Vancouver Breast Augmentation – Gallery #1
Your breasts may be small…because they never developed to the extent you would have liked
42 years old, 5’6 120lbs, 2 Children, Pre Surgery: 34A
Implants: R 325cc filled to 350cc, Post Surgery: 34C
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Vancouver Breast Augmentation – Gallery #2
Or after pregnancy, breast feeding and weight loss
25 years old, 5’7.5 130lbs, 1 Child, Pre Surgery: 36B
Implants: R 425 to 450cc, L 350 to 400cc, Post Surgery: 36D
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Incisions may vary depending on surgeon and patient preference
For minimal incision surgery, either the armpit approach or the umbilical (belly button) approach is used. 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.
Vancouver Breast Augmentation – Gallery #3
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.
Placement above muscle
Placement under muscle
Risks of Vancouver Breast Augmentation surgery
All surgery carries risks of problems. We have continuously assessed the quality of our results to try to minimize risk. The following is a summary of both Dr. Gelfant’s experience at his Vancouver clinic and the general experience with Breast Augmentation.
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.
Vancouver Breast Augmentation – Gallery #3
Capsular Contracture of the right breast on our (screen left)
This condition, which we call capsular contracture, was, for many years, by far the most common problem for both plastic surgeons doing Breast Augmentation and our patients. 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.
Infection: Infection is a rare occurrence in Vancouver Breast Augmentation. 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 never 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.
Scarring: Most incisions are 1″ to 1-1/2″ or less. It is rare for the scar to be visible once complete healing has occurred.
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 with implants. 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 blouse of 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 details read our blog:
http://gelfant.com/2011/12/18/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.
Vancouver Breast Augmentation – Gallery #4
Pseudo Droop: A lift not needed
26 years old, 5’7 148lbs, 2 Children, Pre Surgery: 34B
Implants: R 425 to 450cc, L 425 to 450cc, Post Surgery: 34D
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.
Vancouver Breast Augmentation – Gallery #5
27 years old, 5’1 105lbs, No Children, Pre Surgery: 32A
Implants: 325cc filled to 375cc, Post Surgery: 32C
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Vancouver Breast Augmentation – Gallery #6
20 years old, 5’6 115lbs, No Children, Pre Surgery: 34B
Implants: R 425cc to 450cc, L 425cc to 475cc
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Vancouver Breast Augmentation – Gallery #7
27 years old, 5’9 115lbs, No Children, Pre Surgery: 34B
Implants: R 325cc to 375cc, L 325cc to 350cc, Post Surgery: 36D
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Vancouver Breast Augmentation – Gallery #8
27 years old, 5’9 115lbs, No Children, Pre Surgery: 34B
Implants: R 325cc to 375cc, L 325cc to 350cc, Post Surgery: 36C
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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:
Progression 1: Scapular Wall Slides – Download the Full PDF
Progression 2: No Money Drill – Download the Full PDF
Progression 3: Scapular Floor Slides – Download the Full PDF
Thank you to Carmen of Human Motion for providing the PDF documents.
Disclaimer
Please note that due to Health Canada rules, you must be 22 years of age for Breast Augmentation to be done using silicone gel filled implants. Saline devices may be used for younger patients, although we rarely operate on women of ages under 19.
