Breast augmentation continues to be the most popular and frequently performed aesthetic surgery and has been since 2006, according to the American Society of Plastic Surgeons (ASPS). Similarly, in Texas, breast enhancement surgery is the top cosmetic surgical procedure and has a long and successful track record in satisfying women who wish to enhance, regain or restore balance to their figures.

 

Most of the consistently popularity of breast augmentation is due to technological innovations and improvements in procedural techniques, which resulted in the myriad of options available nowadays to women looking to add volume to their chest. Dr. De La Cruz's practice is based on the philosophy that every patient is unique. Therefore, depending on their medical history, body shape and aesthetic goals, there are two main choices Dr. De La Cruz typically discuss with breast augmentation patients: silicone implants and saline implants.           

Silicone Breast Implants

Silicone implants were used in 87% of all breast augmentations in America in 2017 and are the leading option among Dr. De La Cruz's patients. There are two principal categories of silicone implants: silicone gel-filled breast implants, and cohesive gel silicone gel-filled breast implants. The traditional silicone gel-filled breast implants are filled with soft, elastic gel and are available in a wide range of shapes, sizes and profiles, making them quite appealing and convenient to many of my patients.     

 

 

 

 

 

 

 

An alternative classification of silicone implants are filled with a cohesive gel made of cross-linked molecules of silicone, which makes them thicker and firmer than traditional silicone implants. These innovative prosthetic implants are denominated cohesive gel silicone-gel filled breast implants, and are commonly known as "gummy bear" implants. Although more costly than their conventional counterparts, patients tend to like gummy bear implants due to their tendency to have a superior natural look and feel and because risks of complications, like capsular contracture and gel migration in the case of implant rupture, are considerable reduced. One downside to consider while choosing breast is that all silicone-gel prosthesis are pre-filled and may require a longer incision for implant placement.

 

Saline Breast Implants

Saline-filled implants rank second in popularity among women who opt for a breast enhancing procedure. Saline prosthesis may be sub-divided in two main categories. The first group, traditional saline-filled breast implants, are filled with sterile salt water. They may be prefilled at a predetermined size, or filled at the time of surgery to allow for minor modifications. The second classification of saline implants are the fairly new FDA-approved structured saline-filled breast implants, available in the U.S since 2015. These implants are also filled with sterile water, but contain a structure inside so they behave as if filled with soft, elastic silicone. This structure enables them to hold their shape better than traditional saline implants. Although saline implants are not as popular as their silicone competitors, the former appeal to certain women due to the faculty to customize the sizing on a fairly pinpointed scale. Furthermore, in the case of a potential implant shell rupture, saline breast implants wouldn't pose a risk as significant as silicone-gel implants, since they would release only salt water into the patient's body. 

 

 

Dual Plane Breast Augmentation 

One of the most important decisions prior to a breast augmentation procedure with implants is the selection of the breast implant pocket. In this respect, Dr. De La Cruz favors Dual-Plane over both Partial Submuscular (under the muscle) and Subglandular (above the pectoralis muscle of the chest) breast augmentation, because Dual-Plane placement allows for a more natural appearance while keeping the benefits of having the muscle cover the implant. There is also a reduced tendency for the breast implant to ride high, as well as a reduced tendency for the implant to lateralize.

 

Among the disadvantages of placing the implant over the muscle (subglandularly) are the following: 1) Implant palpability may occur when the patient’s breast soft tissues are very thin; thus, it is vital to assess the soft tissue of the breast before deciding to place the implant subglandularly, and 2) There’s a higher risk of seeing ripples especially with saline breast implants and capsular contracture (almost 1 in 4 women).

On the other hand, under the muscle implant placement is typically more painful, have a significant risk of double-bubble or snoopy deformity of the breast, and it’s associated with a longer period of recovery, and more post-operative discomfort.

 

Breast Augmentations Incisions

Incisions can be made in one of four places, during a breast augmentation procedure:

  • Inframammary: underneath the breast, just above the crease.

  • Transaxillary: Near the armpit, where the arm meets the chest area.

  • Periareolar: Around the lower edge of the areola (the dark area surrounding the nipple).

