Since 1997, Dr. Benjamin Gelfant has been a leader in the development and practice of endoscopic (minimum scar) Breast Augmentation. Since he opened his Vancouver clinic in 2000, this approach has been refined and improved and continues to be the preferred approach for many women.
Over the years, through breast augmentation with placement of breast implants, Dr. Gelfant and his team of professionals at Broadway Cosmetic Plastic Surgery Centre has helped women lead happier, more fulfilling lives. Now, almost two hundred women per year entrust him to either perform their breast augmentation surgery or to treat problems arising from surgery elsewhere. Although breast augmentation surgery has been performed for over forty years, improvements in the implants, in the surgical technique, and even in anesthesia, have all contributed to making this a safer, more predictable, and ultimately more satisfying operation.
Incisions may vary depending on surgeon and patient preference
Dr. Gelfant is a leader in the use of the armpit approach, having used it almost exclusively since 1997, and has taught many surgeons this technique.
The armpit is one of the best areas of the body for scars. Most patients eventually have invisible scars with this approach, even in skin types who often get poor scars elsewhere.
Post Breast Augmentation through armpit – Scars nearly invisible:
Belly Button (TUBA) approach to Breast Augmentations
While the umbilical technique may appear attractive, it has the disadvantage of not being a gentle, refined operation done with the excellent visibility of the endoscopic armpit approach, in which cutting is precise and pinpoint control of bleeding is maintained at all times. The TUBA technique tends to be done “blindly”, that is, without seeing what is actually being done, using the telescope only later, to ensure there isn’t active bleeding before stitching the incision closed. It has the disadvantages of inaccuracy and roughness, and all the consequences.
Placement of the implants can be above or under the pectoralis major muscle. But our experience has shown that if you want a long-lasting, natural-looking and feeling result, placement under the muscle produces the desired results far more readily.
Risks of Breast Augmentation
All surgery carries risks of problems. We have continuously assessed the quality of our results to try to minimize risk. Risks include but are not restricted to:
- post-operative bleeding
- loss of feeling
- “capsular contracture” ( hardness)
Infection: Infection is a rare occurrence in Breast Augmentations. If it occurs, it is usually present in the first week after surgery and almost always requires removal of the affected implant, cleansing of the space, and antibiotics. The implant can later be replaced once infection has completely settled. The risk of this occurring is less than 1/2%.
Post-operative bleeding: Bleeding inside the implant space can accumulate as a hematoma and this requires urgent re-operation. Prior to our change to under the muscle with endoscopic assistance (through the armpit) the risk was about 2%, the same as most plastic surgeons report. This has been reduced to fewer than 10 in the past more than 2000 patients (less than 0.5%). While this is a profound reduction, bleeding can still occur. We also warn patients that if uncontrollable bleeding during surgery occurs, obscuring the lens of the telescope repeatedly, an incision in one of the traditional locations on the breast would be made, but this has yet been needed.
Loss of feeling: or reduced feeling of the breast and nipple can occur. It used to be said this was in about 15% of patients. Although this appears to be far more than we usually see, it still occurs periodically. Although feeling usually gradually returns, it may not, or it may result in increased sensitivity for several months.
Pain: Sub or under the muscle, placement has a reputation of producing far more pain and a prolonged recovery. This is FALSE. If careful, gentle surgical technique is used, aided by the magnified view of the operation we have with endoscopic guidance, bleeding is minimized, the implant space is carefully prepared, and all factors are working in favour of rapid recovery. Most patients return to work within five to seven days.
Secondary surgery, bleeding postoperatively, pain, time away from work and from social activities are all minimized. Most patients are able to take only mild pain relievers by the second post operative day.
