BEFORE AND AFTER PHOTOS
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WHAT TO EXPECT AFTER SURGERY
Immediately after surgery, the local anesthetic is working, so that there is usually minimal discomfort on awakening. The breasts may feel numb or tight from stretching the tissues to accommodate the implants. A sports bra (which fastens in front, making it easy to take off and put back on) is already on. Usually patients wake up quickly after surgery, and are able to go home within an hour. Medication is administered during surgery to prevent nausea, but some women are still be nauseous after surgery, especially in the first 24 hours. Painkillers are needed regularly during the first few days, but then can be tapered and taken only at night. Patients take the prescription painkillers for 5 days, on average. Tylenol may be used as an alternative during the day, but patients should take either the prescribed painkiller or Tylenol, but not both simultaneously to avoid too much acetaminophen (Vicodin and Norco contain acetaminophen too).
I see patients in follow-up the day after surgery. The small dressings under each breast are removed. There is a semi-transparent adhesive tape (“Steri-Strips”) that remains in place over the wound. A folded gauze is placed over the incision to protect it from pressure. The bra is then reapplied.
At home, a bra is used both during the day and night for a minimum of 2 weeks, although most patients wear the bra day and night for a month. After the dressings are removed on the day after surgery, women may take a bath and shower. It is okay to get the breasts wet. The small tapes on the incisions usually stay on and there is no need to worry if they come off in the shower. If they come off, it’s okay just to leave them off.
Sometimes patients notice a sound like “sloshing” after surgery. This is caused by a small amount of air in the pocket surrounding the implant. This air gradually dissolves into the tissues and the sloshing goes away on its own.
Should I Massage My Breasts?
In the past, patients have been instructed to massage their breasts in an effort to reduce the risk of capsular contracture, although such a benefit has never been demonstrated scientifically. Most plastic surgeons, including myself, do not recommend massage. I believe it can do more harm than good.
Swelling and Bruising
After surgery, the breasts are swollen and bruised. Almost always, one breast swells and bruises more than the other. This is normal. There may be very little bruising, or the bruising may cover a large area, sometimes all the way down the abdomen. This appearance can be quite dramatic, but normal and nothing to worry about. The bruising results from blood that trickles down under the skin, pulled by gravity. As this blood is absorbed by the body, the bruising goes away, usually within 1 month.
The swelling gradually goes down over a period of about 1 month, too. In patients who had loose skin before the procedure, usually from pregnancy, the early appearance is often very natural. In patients who have not undergone the stretching process from pregnancy, the breasts may feel very tight after surgery. Gradually the skin stretches to accommodate the implants. As the skin stretches, the implants gradually settle. The appearance improves as the breasts become more pendulous, adopting a more natural appearance. The cleavage gradually appears. Excessive, painful swelling and bruising, much more on one side than the other, needs to be brought immediately to the attention of the plastic surgeon, because this may signal the development of a hematoma. When it occurs, this complication almost always happens within the first 12 or 24 hours after surgery.
Patients worry that others will notice right away that they have had a breast augmentation. They are often surprised that friends do not usually notice, particularly in loose-fitting clothing, so that this is not as much of a problem as they expected.
Women may worry at first that their breasts are “huge” and “too high”—this reaction is expected. The envelope gradually expands to accept the implants and the swelling goes down. After 1 month, the swelling is gone and the implants may still be a little high, although this is not objectionable for most patients who enjoy their newfound perkiness. After several months to a year, the breasts tend to settle into a more natural position.
Numbness/ Painful Sensations
In making the incision, small, superficial nerves in the skin are cut and, in making the pocket for the implant, larger nerves are stretched. A major sensory nerve to the nipple comes from the side of the rib cage (lateral branch of the fourth lateral intercostal nerve). This nerve is stretched during surgery. In making the pocket, I use my fingers to tease the muscle off the chest wall on the sides. This way I can feel the deep nerve branches and preserve them.
The skin is numb right after surgery. For the first several hours, this numbness is due to the long-acting local anesthetic (bupivacaine) that was injected into the tissue in the operating room. Later, the sensory nerves send varied signals, such as pain, burning, or extra-sensitivity. These sensations can sometimes be distressing and seem to suggest that something is wrong. It is not uncommon for me to receive anxious calls from patients about these unusual sensations. Gradually, over the course of about 2 months, these uncomfortable feelings subside as the nerves recover.