  • Transumbilical: in the navel.​​

Dr. De La Cruz typically places the incision inframmmary to reduce the risk for capsular contracture, minimize scars visibility and to use the Dua-Planel breast augmentation technique. Furthermore, he employs the “no-touch technique” breast implant placement, which offers among its many advantages to involve a smaller incision (ranging from 2.5cm to 3.0cm). The smaller the incision, the smaller the scar and the lesser risk of infection. Also, it minimizes the risk of implant coming out of the wound (implant extrusion) and reduces postoperative pain and, consequently, provides a faster recovery.

 

Choosing a Breast Implant Size

With regards to size, the maximum implant size recommended would depend on the base diameter of your breasts which will be measured by Dr. De La Cruz during your initial consultation. Going beyond the recommended size based on your breast parameters is associated with higher risk of complications, including poor scarring, bleeding, breast sagginess, implant mal position, thinning of the overlying breast tissue, rippling, palpability, and implant exposure and extrusion.

It is important that your plastic surgeon provide you with a sizing exam using breast implant sizers which can be placed into a sports bra so you can see how various sizes will look.

 

Although there is no accurate rule for a one cup size increase, some plastic surgeons give a rule of thumb of 150cc to 200cc per bra cup size increase. There are multiple factors influencing the actual size increase an implant will provide other than volume, including:

Although there is no accurate rule for a one cup size increase, some plastic surgeons give a rule of thumb of 150cc to 200cc per bra cup size increase. There are multiple factors influencing the actual size increase an implant will provide other than volume, including:

  • The implant profile (projection) and base width,

  • The implant shape (classic round, teardrop shaped, extra upper pole fullness, for instance),

  • How much natural breast tissue patients have,

  • The width and contour of patients' rib cage,

  • Their natural breast shape and dimensions.

Post-operative care to speed up breast augmentation recovery

  • Get plenty of rest after breast augmentation procedure. Patients need to sleep on their back with the head elevated and torso inclined over 45 degrees as if they were sleeping on a recliner. While in bed you are encouraged to move your feet to increase the circulation in your legs.

  • Start walking as soon as possible, as this helps to reduce swelling and lowers the chance of blood clots. Walk as much as you can around the house with assistance from an adult. 

  • Wear compression leg stockings  (above the knee) daily for up to 4 weeks to reduce your risk of deep venous thrombosis. 

  • Take your antibiotic medication as prescribed by Dr. De La Cruz to prevent the development of any infection and analgesics to control post-operative discomfort.   

  • Protect your bed sheets from bloody drainage. A small amount of bloody drainage is normal. 

  • The support bra may be washed on the gentle cycle and air-dried as needed. While this is being done please stay off your feet and minimize activity. 

  • Patients nay shower 72 hours after surgery. Wash all incisions gently with Hibiclens or any other similar antibacterial soap and water. 

  • Do not remove the white tape (steri-strips) on your incisions. The steri-strips placed during surgery will protect the incisions and may be left open to the air after your post-surgical dressing is removed. Your incisions do not required any routine care such as the placement of dressings or ointment. Please do not clean your incisions with Hydrogen Peroxide.

  • The skin sutures are dissolvable and do not need to be removed. 

  • Begin taking liquids slowly and progress to soups or JELL-O(R). You can resume a high protein diet for two weeks, the next day after breast augmentation procedure. Avoid salt intake as it will keep you swollen.

  • For the first 48 hours, keep your movements to a quiet level. No lifting greater than 5 lbs. for 6 weeks. Refrain from pulling or pushing anything that causes pain, There should be no strenuous exercises or activities for 6 weeks after breast augmentation surgery. 

  • Continue taking vitamins. You may take iron supplements if you feel fatigued. 

  • Do not drive until you are no longer taking any pain medications and you have full range of motion with your arms. You may drive one week after your breast augmentation procedure provided you are comfortable enough to stop in an emergency situation. 

  • Do not drink alcohol when taking pain medications. Do not smoke, as smoking delays healing and increases the risk of complications. 

  • Avoid exposing scars to the sun at least 12 months after breast augmentation. If sun exposure is unavoidable, make sure to use a sunblock of SPF 30 or greater. Sun exposure can cause permanent discoloration of the scars. 

  • Keep your incisions clean and inspect daily for signs of infection. Some of the common symptoms of surgical site infection are: redness and pain around the area treated, drainage of cloudy fluid from the surgical wound, and fever above 100.4 F. 

  • Avoid swimming or tub soaking when you have wounds that are still open since these wounds can get infected caused by Vibrio bacteria.  

