- Breast Augmentation Overview
- Tailored Approach
- Consultation with Dr. Zemmel
- Preparing for Breast Augmentation Procedure and Pre-Op Visit
- Patient Safety
- Breast Augmentation Procedure
- Recovery from your Breast Augmentation
- Post-operative Breast Massage
- Anatomy of the Breast
- Incision Location and Pocket Creation
- Breast Asymmetry
- Tubular Breast, Tuberous Breast, and Constricted Breast Shape
- Breast Augmentation in African American, Latin, and Asian Women
- Surgical Complications of Breast Augmentation
Breast Augmentation Overview
Breast Augmentation is the surgical enhancement of the breasts using prosthetic implants. According to the American Society of Plastic Surgeons, 289,328 breast augmentation were performed in the United States in 2009. Breast Augmentation has been performed for over 40 years, and during this time, both the surgical technique and the implants have evolved to give a very safe, reliable, and reproducible surgical outcome.
Breast implant surgery is comprised of the creation of a pocket beneath the breast and pectoralis major muscle of the chest and subsequent placement of a prosthetic implant.
Breast augmentation is a large component of Dr. Zemmel’s practice. Dr. Zemmel strives to give his patients a fuller, more lifted breast, but also a natural look that puts his patients’ upper and lower body in balance and proportion. Dr. Zemmel believes harmony, proportion and balance are the keys to a pleasing aesthetic surgical outcome.
Dr. Zemmel’s patients have a wide range of goals and desires. Many women desiring breast augmentation have modest goals for a size increase, while other women desire a fuller augmentation. Dr. Zemmel treats women of different body shapes and weights, breast sizes, and different ethnicity.
Women have many reasons for seeking breast augmentation. They include:
- Increasing the size and volume of the breast
- Raising the level of nipple and areola
- Repairing significant asymmetry between the breasts
- Reproportioning the upper and lower body
- Desiring better fitting clothing
- Increasing self-esteem and a achieving a sense of well-being
- Countering the effects of pregnancy and breast feeding
Breast augmentation surgery is a relatively non-invasive procedure with a short operative time. Patients seeking breast augmentation should be in relatively good health without significant medical issues. Breast augmentation surgery has a very high patient satisfaction rate and a low complication rate. Dr. Zemmel will review your medical history and determine if you are a candidate for breast augmentation surgery.
Your Consultation with Dr. Zemmel
During your initial consultation, both you and Dr. Zemmel will discuss your reasons for seeking breast augmentation surgery. Dr. Zemmel wants to get to know you as a person and learn your reasons for seeking breast enhancement surgery. Tell Dr. Zemmel about your goals and desires for your surgical outcome. Dr. Zemmel will review your medical history. Please tell Dr. Zemmel about any prior issues with your breasts, including any prior mammogram studies, surgery on the breasts, or family history of breast disease. Dr. Zemmel will then perform a complete physical examination focusing on the breasts.
Dr. Zemmel will then perform an exam and take a number of breast measurements. Some considerations include:
- The overall position of the breasts on the chest wall
- The overall shape of the breasts and symmetry
- Presence of any cysts, lumps, or masses
- The position of the nipple and areola on the breast
- The size and shape of the nipple and areola
- Quality of the breast skin and presence of stretch marks
- Height and width of the breast
- Position and symmetry of the inframammary creases (the fold under the breast)
- The shape of the ribs and breast bone
- The presence of any spinal curvature and height of each shoulder
- Distribution and quality of breast tissue within the breast
Dr. Zemmel will then fit you with an implant. You will change into a form-fitting shirt and try on a range of implants until you find one that meets your desires. Dr. Zemmel believes each woman has her own unique characteristics and therefore a “one size fits all” approach does not work. Dr. Zemmel believes that each woman has a range of implant sizes that will fit her comfortably to give a natural result, and Dr. Zemmel will tailor the operative approach to you as an individual.
Dr. Zemmel will also perform 3-D Vectra imaging to simulate surgery. A digital three-dimensional photograph will be taken, and Dr. Zemmel will use the computer system to simulate surgery. This is accomplished by assigning several topographical points to the surface of the image. The computer then calculates the volume and shape of your breasts. Dr. Zemmel or a member of his team will then select the implants you have selected and digitally place then. You will have the opportunity to see your body with a simulated surgical result.
