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Women who come to my practice to discuss breast implantation surgery are interested in the procedure for a variety of reasons. Some women are considering breast augmentation to reclaim their sense of femininity and enhance the shape and size of their breasts after child birth, after significant weight loss, or simply after some life transforming event. Other women are interested in breast reconstruction following the loss or partial loss of breast tissue due to cancer, an injury, or to correct a birth defect/abnormality. Whatever the reason, I tell my patients that the decision to undergo breast implantation surgery is a personal one, with many choices to be made depending on the desired result.

First and foremost, it is important to note that, as with any other surgery, breast implantation requires a woman to be informed about the procedure and potential complications.

Key procedural considerations include:

• Product options: Today’s patients, together with their surgeons, can choose the volume for their implants (referred to in cc’s), whether the implant is filled with saline or silicone, is textured or smooth surfaced, and whether the implant is round or shaped, all depending on the desired result.
• Implant placement: Surgeons use different methods for inserting and placing the implant, for example, on top of the muscle (subglandular placement) or below the chest muscle (submuscular placement). Submuscular placement is generally associated with longer surgeries and recovery times.
• The surgical incision point: There are a few options for where the incision is placed. The incision can be in the armpit, under the breast fold, or around the areola. In patients undergoing breast reconstruction, previous incisions can be used. Each incision point has advantages and disadvantages which should be discussed with a surgeon. Available options vary based on a woman's anatomy and whether she is having cosmetic breast augmentation, or reconstruction surgery.

The potential complications associated with breast implantation surgery are different depending on the situation. Women undergoing breast augmentation will have different considerations than those undergoing reconstruction. The plan that is determined by the surgeon prior to surgery can be very different in reconstructive versus aesthetic surgery. If a woman is having her breast implants replaced (revision surgery), the risk of potential complications will increase as compared to the first (primary) surgery.1 In addition, the implant placement procedure selected, along with the surgeon's skill, could impact the length and discomfort of the recovery process.

This is a lot of information to consider and it can be overwhelming. In my professional opinion, the most important thing a woman can do to ensure she achieves her desired outcome from breast implantation surgery is to find a surgeon who is certified by the American Board of Plastic Surgery and specializes in breast implantation surgery. A woman should also seek a surgeon who communicates openly about her surgery goals, communicates well with her other physicians as necessary, explains her options and clearly informs her of her risks. Since a woman will be entering into a long-term relationship with her surgeon, it is important to find someone with whom she feels comfortable. Do not hesitate to get other opinions.

The Pre-Operation Planning Process

During the pre-operation (pre-op) planning session with the surgeon, it is very important that patients share their full medical history, present health status and any prescription drugs and nutritional or herbal supplements they are currently using. If the patient smokes cigarettes, she should notify her surgeon of this as well. It is also critical to discuss the goals for surgery and desired outcome. Sometimes the change patients are looking for or expecting can not be achieved with breast implantation surgery, so realistic expectations need to be discussed and established during the discussion with the surgeon. Along these lines, I alert my patients to expect that:

• Similar to other medical devices, breast implants are not lifetime devices. Also, breast implantation may not be a “one time” surgery; a woman may need additional surgeries over the course of her life to replace the implants.
• Routine screening mammography may be more difficult with breast implants. I advise my patients that they will need to inform their mammographers that they have breast implants. Mammograms are performed differently in women with implants.
  Learn more from an expert about mammography screening
• Many of the changes that occur with the breasts after augmentation are irreversible. If a woman decides to have her implants removed at some point, there is no way to predict what her breasts will look like. With age, all of our breasts change. After removing an implant, there is a chance the shape could be irregular, or there is some sagging.
• Health insurance status may change following breast augmentation. Treatment for any complications from breast implants may not be covered by health insurance.

It is also very important to discuss "parenting" status with the surgeon. A woman should let her surgeon know if she already has children, if she is planning to have them in the near future and whether she plans to breastfeed. All of these things can affect the surgeon's approach and the timing for breast implantation surgery.

Click here for expert content about pregnancy and breastfeeding

If I have a woman who is a cancer patient looking to restore her breast following mastectomy, I make sure to obtain a full and complete review of her medical history and current health status. This is particularly important and usually a process that is done in collaboration with the woman’s primary care physician and/or oncologist. Her oncologist and/or oncologic surgeon will work with me to determine what options are available for breast reconstruction. As compared to breast augmentation, the reconstruction surgical process could be longer, more involved and require more steps – and sometimes multiple surgeries – to achieve something close to the desired effect.