Scars: Most incisions are 1″ to 1-1/2″ or less. Scars fade with time, but all scars are permanent. The time during which scarschange is called “maturation” by plastic surgeons, and can take from six to eighteen months, or occasionally longer. Scars peak in terms of their thickness and redness at 4-6 weeks, plateau, for a while, and then soften and fade. Generally speaking, the armpit scar is faster to settle than other locations, and fades more completely
Capsular Contracture: Whenever a foreign material, whether it is a sliver, a piece of glass, shrapnel, or a breast implant is placed under the surface of the body, the body recognizes it as not part of itself, and if it cannot digest the foreign substance, reacts by forming a wall around it. This wall, which we call a capsule, is very much like scar, and may be thin and soft, or tough and thick. In the early phases of healing, all scars contract.
If the capsule contracts around the implant and the space available to the implant becomes tight, the implant comes under pressure, is forced into a more rounded shape, and becomes firm or even hard.
Capsular Contracture of the right breast.
This condition, which we call capsular contracture, was, for many years, by far the most common problem for both plastic surgeons doing Breast Augmentation. We cannot explain why one patient will get contractures and another will not, nor why in some patients one side will develop a contracture and the other will not. Nor can we predict who will get the condition. It poses no major health risk to the patient but may cause enough firmness on occasion to be uncomfortable or even painful and certainly, the more severe, the less natural they appear and feel.
Our experience parallels the experience of the plastic surgery community in general on the issue of contracture. Placement of the implants above the muscle results in contracture rates of roughly 25% by three years and this number continues to increase with time. Beginning in late 1996, we began placing all implants beneath the pectoralis muscle, and the contracture rate dropped profoundly, to less than 1% at three years, in almost 500 patients reviewed. While this has not eliminated the problem, it has reduced it to a rare occurrence.
Silicon Implants are now freely available in Canada!
In October 2006 the 14 year ban and limited use of silicone gel filled implants ended. Surgeons and their patients may now freely choose the implants which best fit their needs, without requesting special approval.
Silicone Versus Saline
Silicone gel filled implants were taken off the market except for investigational purposes in 1992 by the US Food and Drug Administration and Canada’s parallel body, the Health Protection Branch, soon followed with a similar ruling.
There were several concerns which prompted these rulings: possible risk of cancer, a possible link to immune related diseases, and leakage of the implants.
Since 1992 much research has been done to study the effects of implants on the health of women. All the available evidence, which is now very powerful, suggests there is no link between the use of silicone gel filled (or saline filled) implants and increasing risk of development of breast cancer or any of the chronic diseases which were responsible for the controversy.
From April 1992 until October 2006 use of silicone gel-filled breast implants was restricted at first to an outright ban and later to permission from Health Protection in Ottawa after a request from the surgeon. In October 2006, after years of considering all the evidence presented at multiple hearings, permission was granted to the manufacturers to sell the implants to surgeons without restriction. Continued research into health and safety of these devices is a condition of this approval.
What is good about silicone gel implants? There is no question gel feels more natural when the implants are picked up from a desk top. Gel can be varied in its consistency and can be made to feel very much like breast tissue. Cohesive Gel is now being advocated as the best filler for implants. Cohesive gel is said to be more stable so that in the event of a leak or rupture, the gel will be confined to the capsule and more easily removed. It is said to cause less visible rippling, waviness in the implant which may be visible through the skin.
We are pleased to now be able to offer these implants to our patients as one of the choices available.
Although we are now using silicone gel filled implants in many cases, we continue to use saline filled implants in roughly a quarter to a third of women. Why? Saline is the most natural filler. Our bodies are over 70% saline (salt water. Rippling is more of a problem with implants which are above the muscle. Since all of Dr. Gelfant’s implants are placed under the muscle, this is less of a problem, and is mainly seen in patients who have very little breast tissue and minimal body fat. In patients with minimal breast tissue and fat, we will usually suggest silicone as a possible option, to help minimize visibility and rippling.
You should be aware, that despite claims to the contrary, gel can still result in some visible rippling. Generally speaking, this is much less than in saline filled implants, in women with lower body fat and less breast tissue.
Until 2010, we felt there wasn’t a safe way to put silicone gel filled implants in through the armpit incision we usually prefer. That changed when we became aware of the Keller Funnel, a device which allows the implant to be gently squeezed through a small incision without touching the skin, and without placing too much pressure and risking injury to the implant. Since April 2010, we have been using this method with great frequency and success.