The entire consultation lasts for approximately 60 minutes. The consultation is an educational process to inform you about all aspects of breast enhancement surgery. Finally you will receive a quote for the procedure that will include all of the fees including the surgeon’s professional fees, anesthesia fees, operating room fees, and implant cost.
Preparing for Your Breast Augmentation Procedure and Your Pre-Op Visit
Once you have decided to schedule your breast augmentation, Dr. Zemmel will see you for a second consultation approximately 2 weeks before surgery. During the visit Dr. Zemmel will perform a second examination and you will try on implants again to finalize your selection. Dr. Zemmel will go over the entire procedure, the recovery, and your expected results. You will have plenty of opportunity to discuss your concerns and have any remaining questions answered. You will complete all paperwork, consent forms, and releases during this visit. Full payment for the procedure is due at this time. You will also receive your preoperative and postoperative instruction packets. Dr. Zemmel will also give you prescriptions, including antibiotics, pain medicine, muscle relaxants, and anti-nausea medicine at this time. He encourages you to fill these prescriptions before surgery so they are ready for you at home immediately after.
Dr. Zemmel will encourage you to maintain a normal active lifestyle right up until surgery. No special diet is required. You may exercise normally until the time of surgery. Dr. Zemmel encourages smokers to cease tobacco use several weeks prior to surgery. Dr. Zemmel will also provide you will a list of medicines to be avoided for at least 2 weeks prior to surgery. These include blood thinners, some vitamins, and diet pills. Especially important are the NSAID class of medicines, which include aspirin, ibuprofen, naproxen, and Advil.
Dr. Zemmel performs all surgery in St. Francis Hospital in Midlothian, Virginia or St. Mary’s Hospital in Richmond in a fully accredited operating room. Your anesthetic will be administered by Board Certified Anesthesiologists and Board Certified Registered Nurse Anesthetists. He believes that in addition to providing you the most reliable surgical procedure possible, your safety is of paramount importance. Dr. Zemmel believes that surgeries performed in these settings are safest with the lowest possible complication rates. Dr. Zemmel believes that the extra margin of safety provided in the hospital setting allows his patients to have greater confidence in the procedure and greater peace of mind. The safety precautions taken by Dr. Zemmel and his team exceed those typically provided in an office based operating room.
Your Breast Augmentation Procedure
You will be instructed to arrive for your surgery one or two hours prior to the procedure. This will allow the hospital staff to properly check you in and prepare you for surgery. Dr. Zemmel will then examine you a final time and place the marks that serve as the “blue prints” for the procedure. You will have the opportunity to ask questions and discuss any final concerns.
Your Anesthesia provider will then give you a light sedative to relax you before bringing you back to the operating room. Once in the operating room you will be put fully to sleep, and surgery will then begin.
Dr. Zemmel performs breast augmentation surgery in approximately 40 to 60 minutes. Dr. Zemmel begins by making a small incision in the periareolar or inframammary position (depending on the patient’s choice and anatomy). The incision is then tunneled down to the muscle layer where the pectoralis muscle is found. The lower border of the muscle is then found and the muscle is lifted from the chest wall. A pocket behind the muscle is then created for the implant. Dr. Zemmel then places temporary breast implant sizers to mold the overlying tissue and to confirm proper size and shape. Dr. Zemmel then sits you up in surgery, and Dr. Zemmel and his operating room team assess your results. Small modifications to the breast pockets are made at this time to optimize symmetry and volume if needed. Once Dr. Zemmel and his team are pleased with your results, you are then placed lying down once again. The sizers are removed, and the pockets washed with copious amounts of antibiotic solution. The permanent implants are then placed. Dr. Zemmel finally closes your incisions with very fine absorbable sutures and covered by a thin, clear coat of tissue glue to protect the area. You will then be placed in a soft surgery bra. Anesthesia is then discontinued, and you will awaken quickly. At every moment during the procedure, you will be monitored and carefully assessed by Dr. Zemmel, the anesthesia provider, and his operating room team. Your safety is our foremost concern. Dr. Zemmel’s patients experience a very low rate of postoperative nausea and vomiting.