Patients may feel muscle spasms, usually around the sides of the breasts. These are also a normal and temporary consequence of a submuscular breast augmentation. Patients are often surprised that these feelings are more pronounced on one side than the other (thinking quite reasonably that the discomfort would be similar on both sides), but in fact there is usually more discomfort on one side than the other, just as there may be more bruising and swelling on one side than the other.
Temporary Loss of Feeling
Patients may notice a band they can feel under the skin at the crease under the breast (“inframammary fold”). This is due to some tension from the wound closure and some early normal scarring of the tissues under the skin. It gradually softens.
All women have loss of some feeling in their skin after surgery. This feeling gradually returns as the little nerve branches in the skin regenerate. There may be some loss of feeling in the nipple due to stretching of the nerves, but this is usually temporary and gradually returns. In our survey, only 2% of patients had persistent (2 years or more) loss of sensation of one or both nipples after breast augmentation (Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166). The number of patients reporting loss of nipple erectility was similarly low in our study. There may be loss of the normal reactivity of the nipple to stimulation, but this also gradually returns in almost all women. Sometimes one nipple will “wake up” before the other. Typically, if nipple numbness is experienced (39% of women report at least temporary numbness), normal feeling returns within a few months (2½ months on average).
After surgery, the body gradually forms a capsule around the implant. A benefit of wearing the bra after surgery is that it helps hold the implants in their proper position while the capsule forms during the first couple of weeks after surgery. A sports bra that comes together in front may be used. This is more comfortable than a regular bra because it is difficult at first for most women to reach around their back during the first week after surgery. The bra fits snugly, helping to hold the breasts together, so that the capsules form in the right location, allowing a pleasing cleavage. The cleavage is usually not apparent right away, but as the swelling goes down and the tissues loosen, the cleavage becomes more defined. The bra should not fit too tightly. It should feel comfortable and patients should forget they have it on. The straps should not dig in to the skin. Patients report that they are more comfortable wearing a bra than not wearing one. The pull of gravity can be uncomfortable at first. Even a car ride can be uncomfortable. The bra provides protection and support.
Patients can walk right away after surgery and perform light tasks. However, certain arm movements that involve the pectoral muscles, such as pushing up from bed, fixing hair, or pulling open a heavy door, are going to be sore. Heavy housework, or lifting groceries is to be avoided. Patients can certainly lift a small child if they need to—they are not going to damage anything—but they are likely to be sore and may swell more. Women should have someone around to help with small children for the first 3 or 4 days after surgery.
Prescription painkillers, usually hydrocodone (Norco or Vicodin), are needed during the first several days after surgery, one to two every 4 hours. After several days, when the pain level is reduced, patients gradually start taking acetaminophen (Tylenol), instead of this prescription painkiller, weaning off the stronger narcotic. For example, rather than taking two hydrocodone pills, they may take one hydrocodone and one Tylenol. The advantage is fewer side effects—less nausea, sedation, and constipation. Painkillers should not be taken on an empty stomach. The average duration of pain is 10 days. The average pain level is a moderate 5.4 on a scale of 1 (no pain) to 10 (worst possible pain).
Patients may drive when they are no longer taking prescription painkillers during the day. Our survey found that the average patient starts driving again 5 days after surgery. Most patients who work at office jobs are able to return to work in 1 week. However, those whose jobs are more physical (such as waitresses, nurses, and flight attendants) may require 2 weeks. Patients whose work is very physical (assembly line worker, parcel courier, massage therapist) will need 3 weeks to recover. It is important to remember that the breasts will be sore for at least a month after surgery.
Patients may start cardiovascular workouts 2 weeks after surgery—walking at a fast pace on a treadmill, for example. Between 2 and 4 weeks, activity may be increased. Aerobics may be started at 3 weeks. Unrestricted exercise is permitted at 4weeks. Of course, these are simply guidelines. Every patient is different in their recovery times, and in their ability to withstand discomfort. If the breasts are hurting, or become swollen after exercise, it’s too early. Patients report being “back to normal” at 3½ weeks, on average.