We continue to consider saline filled implants to be an excellent choice for many patients, but use gel filled implants under the right circumstances. In practice, this means at least 70% of patients opt for silicone gel filled implants.
Selecting Sizes for Breast Augmentation
Historically there were many methods used to determine breast implant size, but these were, surprisingly, usually dependent more on the surgeon’s sense of balance and esthetics, than on the patient’s desires. Our aim in sizing patients is to try to satisfy the patient, while not compromising safety.
First, we ask the patient to buy a bra of the size she wants to be by trying bras on wearing a sheer blouse or T-shirt, stuffing the bra cup with tissues or other fillers. She then comes in to the office and we give her a standardized bra of the size she desires (one manufacturer, one style, a soft, modified sports bra). We place an implant-like device in the bra while she wears a tank top or t-shirt. The device is a temporary type of implant which can be filled with water until the bra cup is filled to the desired volume with implant plus her own breast.
At this point, we examine the dimensions of the patient’s chest, and if she has sufficient space on her chest to allow the placement of an implant of the size she desires (which is usually the case) we simply use that size of prosthesis. Sometimes this may require a High Profile Implant. Higher profile implants are narrower for a given volume, and we prefer to describe them as narrow base implants rather than high or moderate plus profile devices.
Adjustments can be made for differences in size between the two sides. Most important, the patient determines the size, with my staff’s help. However, no guarantee of size can be made.
What is overfill?
Saline (Inflatable) implants are supplied empty, and have a range of fill volumes. For a 325cc Mentor implant, for example, this is from 325 minimum to 375cc maximum. There is a feeling, among experienced plastic surgeons, that under-filling implants, something that was done before capsular contracture was understood, increases the chance of the implant shell breaking and leaking, simply because over time there is more folding of the shell over and over again. There is also likely to be excessive rippling visible through the skin.
There is also the feeling that maximally filling (to the maximum recommended volume), reduces this risk, and that overfilling may also be worthwhile. Excessive overfill, however, leads to the edges of the implant distorting and being easily felt. We usually fill implants to as near to maximum recommended volume as possible, and don’t overfill by much, if at all. In 494 patients operated on in a series from our clinic, the re-operation rate for size was less than 4% overall.
Silicone Implants are pre-filled and sealed at the factory, and the terms overfill, underfill, etc. do not apply to them.
Caring for implants Post-Augmentation
Stitches: There are no stitches to be removed. Stitches are absorbable and buried under the skin. You may begin showering the day after surgery at which time the small band-aid-type dressing is removed and not replaced. On rare occasions a knot and the very short cut ends of a stitch may protrude through the incision several weeks after surgery. This simply requires gentle removal with a fine pair of tweezers ( forceps).
We usually see patients, in our Vancouver clinic, the first working day after surgery day and check carefully for any problems, discuss how you are feeling, and review any concerns you may have. Subsequent visits are scheduled at frequent intervals at first, and for sic months to a year after surgery. If you are from a distant location, and as is usual, recovery is without problems, we see you in followup when it is convenient for you
Activity: We encourage you to start using your arms within twenty-four hours of surgery. For more details please read our the following post in our blog: Exercise After Breast Augmentation
You may return to most normal activity within twenty-four hours. You may begin riding a stationary bike, walking on a treadmill or outdoors or other gentle aerobic activity within a few days. Aggressive sports and exercise should not resume for two weeks. If you work out regularly in a gym with weights, you may not feel comfortable with “lat pull-downs” “pec fly’s” or “chest press” exercises for six weeks. Our studies have shown our patients to be back to near normal muscle strength by six weeks.
Exercises to keep the implant soft and mobile are rarely advised, in contrast to several years ago. The evidence supporting their ability to prevent contracture is weak. Barring any problems or concerns, we usually have another visit six weeks later and at six months. Thereafter visits are only as needed. We see patients many years later for “checkups” if they desire.