Immediately after surgery you will be transferred to the recovery area where several nurses will care for you over the next 1 or 2 hours. This allows you to be closely monitored as you fully awaken. Any immediate postoperative discomfort or nausea will be addressed with intravenous medications. After recovery you will be moved back to the preoperative holding and then discharged home when you are ready. Dr. Zemmel will see you in the office one or two days after surgery for your first postoperative check up.
Recovery from Your Breast Augmentation
Recovery from breast implant surgery takes approximately 5 to 7 days. Dr. Zemmel will give you prescriptions for muscle relaxants and analgesics at your preoperative appointment. Recovery from breast augmentation comes mainly from placing the implant underneath your pectoralis muscle. The muscle must then stretch over the breast implant to accommodate this new volume. Dr. Zemmel’s past patients liken the postoperative discomfort to a vigorous chest and upper bodywork out in the gym. The discomfort feels like muscle soreness, not a deep body cavity pain or pain from a broken bone for example. Immediately after your breast augmentation surgery, you will feel that your breasts are tight and somewhat swollen. Many women who have had children liken the discomfort to when the milk lets down during pregnancy and breast-feeding.
Dr. Zemmel believes that a gentle, meticulous surgical technique allows his patients to recover within days of surgery. Dr. Zemmel believes that a precise placement of the implants with minimal tissue trauma that results in minimal bruising and swelling allows his patients a much quicker recovery.
You will keep your arms down by your sides for the first few days. You may perform your normal activities of daily living. You may go out, but Dr. Zemmel wants you mainly to relax and not stress your body. After 3 or 4 days you will then be allowed to raise your arms and reach above your head. You may shower 2 days after surgery once the small incisions have become watertight.
Dr. Zemmel will see you for your first follow up visit one or two days after surgery and then one week later. During these visits Dr. Zemmel and his team will closely guide you through the recovery process and monitor your progress. One week after surgery you will be taught postoperative breast massage. Dr. Zemmel and his team will see you again one week later to check you progress.
Dr. Zemmel finds that his patients tolerate the postoperative discomfort very well. Most patients are pleasantly surprise that the recovery is not long or as intense as they expected. At no time during your healing and recovery process will you feel “alone.”
Postoperative Breast Massage
Approximately 1 week after surgery, Dr. Zemmel and his team will instruct you on postoperative breast massage. The goal of postoperative breast implant massage is to keep the implants soft and loose in the submuscular pockets. You will be shown how to gently move the implants up, down, in, and out (in all four directions). Massage is typically performed as soon as the bulk of the postoperative discomfort has resolved. Massage is performed in the morning, mid day, and in the evening. Three sets of ten repetitions are performed. Massage is performed for several months after surgery. These maneuvers break up any small areas of scar tissue and keep the breast implant pockets soft. Dr. Zemmel believes this is a key step in your recovery and the more massage that is performed, the better and more natural your result will be.
Immediately after your procedure you will begin to see the results of your breast implant surgery. Your breasts will be tight and slightly swollen, and initially your implants may appear slightly “high.” As the swelling decreases your implants will “drop.” As the submuscular pocket heals, your implants will take their final position giving a soft mobile implant and a rounded natural shape. You will see the evolution of your results over the first few weeks after surgery. The small incision used to place the implants will also heal rapidly, and you will see this line begin to soften and fade within several weeks after surgery. Dr. Zemmel will prescribe a topical scar treatment such as Scarguard or Mederma to help the incision fade and soften. Remember: healing is a dynamic process and takes several weeks to a couple of months to fully complete.
Anatomy of the Breast
Since the time of antiquity, the female human breast has been a symbol of femininity, maternity, womanhood, and sensuality. Anatomically, the breast develops from modified apocrine glands along the embryological milk line on the ventral surface of the human embryo. The milk line typically contains 4 or 5 bilateral milk buds, only two of which are present at birth. During puberty, the female breast begins to respond to hormonal changes and the tissues begin to elaborate. The breast develops 10-12 lobules separated by connective tissue named Cooper’s Ligaments. The glandular lobules course radially around the breast from the central nipple.
The breast is located on the front of the chest wall and typically spans from the second rib to the sixth rib. The breast directly overlies the pectoralis major muscle centrally and the serratus anterior muscle laterally. The vascular supply to the breast comes from medial internal mammary perforators, laterally from the lateral thoracic artery and posterior intercostal arteries, and superiorly from the thoracoacromial artery. Sensation to the breast is supplied by the anterior lateral cutaneous branch of the 4th, 5th, and 6th intercostal nerves. The nipple and areola sensation is supplied by the 4th intercostal nerve.
