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Breast Augmentation Palo Alto

View Before and After PhotosMammary hypoplasia or small breasts refers to an anatomical state in which the breast size is not in harmony with the rest of the body. Small breasts may be: congenitally inherited, a result from loss of breast tissue secondary to child bearing and breast feeding, a factor of aging (mammary atrophy), or a result from significant weight loss. Occasionally, injury of the breast in childhood may result in lack of breast development. It is also not uncommon to have one breast larger than the other.

There is no ideal age for breast augmentation. The procedure is frequently done on women from their late teens to seventy plus years of age. Motivations, health, and breast anatomy contribute to whether a person is an ideal candidate.

As a rule, breast augmentation will not interfere with normal sensation and breast function. Most of our patients have had no difficulties with breast feeding. Pregnancy and/or breast feeding will usually produce some contour changes in both the augmented and non-augmented breast. Some may prefer to wait until her family is complete and then correct the post nursing breast shape. It is not wrong to have an augmentation prior to pregnancy, but just be advised that the shape will change after nursing.

The optional incision sites for breast enhancement can be: at the base of the areola (nipple), under the breast, in the armpit or in the umbilicus (belly button). I would like to describe and give the pros and cons of each.

Periareolar – This is probably the most popular choice. The incision is made around the base of the areola border (the dark area around the nipple and breast skin). When healed, it virtually defies detection. Healing is quite nice since the nipple skin does not develop hypertrophic scarring. (Hypertrophic scarring is evidenced by a thick red raised scar that the patient’s body produces. It is not typical scarring.) There may be a temporary loss of sensation in the incision line, but nipple sensation is very rarely affected. The incision is positioned to miss as much breast tissue as possible. Periareolar incisions have been very popular with saline distensible implants. The surgeon can still use this periareolar approach with large saline implants. However, silicone gel implants in larger sizes can be a challenge to place through the small periareolar incision. Of course, this also depends on the size of the areola.

Inframammary – This incision is made just above the fold under the breast (inframammary crease) and varies from 1 ½ inches to 2 ½ inches long. Larger silicone implants are often best placed via this incision. With normal healing, it also defies detection. However, the concern about this incision is that it can form a noticeable scar if the patient has a predisposition to hypertrophic (thick) scarring. Unfortunately, this potential for bad scarring cannot be pre-determined, unless the patient has had previous indications of bad scarring on the body. This inframammary incision avoids disturbing the breast tissue and is popular for this reason. Any interferance with breast feeding is eliminated with the inframammary incision since the breast tissue is not disturbed with this incision. This incision is growing in popularity. I feel there is a best incision for each patient. . This will be discussed at your consult.

Axillary – This is better known as the armpit incision. This incision is usually well hidden, but it can show a visible scar in some people when the arms are raised. Like the periareolar incision, it is more difficult for larger silicone gel implants, but it works for saline distensible implants. The axillary approach at times is followed by lateral implant drift (implant moves back toward the side). I feel it is a less efficient way to assure maximal cleavage because of the lateral drift. Another problem is that the axillary incision is a difficult route for solving complications. This may automatically require a second incision to resolve a problem. Over the years, this incision has had varying popularity. If requested I will use this incision but patients prefer the inframammary or periareolar incision.

Umbilical – This belly button incision is mentioned only to be soundly and totally condemned. Only flimsy shell-distensible saline implants are possible, never silicone gel implants. It is largely a blind procedure in which the implant shell is placed under the breast tissue (not under the muscle) and distended to essentially rip the breast from its attachments. The weak shell implant frequently breaks. Replacement often requires implementing one of the other incision methods. Many liability companies that cover plastic surgery and hospitals will not insure for this umbilical approach, because there have been deaths from under the rib misplacement and lung puncture. I will not perform the umbilical technique. The umbilical incision is not done at Stanford University Hospital or at UCSF Medical Center for good reasons! I feel this route is dangerous, produces poor results, will not accommodate silicone gel implants and should be relegated to historical interest only.

The next point of interest is implant placement. Implants can be placed above or below the pectoralis (chest) muscle. Although going above the muscle is easier for the surgeon and less painful for the patient, there are many other reasons why beneath the muscle has been the most common placement site for the last 25 years. Mammography and cancer detection may or may not be easier with the implant placed under the muscle. This is controversial and present thought is that cancer detection is little affected by breast implants regardless of placement. Other once thought advantages of going under the muscle include: an extra layer of protection, a more natural appearance and fewer incidences of capsule contracture (firmness). This is no longer considered valid. Capsule contracture is a condition where the patient’s body reacts to the implant by building scar tissue around it. It is similar to how the body would react to a sliver under the skin. This scar tissue can make the breast firm and asymmetrical. It can happen in one or both breasts at any time. Attempts have been made to reduce the possibility of capsule contracture, but none have proven completely successful. I do not believe that capsule contracture potential can be reduced by placing the implant under the pectoral muscle, rather than just underneath the breast tissue. In fact it is likely there is no difference or possibly sub glandular is a beter choice to minimize hard encapsulated breasts. Every surgeon who has performed breast augmentations has had patients who have experienced capsule contractures. Some will return to surgery to release the scar tissue and replace the implants, and others might choose to just remove the implants. The degree of firmness can vary from acceptably mild to being painful and unnatural. There is no way of pre-determining who will form a capsule contracture. Saggy breasts or breasts with stretch marks tend to have higher incidents of capsule contracture. In the future implant placement is likely to be both below the muscle or just below the gland with equal success rates Remember it is easier and less painful to simply go beneath the breast gland. The sub glandular approach can easily be done under a local anesthesia. This is pleasing to patients and less costly.


