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Michael Law MD Aesthetic Plastic Surgery


Breast Augmentation Surgery in Raleigh NC

Located in Raleigh, North Carolina serving patients in Raleigh, Cary and Durham NC.

The women who choose this practice for breast augmentation in Raleigh want to feel more confident about their breast appearance, to look great in form-fitting clothing, to get rid of their padded bras and swimsuit tops, and to have more options when shopping for clothes or when looking through their closet for what to wear to an important event or just out to lunch with friends – but they do not want to look like their appearance is the result of a surgical procedure.

BREAST AUGMENTATION Surgery: MORE OPTIONS THAN EVER FOR A NATURAL-LOOKING RESULT

WHICH Type of IMPLANT IS BEST? Breast Implant Options

There are more breast implant options than ever before for patients in the United States. We now have four companies that have FDA approval to market and sell breast implants. Three of them offer cohesive silicone gel implants and conventional (single-chamber) saline implants: Allergan, Mentor and Sientra. Cohesive silicone gel implants are now available with varying degrees of ‘cohesiveness’, meaning that you can select exactly how soft or firm you would like your breast implants, and thus your augmented breasts, to be.

The newest company offers one specific implant product, which is a two-lumen ‘structured’ saline implant: the Ideal Implant. This implant represents an attempt to create a saline implant that feels more natural than conventional saline implants, but that does not require a radiologic test to monitor the status of the implant (like the MRI scan you will need if you want to know if one or both of your devices have ruptured).

Round silicone gel implants are available with both smooth and textured surfaces, which have some differences with respect to implant performance. Saline implants all have a smooth shell, while shaped silicone gel implants all have a textured shell. In this practice we place only round breast implants (cohesive silicone gel, structured saline and conventional saline), as shaped implants have been shown to provide no observable improvement in augmented breast shape compared to round implants, and they have a risk of rotation which, when it occurs, requires another trip to the O.R.

This is the most important thing to know about this multitude of implant options: THERE IS NO PERFECT BREAST IMPLANT. There are instead lots of implant options, and there are pros and cons for each implant option that you might consider. Given the natural breast that you are starting with and your goals for the outcome of your augmentation surgery, there is quite likely an implant choice – that combination of implant fill material (silicone gel vs. saline), implant shell type (smooth vs. textured vs. structured smooth) and implant proportions (base diameter / projection / volume) that is perfect for YOU.

The most important step in the process is finding a surgeon who both understands your goal for the outcome of the surgery, and who has experience with all of these implant options. And who has a relationship, I should add, with all of these implant companies.

WILL MY Breast Augmentation Performed LOOK NATURAL?

A natural-appearing breast is noticeably fuller in the lower pole (below the nipple) than it is in the upper pole. In profile (viewing from the side), the upper pole slopes gradually from where the breast begins in the upper chest down to the nipple, and the lower pole is full and rounded. For any patient considering breast enhancement surgery, there is an implant size above which the upper pole begins to look rounded, convex, and unnaturally full.

Mild upper pole fullness can look beautiful and youthful, but excessive upper pole fullness due to overly-large or overly-projecting implants looks decidedly fake, and like what most people think of as a ‘boob job’.

Implant selection is of course a critically important part of the process, but it is but one of many factors that lead to a lasting, natural-appearing breast augmentation result. Patient education and preoperative preparation, surgeon experience, operative technique, precise implant pocket dissection, protective implant insertion technique, implant-stabilizing incision closure technique and attentive post-operative patient management are all absolutely critical components of success in natural-appearing breast augmentation.

Natural-appearing breast augmentation can be achieved for all patients if the surgery is performed by an experienced surgeon who uses biodimensional planning techniques to assure the selection of an appropriate implant type, profile and size, who selects an appropriate approach to implant placement, who pays great attention to detail in the operating room and who provides patients with detailed instructions for and attentive care in the postoperative phase.