Women seeking reconstructive breast surgery also have to consider the timing of surgery. Some patients decide to begin reconstruction immediately (i.e., at the time of mastectomy), while others delay reconstruction surgery until the mastectomy has healed. Often times in reconstructive breast surgery, surgeons use a tissue expander for several months to help stretch the tissue and prepare for the breast implant placement. There are risks and benefits to both the immediate and delayed approaches, and all of these options need to be discussed and evaluated with a woman's physicians. For further information on breast reconstruction options and considerations, please visit one or both of the following resources:

• American Society of Plastic Surgery Web site devoted specifically to patients considering breast reconstruction Visit the ASPS Site
• FDA Web site on breast reconstruction Visit the FDA Site

The Surgical Process: Potential Risks and Complications

As I noted above, every surgery or medical procedure is associated with risks. A woman can reduce the possibility of complications from breast implantation surgery by educating herself about her options and what to prepare for by following her doctor’s instructions carefully and ensuring she is in good health before the surgery. Health risks such as smoking and being overweight may increase the potential risks of your procedure.

Breast implantation surgery can be done in a hospital or as an out-patient procedure in a surgeon’s office. The length of the surgery will vary based on the surgical procedure, the type of implant a woman receives, where the implant is placed, etc., but will generally range from one to several hours.

Before the surgery, I generally will speak with my patient about the anesthesia she will receive and her options for pain medications after surgery. I also discuss the potential risks and complications of surgery and how each will be managed. The most common surgical-based risks that I discuss with my patients are:

• Bleeding: Although excessive bleeding during breast implantation surgery is rare, I make my patients aware of the potential risk of bleeding and the subsequent need for a transfusion. There is a low risk that bleeding can occur after surgery that can require additional surgery.
• Anesthesia: As with any type of surgery requiring anesthesia, there are risks associated with general anesthesia. The anesthesiologist will discuss the risks with a woman prior to surgery. Any previous problems with anesthesia should be discussed, as well as any family history of anesthetic problems.
• Scarring: As with any surgical procedure requiring an incision, anyone undergoing breast implantation surgery should expect a scar, which will fade over time. If a woman is unhappy with her scar, she should speak with her doctor, who can sometimes take steps to reduce it (scar revision).
• Infection: The incidence of infection resulting from breast implantation surgery is relatively rare. In general, women who elect to have augmentation surgery experience fewer infections than cancer patients seeking reconstructive surgery. This is because radiation and chemotherapy put reconstruction patients at higher risk for infection. A woman can reduce her risk of infection after surgery by ensuring that she does not have any active infections before the procedure. Any infections that do develop after surgery – even if they seem unrelated, such as strep throat or a toothache – need to be addressed by a doctor immediately. As with any other surgery, despite the safety measures surgeons take in the operating room, bacteria could enter the bloodstream and travel to the surgical wound, causing infection, pain, additional scarring and/or delayed healing.
• Nipple sensation: This is an unusual complication in which feeling in the nipple and breast can increase or decrease after implant surgery. The range of changes varies from intense sensitivity to no feeling in the nipple or breast following surgery. While some of these changes can be temporary, they can also be permanent, and may affect your sexual response or ability to nurse a baby. In my experience, only about one percent of patients experience total loss of nipple sensation, while about five percent experience numbness and loss of sensation, which lessens or goes away over time.
• Breastfeeding: As I mentioned previously, any type of breast surgery can impact a women's ability to produce adequate milk (a condition known as lactation insufficiency).
• Healing process: Recovery usually goes very smoothly in patients undergoing augmentation surgery. Patients undergoing reconstruction surgery may require more monitoring. Everyone should expect some level of discomfort following surgery, depending on the type of surgery and individual level of pain tolerability.

What to Expect During Surgery

Each surgical procedure is different, depending on the surgeon and the facility. However, a woman can generally expect her surgery to follow this process: She will be asked to arrive for surgery at least an hour before the procedure is scheduled. After she arrives, she will be seen by a nurse who will check her vital signs, and ask some health history questions, similar to those questions already asked in the pre-operation consultation. An IV will be started, and blood tests, a pregnancy test, and/or an EKG may be performed. She will then be seen by her plastic surgeon, who will answer any last-minute questions and then place some markings on her chest as preparation for her surgery. Next, she will be taken to the operating room, where medication is placed in her IV to give her the general anesthetic. During the surgical procedure, medical staff will continuously monitor her vital signs. She will wake up in the operating room, but most patients don't remember anything from the time they enter the operating room until they are in the recovery room. In the recovery room, the nurses will watch her closely and give her pain medications as needed. When she is comfortable and medically stable, the nurses will discuss "post-op" instructions with the patient and her caretaker. She will then be discharged or taken to her room if she is spending the night at the hospital or surgery center. It is important to have a caretaker with her after surgery because she may be uncomfortable, as well as drowsy or disoriented from anesthesia, and will not be able to drive herself home.