The breast is covered by the “skin envelope” followed by layers of fatty and milk producing tissue. The composition and density of the tissue varies during a woman’s lifetime. Younger women have a higher gland-to-fat ratio. Women who are lactating have the highest gland-to-fat ratio, which may reach 2:1. Breast composition in older woman changes to a lower gland-to-fat ratio of 1:2.
The milk ducts number from 4-18 and drain to the central nipple. The areolar tissue is pigmented and may be pink to brown in color and contains sebaceous glands (Montgomery tubercles), which lubricate and soften the nipple during breast-feeding.
- Ribs and Intercostal Muscle
- Pectoralis Major Muscle
- Breast tissue
- Lactiferous Ducts
- Fatty tissue
- Inframammary Fold
Incision Location and Breast Implant Pocket Creation
There are several incision approaches for the placement of breasts implants. The goal of the procedure is to create a perfectly-shaped pocket under your breast tissue and pectoralis muscle for your new implant. Dr. Zemmel will create this pocket precisely so your new implant will be perfectly placed on your chest wall. Creating a pocket too wide will cause the implant to fall to the side, while creating a pocket to narrow will constrict the implant and distort shape. Therefore choosing the proper incision is critical in allowing Dr. Zemmel access into the interior of breast. The length of the incision can range in length from 2.0 to 2.5 cm for saline implants to 3.0 to 4.0 cm for silicone. Silicone implants require a slightly longer incision length as mandated by the FDA. Silicone implants come prefilled and sealed. Dr. Zemmel uses a Keller Funnel to place both saline and silicone implants. This allows a much easier, less traumatic placement of the implants, and minimizes potential damage to the implant. As important is that the use of the Keller Funnel prevents contact between the implant and the surface of the skin. This dramatically reduces the rate of infection and capsular contracture for both saline and silicone implants. In Dr. Zemmel’s practice these rate are less than 1%.
There are three different incision approaches for breast augmentation: The inframammary approach, the periareolar approach, and the transaxillary approach.
If you are also undergoing a breast augmentation with a breast lift (mastopexy), Dr. Zemmel will combine the incisions need for the lift with the incision needed for the breast augmentation. This minimizes the number of incisions on the breast giving you a much better cosmetic outcome.
The approach uses an incision located at the junction of the nipple/areola and regular breast skin. By placing the incision in this location, Dr. Zemmel effectively camouflages the final incision in this natural boundary. The incision in this location heals beautifully and often is not visible several months after surgery. By accessing the breast and submuscular pocket from the center of the breast through the areolar, Dr. Zemmel has a wide view of the pocket. Conceptually, Dr. Zemmel thinks of this as looking into the pocket from the top of a dome. Dr. Zemmel can look into the breast and have a 360 degree view of the pocket. This view allows Dr. Zemmel to perfectly shape the pocket for the implant.
Many patients ask if the periareolar approach has a higher risk of reducing nipple/areola sensation. The data show that a comparison of all three approaches for breast augmentation (transaxillary, inframammary, and periareolar), the rate of nipple sensation disturbance is approximately 15%. This is independent of the incision. Anatomically, the nerve to the nipple comes from the T4 intercostal sensory nerve on the lateral chest wall. The nerve to the nipple and areolar comes around the chest wall from the back and directly underneath the nipple. If sensation is disturbed to the nipple and areola, it usually occurs underneath the muscle towards to armpit and not around the areola itself.
The periareolar incision is also the most versatile. If you need a breast lift in addition to the implant, no further incisions are necessary. If future revisions are necessary, the same incision can be used.
The inframammary approach is the most traditional approach to breast augmentation. It calls for an incision tucked under the crease of the breast (the inframammary fold). It allows wide access to the breast tissue and easy access to the submuscular space. And while this incision heals beautiful as well, the chance of being able to see it in a small bikini top for example is greater. Dr. Zemmel uses the inframammary incision in women who prefer not to locate the incision around the areola, or in women who have a nipple/areola diameter that is too small to allow implant placement. Dr. Zemmel will discuss this in detail with you during your initial consultation and examination.