Many women are unaware of subtle existing differences in the shape and size of their breasts. Plastic surgeons point out these differences because patients tend to look more critically at their breasts after surgery. It is common for one breast to be larger than the other. One implant may be inflated slightly more than the other (when using saline-filled implants) to compensate for small differences (<30 cc) in volume. If the asymmetry is greater, exceeding the fill range of a specific implant size, different implant sizes may be used.
How Do Breast Implants Feel?
Breast implants are certainly not a perfect substitute for breast tissue. They do not feel like breast tissue. They are firmer, and can be felt, especially laterally, on the underside of the breast, where they are not covered by the pectoralis muscle.
Sometimes breast implants develop ripples (also called wrinkles) that can be felt or even seen. For this reason, additional inflation of the implant, called overfilling or, more accurately “maximum filling” is done routinely by plastic surgeons to help prevent this problem. Why do ripples happen in the first place? In an effort to make more durable implants that do not rupture, the manufacturers have used thicker envelopes, which can form ripples, even when the implant is maximally filled. Furthermore, in thin women, it is sometimes possible to feel the bump at the site of the valve (these are present in saline implants, not silicone gel implants), even when the implant is under the muscle.
In the past (before 1999), I used textured implants because of their theoretical advantage in reducing the risk of capsular contracture. I now use smooth implants, in hopes of decreasing the likelihood of rippling, which is a problem in implant design that has not yet been solved. However, even a patient with wrinkling is typically a happy patient and would not give up her implants. It also now appears that smooth implants are less likely than textured implants to cause “double capsules” and late seromas (fluid collections).
Breasts naturally fall to the side because of the curvature of the chest wall. Women who have never had large breasts may be surprised that they can now feel the sides of their breasts touching their upper arms. This is normal, and women get used to this new sensation. In fact, it would be abnormal for women not to feel their breasts on the sides. Breasts do not naturally project straight ahead like torpedoes. When a woman lies down, in a bikini on a beach for example, the breasts should naturally settle slightly to the sides. This fullness on the sides helps give a pleasing feminine contour. It balances the curve of the hips. The upper body now complements the lower body.
Part of the purpose of a breast augmentation is to reduce reliance on external devices such as a Wonder-Bra or bra inserts. No woman likes wearing bra inserts; it is much better to achieve cleavage with a regular bra. Most women with larger breasts, whether natural or augmented, will still need a bra for cleavage, because breasts normally settle to the side due to the curved contour of the rib cage.
The area between the breasts is a test of the quality of a breast augmentation. Everyone finds the “half grapefruit stuck to the chest” appearance unnatural. The edges of the implant can be seen, producing an unnatural demarcation around the circumference of the implant. It almost looks as if the breast could be moved around on the chest like a pool ball on a pool table! This non-ideal result is found even in well-known models and actresses. If the implants are placed above the muscle, there will be a flat-bottomed valley between the breasts which rise up like bookends on either side. (See K.N. in “Complications”). Consequently, most plastic surgeons place breast implants under the muscle, to add tissue and to help obscure the implant margins. If the implants are simply placed under the muscle without releasing the muscle, particularly in a thin patient, the distance between the implants will be too great, and it will be difficult to produce a cleavage.
So how do we get a nice cleavage and still have the implant under the muscle? By carefully releasing the pectoral muscle from its attachment to the lower part of the breastbone (sternum). This maneuver allows the pockets that accept the implants to be situated close to each other in the middle, separated by a small valley—a V instead of a U. The right amount of muscle release is the key to an ideal result: Not enough release and the valley is too wide; too much and the breasts unnaturally abut each other in the middle, or some of the cleavage is filled in, a complication called “synmastia” (See L.M. in “Complications”).
Will I Sag More Later on If I Have Implants?
It’s a good question, but unfortunately one without a good answer because no study has evaluated sagging in women with and without implants.
We know that sagging is related to heredity, age, weight of the breasts, pregnancy and substantial weight loss. Among these factors, breast implants affects only one—the weight of the breasts. With additional weight, it would seem reasonable that augmented breasts would sag more with time and gravity. It makes sense that larger implants would cause more sagging because they are heavier. But this is just working from first principles. The trade-off of possibly more sagging needs to be balanced against the “here and now” benefits of a breast augmentation. A breast lift may be performed years from now, and the implants may or may not make this more likely.