Hundreds of thousands of women have their breasts augmented each year in the United States, and those who have had great breast augmentation procedures don’t look artificial – they look beautiful and natural, with breasts that are full but in harmony with their figure. They look great, they wear what they want to and fill out their clothes nicely, and the fact that their breast appearance is a result of a breast enlargement surgery is their little secret.

When the goal of this operation is a natural-appearing breast enhancement, the results can be absolutely beautiful. However, if the goal is to create an excessively full breast profile which is out of proportion to the shoulders, waist and hips, then the results – by definition – never appear natural. These patients not infrequently end up having a series of operations to address problems related to the excessive implant volume.

Make sure you choose a surgeon who understands your goals, who takes time to show you why a certain implant is a great choice for you, and who clearly explains all aspects of the procedure to you. A surgeon whose ‘before and after’ gallery clearly demonstrates to you that they are capable of creating the kind of breast augmentation result that is consistent with your own personal aesthetic ideal.

You should also know this: the process of having breast enlargement surgery can and should be a pleasant experience for the patient, with a quick recovery and return to non-strenuous activity, if measures are taken to minimize postoperative discomfort. It is our pleasure and privilege to provide natural-appearing breast augmentation results and a rapid-recovery breast augmentation experience for our patients from North Carolina, from around the United States and from around the world.

Why are there textured and smooth breast implants?

The answer to that question depends on a number of factors, including your preop breast appearance, what your lifestyle is like, what breast volume you would like to have and what is pleasing to you aesthetically. Sientra, Mentor and Allergan all have silicone gel breast implant product lines for cosmetic breast augmentation that include the traditional round implants in both smooth and textured surfaces, and shaped / form-stable implants all of which have textured surfaces. For a number of reasons this practice offers only round implants for breast augmentation; our decision to stop placing shaped implants as of 2016 is discussed in another section.

Traditional, single-chamber saline implants are also available from Sientra, Mentor and Allergan. All available saline implants have a smooth shell, as saline-filled implants with a textured surface shell have a higher failure rate and are therefore no longer produced. Textured surface silicone gel implants, on the other hand, do not have a higher failure rate than smooth surface silicone gel implants. The newest implant to market is the structured Ideal Implant; this saline-filled implant has a smooth shell and is designed with two separate saline-filled chambers with internal ‘baffles’ (sheet of smooth silicone elastomer shell material) between the chambers.

So if you go with traditional or structured saline implants, your implants will by default have a smooth shell. If you go with a shaped silicone gel implant, your implants will by default have a textured shell. If you prefer round silicone gel implants, which is the most commonly placed implant around the world today, you and your surgeon will need to decide between smooth surface and textured surface implants.

Textured surface implants were originally developed with the hope in mind of reducing the rate of capsular contracture (CC). The general consensus in the plastic surgery literature for many years has been that there does not seem to be a significant difference in the contracture rate between smooth and textured surface implants, but some recent data from the implant companies shows that some textured surface implants do have a slightly lower rate of capsular contracture. The difference in the CC rate is small, however, and one needs a large study with many patients enrolled to observe a difference.

So for a single patient any potential small difference in CC rates in smooth vs textured implants, in my opinion, is not that relevant. There are a number of steps that a surgeon can take to reduce the risk of capsular contracture that are much more significant than the type of implant shell that is selected. Read more about the things we do to prevent capsular contracture at The Plastic Surgery Center here: What can be done to prevent capsular contracture?

Up until recently, most U.S. plastic surgeons have preferred to use smooth / round silicone gel implants. This bias comes from years of using primarily smooth / round saline implants, during the fourteen year (1992-2006) FDA-mandated moratorium on silicone gel breast implants, until the FDA gave approval to the new generation of cohesive silicone gel implants in 2006. Saline implants were previously available in smooth and textured versions, however the textured shell saline implants had a higher deflation rate and fell out of favor.