Let’s discuss implants. All breast implants contain silicone. The main two types available are silicone shell with saline fill or silicone shell with silicone gel fill. Over the years, the companies producing breast implants have produced many types of implants with various fills. They have differed in size, shapes, textures and profiles. Many arguments and controversies have ensued. The greatest and most recent controversy definitely is the safety of the silicone gel filled implant. Silicone gel implants have now been approved for safety. The silicone gel implant possibly is better, possibly is more natural in appearance and feel, possibly has better longevity but possibly the two types (gel and saline) are equal and should be chosen on the basis of what is better for a selected patient and that patients situation. Natural round, smooth gel implants “teardrop” when standing up and will act like normal breast tissue in a reclined position. The saline implants are also fine, but can rarely produce a ruffled unnatural feel and appearance in some patients.This can be prevented by slight overfill which is a great technique. Saline implants have less capsule contracture potential, but they can break or leak as can gel implants over years of use. When they do, either will need replacement. The two main manufacturers today, offer limited warranty to replace broken implants. If deflation or breakage occurs implants can be replaced at surgery. The best implant for you will be discussed at your consult.

There are smooth and textured implants. I prefer the smooth, because I feel the rough surface of a textured implant may act like sandpaper in the body of some patients. The most common implant shape in augmentation is the mid profile. Candidacy for low, mid or high profile is discussed and determined during the consultation. The “teardrop” shaped implants can be problematic and very few patients are candidates for this shape. Round smooth implants teardrop on standing and are natural in all positions.

Choosing the right size implant is a major point of discussion and interest. The right size is based on the patient’s desire and the limitations of her anatomy (amount of existing breast tissue and body frame). I feel for every patient, there are multiple “correct sizes”. It is a plastic surgeon’s job to listen very carefully, then examine, assess and then offer ranges in sizing. It is interesting to know that probably 95% of breast augmentation patients wish that they had gone larger one year post surgery. On the other hand, if a surgeon implants a size too large for the patients body and there is lack of tissue to comfortably accommodate it, this can increase the chance of creating a capsule contracture complication. In addition, if excessively large implants are used, there is a greater tendency for the implants to bottom out. This means that the lower pole of the breast expands and the implant drops. Gravity is often not our friend. I have a formula for my patients that helps them determine which size they prefer within the range I’ve given them. This gives them the opportunity to determine or confirm the size they think is correct. This works out fine 99% of the time. The formula will be discussed at your consultation.

Breast augmentation is an “out patient” procedure that is possibly performed best with the patient asleep. Local anesthesia also works well when placement is above the muscle. It takes 1 ½ – 2 hrs. The patient may go home with a responsible adult that will remain with them the first 24 hours. Recovery takes about 5 to seven days. Most patients return to work after one week with minimal discomfort. Breast augmentation remains on of the most popular plastic surgery procedures.

The Natrelle breast implant in Dr Commons’ office.

View Before and After PhotosI have been doing breast implant surgery for over 30 years and can say with ease that the Natrelle implant by Allergen is the best ever. My introduction is accompanied by information by Allergen regarding the Natrelle. Breast augmentation began in the late 50s with the advent of the silicone gel implants. Breast augmentation prior to that time was very poorly done, but with the gels came improvement. Then came the saline implants which in the late 60s gained some acclaim. Since that time there has been steady progress of excellence and the crowning achievement has of course been the Natrelle breast implant series. I prefer the round, smooth, mid profile implant by Allergan, but there is a wide selection. There are multiple sizes and shapes to choose from to accommodate the needs and desires of all patients.

Breast implant surgery helps so many women. When is breast implantation indicated? The list of potential candidates is very long. First and foremost are the many women who have nearly no breast tissue, the women with congenital deformity, those who have lost breasts to injury or cancer, and of course the millions of women who have lost breast tissue after multiple breast feeding episodes and pregnancies. It suffices to say there are many millions of candidates for breast implants. Natrelle breast implants have been studied exhaustively and are very safe.

Download Patient BrochureBreast implants are placed either under the muscle or on top of the muscle depending on the woman and the breast contour and consistency. Incisions can be under the breast just above the crease area, around the nipple, or in the underarm area. There are advocates of each. Gel or saline implants can be used. Size determination depends on the desires of the patient and although always discussed can be complicated to predict. Size is determined by discussion and by surgical judgement and experience. The operation is done under a general anesthesia in a formal certified operating room. Recovery after a breast implantation is quite easy but the first few days can be uncomfortable if the sub muscular approach is needed. The above the muscle approach can often be accompanied by a return to work in a few days. I follow patients for a year and then offer them yearly checkups free of charge . All the patient has to do is show up. I love the opportunity to see and follow my patients.

All aspects of breast implantation are discussed by me personally in an hour consultation. We are all so fortunate to have such a wonderful product as Natrelle breast Implants by the outstanding Allergan Corporation.

Contact Dr. Commons today to learn more about breast implants.

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