The transaxillary approach, or armpit approach, uses an incision located in the underarm area for implant placement. There are a number of drawbacks to this procedure. The data show a somewhat higher complication rate for transaxillary breast augmentation. The rate of implant malposition is higher. Furthermore, it is anatomically impossible to perform a dual plane breast augmentation through this approach. If a lift is also necessary with breast augmentation, a separate, additional incision must be used. The incision is also the most visible of the three approaches.
A number of studies preformed by board-certified plastic surgeons over the last several decades have shown that approximately 85% to 97% of women have measurable asymmetry of the breasts. This means that some asymmetry between the right and left is normal and expected. Perfect symmetry is extremely rare! During your consultation, Dr. Zemmel will examine and measure your trunk and breasts and demonstrate any existing asymmetry. There are a number of parameters that he will consider. These include:
- The overall size of the breast
- The overall shape of the breast
- The position of the breast on the chest wall
- The position of the inframammary fold (the crease) of the breast
- The position of the nipple and areola on the breast
- The size, shape, and project of the nipple and areola
- The shape of the breast bone and ribs
- The height of your shoulders and curvature of your spine
- The quality of the skin of your breasts
- The compliance of your skin (its ability to stretch)
- The presence of stretch marks on the breasts
- The distribution of breast tissue within the breasts
There are a number of minor asymmetries that can be readily addressed with breast augmentation.
- Differences between breast size and volume: Dr. Zemmel make elect to use slightly different sized implants between the right and left breasts or place different fill volumes.
- Difference between rib cage shapes can often be addressed by placing addition volume on one side. Often one side of the rib cage is slightly depressed compared to the other side. (This is completely normal and is not a medical issue). Because the implants are placed directly on the rib cage additional volume maybe needed to achieve the same level of projection.
- Discrepancies is the height of the inframammary fold can be addressed by lowering or raising the crease.
- Small differences in the shape of the breast can be addressed by molding the breast tissue from inside of the breast when implants are places. Dr. Zemmel often rounds the lower part of the breast to achieve improved contour.
There are significant asymmetries that may require additional breast lifting procedures in addition to breast augmentation. A breast lift (mastopexy) is often needed to achieve the best contour and shape. The type of lift required depends on how “powerful” of a lift you may require. Dr. Zemmel may recommend a breast lift (mastopexy) in addition to breast implants in women who have one or more of the following:
- A significant difference is nipple/areolar height (usually greater the 2 cm). A breast lift technique would be used to raise and level the nipple/areola height.
- A large difference in the diameter of the areola. A periareolar breast lift maybe used to even out the areolar diameter.
- Low positioning of the nipple and areola on the front surface of the breast. A periareolar, vertical, or full breast lift maybe needed to raise the nipple up so it lies on the most projecting part of the front surface of the breast.
- A large amount of excess breast skin. A breast lift (mastopexy) maybe used to tighten the skin “envelope” of the breast.
- Significant difference between the shape of the breast. A breast lift technique maybe used reshape the actual breast tissue to provide a rounder, more pleasing contour.
- Low positioning of the breasts on the chest wall. A breast lift (mastopexy) may be used to raise the position of the breast on the chest wall.
The decision to perform breast augmentation with a breast lift (mastopexy) is complex and usually requires altering nearly all of the parameters of the best at once. Dr. Zemmel will perform a thorough examination during your constellation and discuss all of your options.
Tubular Breast, Tuberous Breast, and Constricted Breast Shape
Tubular, tuberous breast, and constricted breast shape refer to a spectrum of breast shapes found in a large percentage of women with breast asymmetry. All three terms listed above refers to the same breast condition. A recent study suggested that approximately 60% of all women with measurable breast asymmetry have a variation of tubular breast shape. Women presenting to Dr. Zemmel’s office may have a very mild tubular shape or a very severe tubular shape on one or both sides. Each one of Dr. Zemmel’s patients is unique, and Dr. Zemmel will customize an individual treatment plan.
Tubular breasts are characterized by an underdevelopment of the lower pole (or lower hemisphere) of the breast. A number of common factors contribute to this shape. Tubular breasts are typically characterized by:
- A deficiency of horizontal and/or vertical breast skin
- Narrowing or tightening of the base (or width) of the breast
- Enlargement and widening of the nipple/areolar diameter
- Herniation of breast tissue behind the nipple and areola
- An elevated, narrow inframammary fold (crease under the breast)
These factors combine to give the overall tubular shape. Women with tubular breast shape maybe classified into one of several shapes depending on the shape and severity of the breast constriction.