So the primary implant used in the United States for almost a decade and a half was a smooth-surface saline implant, and when the FDA lifted the moratorium in 2006 most American surgeons transitioned to using smooth-surface silicone gel implants. Again, it is important to understand that the ‘smooth vs. textured’ decision only applies to silicone gel implants; if you seek a saline implant breast augmentation then smooth shell implants are the only option.

Cohesive silicone gel implants vs. conventional saline implants vs. structured saline breast implants

Women considering breast augmentation now have the luxury of deciding between three kinds of breast implants: cohesive silicone gel implants (approved for cosmetic use by the FDA in 2006), conventional (single-chamber) saline implants, and structured saline implants. There are a number of pros and cons to consider with each type of implant, however the most important thing to know is that patient satisfaction is very high with all three. You can’t really go wrong with this decision – it is merely a matter of deciding which is best for you personally.

Regarding silicone gel implants, it is important to understand that a cohesive silicone implant is a very different (and vastly superior) medical device compared to the older liquid silicone gel implants that were available for cosmetic use in the 70’s and 80’s, but were not approved by the FDA for cosmetic use from 1991 to 2006 (although they still could be used for breast reconstruction). The new cohesive gel implants are manufactured so that the gel material is in a semi-solid to solid state which, means that if the implant’s outer shell fails the gel material does not easily leak out of the implant – as it would with the older liquid silicone gel implants.

The design and manufacturing process for the outer shell has also improved a great deal, resulting in significantly lower implant shell failure rates. These improvements make gel implants much more appealing as long-term medical devices, and because of these major improvements and positive data from clinical trials the FDA cleared them for cosmetic use in 2006.

One very important issue to consider is implant palpability, i.e. whether you can feel the implant or not when you – or someone else – feels your breast. Silicone gel, structured saline and conventional saline implants are soft to the touch and compressible. Most surgeons and patients agree, however, that silicone gel  tend to feel much more natural than saline  implants, at least in patients who are starting out with a relatively small breast volume (say A to B), and that structured saline implants fall somewhere in between.

Because saline is non-viscous, it tends to allow the edges of the implant to collapse and this makes the implant edges of a conventional, single-chamber saline implant much more easily palpable in a patient who has a small preoperative breast volume. This will be quite obvious to you when you examine samples of saline and silicone gel implants during your consultation.

breast augmentation

Click for more photos

 

How many cc’s? – Size Implant

The actual size of a breast implant, measured in cc’s, is really not very descriptive of what a breast augmentation will look like, or what the cup size will be. The augmentation effect of any implant varies in different patients, and is relative to the preoperative size of a patient’s breast and the size and stature of the patient overall. A tall, broad-shouldered patient with small A-cup breasts may require 400cc implants to achieve a C-cup breast volume postoperatively, while a shorter patient with medium B-cup breasts may only need a 200cc implant to achieve a C-cup breast volume.

During the consultation process it is important for patients to be given the opportunity to examine a large number of sample implants to get a sense of how implants vary according to base diameter, projection and volume. Sample implants can be placed in a soft, non-padded bra to give prospective patients a sense of what their postoperative breast profile will be with a given implant volume. Breast forms (silicone gel bra inserts that are concave on their posterior surface, which fit over the breasts to simulate an augmentation) can also be used to give patients a sense of what their appearance will be with a certain number of cc’s added to their breast volume. Sample implants and breast forms placed in a non-padded bra, evaluated both without a shirt on and while wearing a form-fitting shirt, are a very useful means of helping patients to determine what implant volume is most appealing to them.

When a natural breast appearance is the goal, it is helpful in some patients to ‘try out’ different implant volumes and profiles in the operating room. Once the implant pockets have been created, sterile sizers can be placed in the implant pockets and the upper half of the O.R. table raised so that the resulting breast appearance can be assessed with the patient in an upright ‘sitting’ position (chest fully upright) while under anesthesia. These sizers are available not only for each implant size but also for each implant profile (low, low plus, moderate, moderate plus, high, extra high). Pre-filled gel sizers are used for silicone gel implant augmentations, while Inflatable sizers are used for saline implant augmentation. Sizers are especially useful in cases where the surgeon is trying to improve a preoperative breast asymmetry, and implants of different sizes and/or profiles may be the best choice.