Post-Operation Care

After the surgery, a woman will likely experience some pain, bruising and tenderness. The pain is usually worst the first night and improves with time. Most women need pain medication for the first few days, and can change to Tylenol® or ibuprofen in 3-4 days. I advise my patients to alert me immediately to any unmanageable pain, fever, warmth or redness of the breast, or bleeding. Most patients go home in an elastic bra for comfort and to hold dressings in place. The sutures from the surgery are usually removed 7-12 days after the surgery. A small amount of activity is okay as tolerated, but aerobic exercise should be avoided for at least three weeks.

A woman can minimize her risk of complications by taking good care of herself after surgery and following the doctor's instructions. Keep surgical wounds clean and avoid undergarments or clothes that will irritate or rub them. If an antibiotic to treat or prevent infection is prescribed, be sure to take it exactly as prescribed. Call the doctor's office for any concerns. It is best to call during regular office hours, when someone is there who can talk with and see the patient, if needed. Soreness and swelling are common after surgery and may last a few weeks, but sudden severe swelling, especially if on one side, could indicate bleeding and should be checked. Low grade fever is not unusual after surgery, but a high fever (greater than 101 degrees) accompanied by redness and chills should be reported to the doctor immediately.

Overall, the potential risks and complications of breast implantation surgery need to be considered and balanced against the potential and perceived benefits of the surgery. This is best done after carefully considering the expectations and goals for surgery, and then finding a board-certified, specialized surgeon who will talk openly about surgical procedures as well as potential risks, and help prepare a woman to have the safest and best outcome possible.

• You can find additional information about breast implantation surgery at the FDA web site
• Click here to find a plastic surgeon or questions to discuss with your plastic surgeon

Q.

It seems that the surgeon I select will have a big impact on the success of my surgery and the risk of complications. How can I be sure I'm selecting a qualified, experienced surgeon?

A.

Choosing an experienced surgeon is a critical part of the breast implantation surgery pre-op process. To get the best sense of the surgeon's technical qualifications, I recommend using the following checklist from the United States Food and Drug Administration (FDA):

• In which states is he/she licensed to practice surgery? Note that some state medical licensing boards provide information on disciplinary action and malpractice claims/settlements to prospective patients either by request or on the internet.
• Is he/she board-certified, and if so, with which board?
• How many breast augmentation, reconstruction, or revision surgeries does he/she perform per year?
• How many years has he/she performed breast implantation surgeries?
• What are the most common complications he/she encounters with patients after breast implantation?
• What is his/her re-operation rate with breast implants, and what is the most common type of re-operation he/she performs?2

Q.

How long will breast implants last? Is it possible I may need more than one surgery?

A.

Similar to other medical devices, silicone gel-filled breast implants are not lifetime devices. It is possible at some point in a patient's lifetime that the implant(s) would need to be removed or replaced, and therefore needs to be monitored by the physician and patient. The need for revision surgery depends on a number of factors, such as the age of the patient and the breast implant type.

Q.

Will I be in pain after surgery?

A.

Pain is, unfortunately, a common occurrence following any type of surgery or medical procedure. A woman with breast implants who experiences pain for an extended period should consult her physician.

Q.

How long will I need to stay home from work?

A.

Typically, I advise my patients that if they don't do heavy physical work, they can return to work within about a week. If a patient does perform a lot of physical tasks at work, I may recommend that she take off more time from work.

Q.

Will my breasts be the same size?

A.

Interestingly, a woman's breasts are asymmetrical or not exactly the same size or shape to begin with. While she may not have noticed this before, her surgeon may point it out during the pre-op session and may then discuss ways that he or she will adjust their surgical technique to make the asymmetry less pronounced. However, don't expect implants to fully resolve any pre-existing asymmetry. For the first few weeks after surgery, the differences between the two breasts may be more pronounced because breast swelling tends to reduce unevenly. After that, the breast will generally become much closer to the same size.

Q.

After surgery, will my risk of breast cancer increase?

A.

There is a very thorough, solid discussion of this topic in our expert content. In general, I tell my patients that the data on this topic do not show any increase in breast cancer in women with breast implants, as compared to women who do not have them.

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1 http://www.fda.gov/cdrh/breastimplants/qa2006.html
2 http://www.fda.gov/cdrh/breastimplants/handbook2004/surgery.html