It should be noted that tubular breast are a developmental variation of breast shape. The condition is not harmful and does not predispose one to other medical illness.
Correction of tubular breasts usually consists of placement of a breast implant combined with a periareolar breast lift (mastopexy) or other lifting technique. There are also a number of other maneuvers Dr. Zemmel will perform in surgery to refine your result. The classic procedure consists of:
- Breast augmentation with either saline or silicone implants: This will add volume to the breast and dramatically alter the shape providing a rounder more natural contour.
- Lowering of the inframammary fold: This will assist in rounding out of the lower pole of the breast and expand the base width of the breast.
- Radial breast tissue scoring: Dr. Zemmel will perform this maneuver in surgery to “unfurl” and spread out the breast tissue. Conceptually this is similar to the opening of an umbrella.
- Periareolar breast lift (mastopexy): This will reduce the diameter of the areola, reduce areolar herniation, and improve symmetry.
While tubular breasts are a developmental breast condition, the cost of the correction is not covered by government or commercial insurance plans.
Breast Augmentation in African American, Latin, and Asian Women
The latest data from the American Society of Plastic Surgeons shows that African-American Women, Asian-American Women, and Latin-American Women are seeking plastic surgery more often. Oftentimes, these women are concerned with the quality of scarring from surgery. There are two types of scars that rarely may form after surgery or any other skin trauma. They are hypertrophic scars and keloid scar.
A hypertrophic scar is a scar that forms with the original boundaries of the surgery incision. Instead of healing as a thin, flat, soft, pale line, the scar becomes thick, raised and red. Again, the important factor is that the hypertrophic does not extend beyond the original incision. Treatment for thickened hypertrophic scars include over-the-counter scar remedies such as Mederma and Scar Guard, silicone sheet, steroid injections, laser treatments and surgery revision.
A keloid is a pathologic scar that becomes thick, raised, discolored, and extends beyond the boarders of the original incision. Most people who form keloids throughout their body discover this earlier in life. Dr. Zemmel may recommend avoiding cosmetic surgery for this reason.
Dr. Zemmel will make every effort to minimize scar by utilizing precise surgical technique, minimal trauma, and using suture material that is the least reactive possible. You will also be placed on a program of scar protection immediately after surgery. Dr. Zemmel and his team will cover this in your post-operative visits.
Surgical Complications of Breast Augmentation
Breast augmentation surgery, like any other surgery, has associated complications. Dr. Zemmel will do everything in his power to lower the risks of an untoward event happening with his patients.
All cosmetic breast surgery should be performed by a board-certified plastic surgeon. Dr. Zemmel is certified by the American Board of Plastic Surgery and is an Active Member of the American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgery. While the magnitude of a breast augmentation is less than a major abdominal operation for example, breast augmentation has risks that must be proactively addressed. Dr. Zemmel accomplishes this through a number of ways:
- Dr. Zemmel performs all surgery in the hospital setting and uses only operating rooms with the highest level of safety accreditation.
- Dr. Zemmel performs surgery with Board Certified Anesthesiologists and Board Certified Nurse Anesthetists to ensure the safest anesthesia.
- Dr. Zemmel performs surgery with the same operating room team in order to maintain consistency with each procedure.
- Dr. Zemmel uses the highest quality materials and instruments when performing your procedure.
- Dr. Zemmel follows his patient very closely after surgery to ensure the smoothest and easiest recovery for his patients.
With any surgery, however, there is always a small possibility of complications or a reaction to the anesthesia. Bleeding and infection following a breast augmentation are extremely uncommon and occur less than 1% of the time. Your incisions can widen to form thickened scars, or you may have some asymmetry between the breasts. Capsular contracture, or scar tissue forming around the implant, occurs approximately in 2% to 4% of patients. You can reduce your risks by closely following Dr. Zemmel’s advice before surgery and postoperatively. Dr. Zemmel will discuss all of the risks and potential complications during you initial and preoperative appointments.
Contact Richmond Aesthetic Surgery
If you would like more information on breast augmentation procedures, or if you would like to schedule a consultation, please contact Richmond Aesthetic Surgery today.