Preoperative measurements that are made by your plastic surgeon such as breast base diameter, upper pole tissue thickness and lower pole skin stretch are of critical importance. For every patient there is a fairly specific range of implant volumes that will create a breast profile that would be considered natural-appearing. And for each patient there is an implant volume and profile at which the upper pole of the breast begins to appear unnatural. If your goal is a natural-appearing breast enhancement, make sure that the surgeon you select clearly understands your aesthetic ideal, and that you feel confident that they are committed to and capable of providing you with that kind of result.

There is, of course, a range of implant volumes and profiles for each patient that could potentially produce a plausibly natural-appearing result. While one patient may seek an augmentation that is ‘perfectly natural’, another may be interested in a result that is more on ‘the full side of natural’. Many patients do ask that the largest implant volume be selected that does not produce an unnatural fullness in the upper pole. By using sample implants and breast forms in consultation, and in some cases by using implant sizers during the surgery to confirm exactly what implant profile and volume produces the best breast appearance, patients can be provided with the closest possible approximation of their preoperative goals, and can be assured of a natural-appearing result.

Incision locations – Implant Placed

Three incisional approaches to breast augmentation have been widely used: inframammary fold (the crease at the bottom of the breast), trans-axillary (underarm area) and periareolar (along the inferior border of the areolas). Many board-certified plastic surgeons – myself included – have abandoned the periareolar incision, as we now know that it is associated with a higher risk of capsular contracture and scar contracture compared to the other two approaches.

The inframammary fold (the crease at the bottom of the breast) is by far the most commonly used incision for placement of breast implants. It always has been, and it always will be. An incision that is planned and executed so that it falls within the inframammary fold is, in most cases, functionally invisible once it has healed and the resulting scar has fully matured. In some cases the preoperative level of the inframammary fold needs to be lowered, and in those instances it is important to use careful preoperative planning to determine exactly where the incision should be made – as one is planning an incision that is below the existing (pre-operative) fold.

The inframammary fold incision has a number of distinct advantages;

  1. The incision is at the periphery of the breast, so one does not have to cut through breast tissue to create the implant pocket.
  2. Direct access to the implant pocket permits full access to the pectoralis major muscle and the greatest number of options for altering pec major muscle anatomy, such as release of inframammary fold and parasternal origin fibers, and varying the degree of muscle separation from the posterior surface of the breast (dual-plane I, II or III dissection).
  3. The greatest number of options for improving preoperative breast asymmetry are available via the inframammary fold incision.
  4. The definition of the inframammary fold can be enhanced via the inframammary fold incision.
  5. If the inframammary fold needs to be lowered, this incision allows the surgeon to redefine and protect the new inframammary fold.
  6. Sutures can be placed that reduce the likelihood of postoperative inferior implant malposition (‘bottoming out’).

The trans-axillary or underarm area incision is also a perfectly reasonable approach to breast augmentation, and it is one I use frequently; however this incision is best reserved for specific patients. The trans-axillary approach is ideal for patients with very youthful-appearing breasts that are close to symmetrical, especially younger women with no history of pregnancy. In patients with small, youthful-appearing breasts the inframammary fold (and thus a scar in that location) can be more easily seen compared to women in which the lower pole of the breast conceals the inframammary fold. This may be a particular concern for patients that are prone to more noticeable scarring.

There are important limitations to know about the transaxillary or underarm approach. There are significant limits to the breast shape and pec major modifications that can be made, there are limits to what can be done to improve asymmetry, and when lowering the inframammary fold there is really nothing you can do to help define, support and maintain the new level of the fold. Also, it is important to know that most  revisional surgeries require an anterior (i.e. inframammary fold) incision.

