Breast augmentation not only increases the size of the breasts, but can also improve their shape. Some women have naturally smaller breasts which they would like enhanced, while others are looking to regain volume that they have lost after pregnancy and breast feeding or weight loss. While the concept of breast augmentation is straightforward, there are a number of choices which allow us to customize the surgery for each individual.
Breast Augmentation Incisions
There are 3 incisions through which a breast implant can be placed. These are:
  • Inframammary – in the fold beneath the breast
  • Periareolar – around the edge of the areola
  • Transaxillary – through the armpit
The choice of which approach is used depends upon the preference of the patient and physician as well as the size and type of implant.
The inframammary incision is placed at or just above the fold beneath the breast. The advantage of this approach is that the pocket where the implant will sit can be developed without cutting through any breast tissue. There is no limitation as to the size or type of implant that can be placed.
The periareolar incision is placed on the edge of the nipple at the junction of the pigmented skin of the areola and the lighter skin of the breast. From this approach, dissection can easily proceed either directly through the breast tissue with minimal interruption of the ducts, or parallel to the skin down to the inframammary fold and under the breast tissue. Any size saline implant can be placed via this incision as they come deflated and are filled once they are in position, but there may be an upper limit on how large of a silicone implant can be used, depending upon the size of the areola. This is the best approach to release a tubular or constricted inferior pole breast deformity.
The transaxillary approach hides the incision in a natural crease in the armpit. To best develop the pocket, endoscopic techniques are utilized. Only saline implants can be placed via this approach, since the incisions are too small for silicone implants. The advantage of this incision is that there are no scars on the breast itself.
Breast Reduction
The typical patient with excessively large breasts presents complaining of shoulder grooving, shoulder pain, neck pain, and/or back pain. When breasts are large and in a low hanging position, the patient is forced to overly arch her lower back in an attempt to raise her breasts to a more anatomic position, altering the natural curvature of the spine. Additionally, intertrigo, irritation beneath the breasts due to moisture, is commonly found in the summer months. It also may be difficult to exercise despite wearing supportive bras. An enlarged breast not only has an excess of breast tissue, but also an excess of skin. A breast reduction removes both skin and breast tissue, creating a smaller breast which is also lifted to a more anatomic position. There are many techniques for breast reduction, but they all achieve the same goal of creating a smaller, lifted breast which is in better proportion to the patient’s body.
Breast Reduction Surgery
The procedure is typically performed on an outpatient basis with general anesthesia. The patient is first marked in an upright position prior to entering the operating room. The typical scar pattern extends around the nipple, vertically to the inframammary fold, and then horizontally in the fold. This is known as a “Wise pattern” or “keyhole pattern”. The skin and breast tissue to be excised is marked, and the nipple/areola complex is left attached to the remaining breast tissue. Breast feeding is a possibility in the future, but varies with each individual. Liposuction may be utilized on the sides to minimize the length of the incision. Occasionally, the procedure can be performed entirely with liposuction, and in some cases, an incision in the fold may not be required or minimal. At the end of the case, a temporary drain is placed on each side to prevent fluid accumulation in the breast. The patient is then placed in a dressing consisting of gauze padding and ace bandages placed circumferentially like a tube top.
Recovery from Breast Reduction Surgery
For the initial 24 hrs after surgery, it is normal for there to be drainage staining the dressing out the outside. Depending on the type of drainage tubes used, the patient is seen in the next few days for dressing and drain removal. If non-dissolving sutures are used around the nipple/areola complex, these are removed at 4 and 8 days after surgery. All of the remaining sutures dissolve. The patient is asked to limit the use of her arms, keeping her elbows by her side for a period of 2 weeks from the day of the surgery. At that time, she will gradually start resuming her normal level of activity with the expectation that she will be back to normal at approximately 3-4 weeks. It is recommended that a mammogram not be performed until approximately 9-12 months after surgery to allow the scar tissue to settle and remodel.
Breast Reduction Risks and complications
Risks and complications are uncommon, but may occur. They include, but are not limited to: infection, bleeding, unfavorable scarring, delayed wound healing, sensory changes of the nipple and surrounding skin (increased, decreased, lost), loss of the actual nipple (very rare), persistent asymmetry, and need for revision in the future.