture rate. Silicone gel filled implants are more expensive compared to saline implants, and form stable silicone gel implants are more expensive compared to conventional silicone gel filled implants.
Picking the Incision Location
- Inframammary (in the fold under the breast)
The most commonly used incision in breast augmentation offers surgeons the greatest degree of control in the widest range of breast types and implant types and sizes: The standard by which all other incisions must be measured. The only reason not to have an inframammary incision is 1) you absolutely do not want a scar on the breast or 2) you have a documented history of hypertrophic (heavy) scarring from a surgical procedure (not from an accident where the cut was caused by trauma). - Periareolar (around the areola)
A good selection if you have a history of hypertrophic scarring or if you just prefer this location. The implant has more exposure to bacteria in breast tissue by this approach, but no scientific studies prove a higher risk of infection or capsular contracture. Nipple sensation is an issue. Nursing should not be an issue if the procedure is performed properly. - Axillary (in the armpit)
The ideal location if your main goal is to get the scar off the breast. Much better control during surgery compared to the umbilical approach. The entire pocket can be created under direct vision by the surgeon using endoscopic instruments. This scar is not visible in over 90 percent of patients even with the arms raised. - Umbilical (around the belly button)
Attractive to some surgeons from a marketing standpoint. You’ll find that the vast majority of highly experienced surgeons feel this approach offers much less control compared to other approaches, unnecessarily traumatizes abdominal tissues, and requires that most, if not all, dissection of the implant pocket be performed bluntly and blindly. The entire pocket is created by tearing tissue with an expander balloon and by forceful, manual movement of the inflated device or by using some other form of blunt dissector that tears tissues. You’ll have injury with discomfort and bruising in the upper abdomen that rarely, if ever, occur with procedures that assure less tissue trauma and bleeding, and in a few cases, you may develop deformities of the upper abdomen. You can’t judge by pictures because many of the irregularities under the breast or in the abdomen aren’t visible in standard pictures. You get all of the benefits of the umbilical approach without the trade-offs and risks by selecting an axillary incision!
What About Costs?
We’ll cover costs in the next chapter, and discuss options for dealing with costs.
The Next Step...
Congratulations! You’ve done your homework and made your choices. Now it’s time to prepare for your surgery.
References
1 Tebbetts, J. B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 106(1): 139-147, 2000.
2 Tebbetts, J. B. Dual plan (DP) breast augmentation: Optimizing implant soft-tissue relationships in a wide range of breast types. Plast. Reconstr. Surg. 107: 1255, 2001.
3 Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation, part II: patient preparation, refined surgical techniques and instrumentation. Plast. Reconstr. Surg. 109: 293-305, 2002.
4 Tebbetts, J. B. Achieving a zero percent reoperation rate at 3 years in a 50 consecutive case augmentation mammaplasty PMA study. Plast. Reconstr. Surg. 108(6): 1453-1457, 2006.