The patients for whom I use a transaxillary incision are most commonly young women (20’s and early 30’s) with small, youthful-appearing breasts which are roughly symmetrical and which do not require lowering of the inframammary fold to create an aesthetically ideal appearance. Many of these patients have not yet met their life partner, and they are therefore interested in the ‘stealthiest’ approach to breast augmentation. And it is definitely a very stealthy approach, for when a soft, cohesive (not highly-cohesive or ‘gummy bear’) implant is placed through an underarm incision, the breasts feel completely natural and the scar is in most cases impossible to detect.

Breast implants can be inserted through an incision in the belly button area (’trans-umbilical’ breast augmentation), however there are a number of problems with this approach and it therefore is not widely used. Approaching the surgery from such a remote location does not lend itself to the creation of a precisely-defined implant pocket, or the creation of a natural-appearing result, and this approach has a higher rate of complications and reoperation compared to the standard breast augmentation incisions. Most board-certified plastic surgeons do not use this approach.

Sub-pectoral vs. submammary implant position

Plastic Surgery Recovery and downtime

The recovery from subpectoral breast augmentation used to routinely be a rather unpleasant experience, but it no longer has to be. Almost all of our patients leave The Plastic Surgery Center with little to no pain, can shower the night of surgery, and experience a 24-hour return to routine, non-strenuous activities of daily living. Out-of-town patients who are travelling with a friend or family member may fly home the day after their breast augmentation surgery. We ask those that are travelling alone to plan on flying home two days after surgery.

During subpectoral augmentation a space for the implants must be developed behind both pectoralis major muscles, and a major portion of each muscle’s inferior origin must be released. Surgery performed directly on a muscle will in most cases produce significant and potentially prolonged postoperative pain, and that is certainly can be true for sub-pectoral breast augmentation – unless a number of preventative measures are taken.

Our protocol includes the following measures that have a synergistic effect that result in the major reduction of, or complete elimination of, postoperative pain:

  1. Preoperative administration of three non-narcotic oral medications that have been shown in randomized, blinded clinical trials to reduce the need for postop narcotic pain medications
  2. Pre-incision injection of all incision sites with a combination of local anesthetics
  3. Minimally-traumatic surgical technique, using low-power electrocautery for surgical dissection and hemostasis (hemostasis is the medical term for the prevention of bleeding from tissue surfaces including the highly vascular pectoralis major muscles)
  4. Injection of an extra-long-lasting local anesthetic (Exparel) into the inferior margins of the pectoralis major muscles (in the area where they have been divided using electrocautery)

As most of our breast augmentation Raleigh patients never require postop narcotic pain medication, we do not routinely prescribe it for this surgery. We provide patients with a non-narcotic anti-inflammatory pain medication called Celebrex (generic name celecoxib) to take twice a day for the first five days regardless of symptom level. Most patients report little to no pain in the evening following surgery, and perhaps some mild discomfort on postop day one, two and three. Patients can resume all routine, non-strenuous activities of daily living immediately after surgery, and can begin pec major range of motion exercises (arms above head and behind back) on the evening of their procedure.

Patients are seen in the office on postop day one, two or three. Those who work in an office environment usually return to work two to three days following the surgery. Stay-at-home moms should arrange some help with toddlers for the first two to three days after surgery. Exercise is limited to casual walking only for the first two weeks; in weeks three and four some light exercise is permissible.

Patients can gradually increase their isometric exercise level in the second month (weeks five through eight), however it is a full eight weeks before patients are allowed to return to activities that require forceful, repetitive, sustained pec major contraction – such as pushups and heavy weight lifting. Impact exercise may be resumed at 12 weeks postop, and it is important to ensure that the breasts are well supported in snug-fitting sports bra (or two) when first returning to impact exercise such as running or high-intensity cardio training.

For more information about breast augmentation or breast lift  – schedule a consultation with board-certified plastic surgeon Michael Law MD today!

    Schedule a Consultation with Dr. Law Today