  • Resume desk-type employment and regular activities, one week after breast augmentation. You may be instructed by Dr. De La Cruz to expect a longer recovery time before you return to a physically demanding job such as  

   

     

Potential Breast Augmentation Complications

 

As with every surgery, there are some risks associated with breast augmentation with implants (both silicone and saline implants). A highly trained and skilled plastic surgeon as Dr. De La Cruz will inform you about the potential complications before performing a breast augmentation procedure and will help you diminish the risk of those complications.

The most common adverse outcomes include capsular contracture (hardening of breast area around the implant), reoperation (additional surgeries), implant removal and deflation or rupture of the implant. It is always in Dr. De La Cruz best interest to make sure all post-operative issues are handled quickly. Therefore, he give all post-op patients his cell phone number so he can communicate immediately if any problems or concerns arise.

 

Capsular Contracture after Breast Augmentation 

 

Hardening of the breast (capsular contracture) is one of the more common problems with breast implants, with clinically significant rates reported at 15-45%. The earlier you seek treatment for this issue, the better. Capsular contracture is actually caused by the body reacting to foreign substance of the implant. It forms scar tissue around the implant, squeezing it. Once this occurs, the implant no longer has leeway to move around naturally, and instead it is fixed into place by the scar tissue. This is not only painful for the patient, but it also causes the breasts to look very unnatural or disfigured. Since every case is different, Dr. De La Cruz recommends consulting with an experienced plastic surgeon to get a proper diagnosis and treatment.

It should be noted that saline implants have a lower rate of capsular contracture than silicone gel-filled implants, and that the risk of capsular contracture is significantly reduced with Dual-Plane breast augmentation and the “No-touch-technique” implant placement that Dr. De La Cruz uses during breast augmentation. With subglandular (over the muscle) implant placement there’s a higher risk of capsular contracture (almost 1 in 4 women). Other factors that may increase the risk of developing capsular contracture include: post-surgical complications like hematoma (broken blood vessels under the skin), seroma (collection of fluid under the skin) and bacterial infection.

Management of Seroma (fluids collection) 

 

Seromas are a collection of fluids around the implant. These complications can cause swelling, pain and bruising after breast augmentation surgery. Most seromas heal naturally since they are usually reabsorbed into the body within a month. In more severe cases, it can take up to a year for them to be reabsorbed, or they can form a capsule and remain until they are removed surgically. Depending on the severity, a seroma may have to be drained more than once. Heat can be applied to the area to help the seromas heal more quickly. A heating pad or hot compress can be applied for about 15 minutes every few hours. Doing so would help with fluid drainage while providing additional comfort to the incision area. However, if the area is sore, warm, red, or swollen, Dr. De La Cruz recommends consulting with an experienced plastic surgeon promptly. Seromas can increase the chances of a surgical site infection, so it is very important to monitor them carefully. 

Minimizing the Risk of Infections 

Infection, which can occur after any surgery, is devastating when it follows a breast augmentation operation.  If after breast augmentation surgery an infection develops, it might require hospitalization and intravenous antibiotics. More important, an infected implant almost always requires removal of the breast implant. Months (or in some cases years) afterwards, a new implant can be placed. During that time, your breast asymmetry will be awkward. You will feel uncomfortable both physically and emotionally. The implant position and the incision site may influence your risk of infection. Implants placed under the muscle have a slightly lower rate of infection than those placed over the muscle. Similarly, implants placed through an inframammary incision (the incision placement preferred by Dr. De La Cruz) have a lower rate of infection compared to implants placed through an areolar, transaxillar or transumbilical incision.

Plastic surgeons have different post-operative protocols, customized for every patient to prevent post-operative complications and achieve the best results. Dr. De La Cruz typically recommends the following care measures to his patients in order to prevent infections:

  • Take the antibiotics medication as prescribed to prevent the development of any infection, and analgesics to control post-operative discomfort.

  • The support bra may be washed on the gentle cycle and air-dried as needed. You may shower 72 hours after surgery. Wash all incisions gently with Hibiclens or any other similar antibacterial soap and water.

  • Do not remove the white tape (steri-strips) on your incisions. The steri-strips placed during surgery will protect the incisions and may be left open to the air after your post-surgical dressing is removed.

  • Your incisions do not require any routine care such as the placement of dressings or ointment. Please, do not clean your incisions with Hydrogen Peroxide.

  • Do not apply hot or warm compresses to any of the surgical areas.