Implants do settle with time. This fact is taken into consideration by experienced surgeons in creating the pockets for the implants at the time of surgery. I tell patients to expect the implants to look too big and too high right after surgery. Nevertheless, the usual reaction after surgery is: “Doctor, they are too big and too high!” And my response is: “Give them a few months to settle, and they will be just right.” (See Before and After—Implants Settling Over Time)
Implants Settle With Time
C.C., Age 30, Accountant
Implant Size: 450 cc
Implant Type: Mentor smooth, round, moderate-plus profile, saline
Preop. Bra Size A
Postop. Bra Size: D
Comments: This patient had a small frame and wanted to be a D-cup size. Despite her small size and the fact that her breasts had not been stretched by pregnancy, the desired size was achieved in one operation. The photos demonstrate the tightness of the skin after surgery and the high implant position. Three-and-a-half months after surgery, the skin has relaxed and the implants have settled nicely into position.
Before, 1 month after, 3½ months after
Breast Implants and Pregnancy
Fortunately, saline-filled implants have no known harmful effect on fertility or breast milk. Saline-filled implants do not hold any silicone gel that may ooze into the surrounding tissue, and saline solution is harmless. Reports indicate that even silicone gel implants are safe because of the extremely minute quantities of silicone that gets into the breast milk. Evidently, cow’s milk contains more silicone than human breast milk from women who have silicone gel implants! Breast tissue swells as it engorges with breast milk, regardless of whether an implant is located close by, just behind the pectoral muscle. When the breast tissue shrinks after pregnancy and the completion of breast feeding, the breasts will get smaller, but this reduction will be limited by the implants, so that apparent breast shrinkage will be limited. This is an advantage for women who had implants inserted before their pregnancy.
Of course, waiting to have the surgery until after child-bearing is an option, but this is not medically necessary. Women can enjoy the benefits of their augmentation before, during, and after their child-bearing years.
Breast Implants and Mammograms
Even though they are filled with salt water (“saline”), breast implants still interfere with mammograms by casting a shadow. Nevertheless, it is still possible to perform mammograms with special views. Recommendations for self-examination and mammograms remain the same after augmentation as they did before. If you are due for a mammogram, it is best to have this done before your breast augmentation, so that normal scar tissue after surgery is not a source of confusion to the radiologist.
There are certain outcomes that need to be regarded as unavoidable and acceptable, at least with saline-filled implants available today. For example, slight asymmetry or wrinkling that you can feel is regarded as normal. On the other hand, visible rippling or excessive hardness is unacceptable. If a patient has a result which is almost ideal (for example, one breast looks very slightly higher than the other), it is usually better to accept this imperfection rather than to reoperate. An old adage applies, “Great is the enemy of good.” In other words, the risk and unpredictability of additional surgery may outweigh the marginal improvement that may be possible if everything goes just right and the body heals just the way you want.
Surgeons differ widely as to what level of result is acceptable and what deserves a “redo.” Some surgeons even consider reoperation rates an acknowledgment of failure and tout low reoperation rates as a sign of proficiency. However, all surgeons have suboptimal results and the perfectionistic surgeon will want to do the best he or she can for the patient and this may mean a reoperation—or the prudence of not reoperating.
Indeed, reoperations or touch-ups are a part of cosmetic surgery. They should not be regarded as failures. Patients are generally pleased, but simply need some additional “fine tuning.” Knowing when to reoperate and when not to reoperate comes with experience, and it can be a challenge, even for experienced surgeons. Part of the decision involves the patient’s attitude and expectations. If the patient expects perfection, or has an exaggerated importance placed on relatively small physical details (i.e. “Body Dysmorphic Syndrome”), additional surgery may be unwise.
What Result Is Acceptable and What Is Not?
This determination is largely within the realm of the surgeon’s experience, judgment, and capabilities. There is a wide variation between surgeons. Some surgeons make it a point to almost never reoperate. That may be well and good for the surgeon, but what is the patient to do? Other surgeons, with the best intentions, go back excessively and sometimes regrettably, making a bad situation worse. So it just depends. Most patients are willing to let their surgeon do his or her best to remedy a problem. If they are still unhappy, they are probably best advised to seek a second opinion.