Breast Feeding after Augmentation
With placement of the implants under the muscle, especially when the armpit incision is used, the breast itself is not disturbed. There is usually no interference with the function of the breast gland, and as long as there is some sensation to the nipple (it is rare for complete loss of sensation to occur) nursing is possible. However, not all new mothers are successful at nursing even without implants, so no guarantees can be made.
Mammograms and the detection of breast cancer
Saline filled implants placed under the muscle interfere least with examination of the breasts by mammography; although there is still some reduction in how well the breast can be seen, this is much less than with silicone gel filled implants placed under the breast. Detection of cancer by self examination is not made more difficult by augmentation.
Droop? Or Loss of Volume
One of the most common questions we are asked is “DO I need a lift??” and this is important because a breast lift is quite different from augmentation and involves more incisions and therefore more scar than a breast augmentation. Plastic surgeons think backwards about this. Some patients feel they have developed droop but the nipple and areola are still above the level of the fold under the breast; in this type of case, the cause is generally loss of breast volume alone and placement of an implant is the usual recommended treatment
In most cases when the patient complains of drooping, the nipple and areola are still above the level of the fold, but the upper breast has lost its fullness so the breast looks collapsed. This requires filling out the breast volume, an augmentation, not a lift.
If the nipple and areola are below the level of the fold a lift is usually required. How much droop is described by the plastic surgeon by the distance from the level of the fold to the level of the nipple.
Early Range of Motion Exercises After Breast Augmentation
Reduce muscle spasm and pain after breast surgery. See our early range of motion exercises for Breast Augmentation below:
Thank you to Carmen of Human Motion for providing the PDF documents.
If you have had breast augmentation, and the results have been disappointing or you’ve experienced a problem with one or both breasts, we may be able to offer you a surgical solution. Learn more about secondary breast revision surgery.
Breast Augmentation Facts
Answering all your questions about breast augmentation is beyond the scope of this site. At consultation we will go into extensive detail and be sure you are thoroughly familiar with the entire subject so you can make a well informed decision.
Saline implants are not new. They were also used from the early 1960′s, but were used less frequently than silicone gel implants. The implants have a very good long term safety record and were the only implants available from 1992-2002. In 2002, gel implants became more freely available in Canada, although each case had to be be approved by the Health Protection Branch in Ottawa. In 2006, HPB Canada and the FDA in the USA gave full approval for the use of silicone gel filled implants, and made the decision as to whether to use saline or silicone up to the doctor and patient only. Today, over 70% of the implants in our practice are silicone gel filled.
We will be happy to discuss all possible options with you at consultation, and to do what is best for you.
Although saline implants can leak, collapsing in the process, this is very uncommon. When leaks occur, deflation is quite rapid, and harmless. Removal of the implant and replacement is generally a simple procedure, so periodic replacement before leakage occurs does not seem to be worthwhile. The leak rate is about 4% over ten years per implant, so your chance of having intact saline filled implants at ten years is over 90%. The manufacturers guarantee the implants against failure, so I suggest replacement only if there are problems.
Gel filled implants can also leak, but leaks are not as obvious. Current implant models are tougher than those used in the mid-1970′s through mid 1980′s, when early leakage was very common. When leaks occur, the gel is what is referred to by manufacturers as cohesive or memory gel, meaning that the gel is not semi-liquid and will remain as one collection of filler, without spreading elsewhere. There will be little external sign of the leak. For this reason, the FDA in the USA strongly suggests regular MRI ( magnetic resonance imaging) to screen for silent ruptures, beginning three years after surgery and every two years thereafter. IN CANADA, and in most other countries, there are no such stipulations, although we feel it may be worthwhile having a screening MRI sometime about eight to ten years after surgery.
Hi Definition ultrasound is a newer testing method which may become the standard for screening implant integrity in the next few years and will be more accessible, and less expensive.
Read our blog post http://gelfant.com/how-long-do-breast-implants-last/ for further information
Yes. There is no change in the pressure within the implant at altitude or underwater, so there is no increased risk of rupture.
To learn more please contact Broadway Cosmetic Plastic Surgery Centre.