  • Some itching of the healing wound is expected, but avoid scratching the incisions. 

  • Keep your incisions clean and inspect daily for signs of infection. Some of the common symptoms of surgical site infection are: redness and pain around the area treated, drainage of cloudy fluid from the surgical wound, and fever (above 100.4 F).

  • No tub soaking while sutures are in place. It's typically recommended to avoid swimming or being in a bath tub (at least for 6 weeks) when you have wounds that are still open since these wounds can get infected caused by Vibrio bacteria.

  • Contact Dr. De La Cruz promptly if you notice an increase in swelling, pain, redness, drainage, or bleeding in the surgical area, or if you develop fever (above 100.4 F), dizziness, nausea, or vomiting.

Breast Sensitivity after Breast Augmentation

After breast augmentation with implants, patients may experience some loss of sensation in their nipple and breast area. This results from damage to nerve endings in the breast and nipple. The ratio of sensory loss from breast augmentation is 5-10% with the inframammary fold incision being the least (lowest) ratio of nipple sensation loss. Dr. De La Cruz favors the inframammary fold incision to prevent post-operative complications such as loss of sensation, capsular contracture and visible scarring. This loss of sensation may be temporary or permanent. It may affect sexual response or breast feeding. Certain breast augmentation techniques may confer a higher risk of this complication than others. Plastic surgeons can determine the most appropriate implant type and surgical technique to reduce patients risk of this breast sensitivity side effect. 

Breast Implant Revision Surgery 

Over time, even the most successfully placed implants may rupture or leak, and should be replaced. Typically, both silicone and saline breast implants last between ten and fifteen years. After the estimated implants' useful time has expired, breast revision surgery will typically become necessary in order to maintain volume and shape. Also, many breast implants have a lifetime warranty on the actual implant device, but after ten years the costs associated with having surgery to replace the implants are no longer covered. Because of this, many patients benefit from choosing to replace or update their breast implants at or around the 10-year time frame. 

Moreover, some of our patients had breasts implants before they have started conceiving and now, after having children, their breast might be saggy, or smaller or they have gain some weight and they don't want the implants anymore. As time goes by women's bodies change around the implants and breast revision surgery is the best option to recover a youthful breast contour. Patients self-confidence, as well as their breast's well-being and appearance will profit from having an opportune breast implant and replacement surgery. 

Breast implant revision surgery should be performed by an aesthetic plastic surgeon who is well-trained and experienced in all different kinds of breast surgery as Dr. De La Cruz and who will listen to the patients' desires and expectations, since this surgery is not a standard procedure and requires to be customized to fit patients' cosmetic goals and particular needs. Among the most common reasons why Dr. De La Cruz patients opt for breast implant revision surgery are the following:   

  • Saline breast implants have deflated or an X-ray or MRI suggests that silicone implant has a shell leak, 

  • Desire to change their implant/breast size, 

  • Pain from capsular contracture (tightening of the scar tissue around the implant) or concern about rupture or migration of implant, 

  • Breast tissue has changed as a result of skin stretching, or weight loss or gain, 

  • Change from saline to silicone implants, or different style of implant. 

 

The exact surgical procedure for breast implant and replacement varies depending on the particular reason for breast revision. Usually, the procedure to either replace or remove implants is more comfortable than the initial breast augmentation surgery, and the downtime is relatively short. Nonetheless, the amount of post-operative discomfort depends mostly on whether the scar tissue is removed along with the implant. Dr. De La Cruz patients typically return to work and their normal daily activities within a week after revisionary breast surgery. Healing will continue for several weeks as swelling decreases. For a successful recovery, patients should follow closely Dr. De La Cruz post-operative instructions and attend their follow-up visits as scheduled. 

Ruptured Breast Implants Treatment 

When a silicone gel-filled implant ruptures, patients may notice a decrease in breast size, change in breast implant shape, hard lumps over the implant or chest area, an uneven appearance of the breasts, pain or tenderness, tingling, swelling, numbness, burning, or changes in sensation. Ruptures that show symptoms usually happen outside of the capsule. However, some ruptures are called “silent ruptures.” A silent rupture doesn’t change the way an implant looks or feels to a woman because the rupture occurs within the capsule. Silent ruptures are not usually evident by a physical examination by a physician. Magnetic resonance imaging (MRI) is the most effective method for detecting silent rupture of silicone gel-filled breast implants. The U.S Food and Drug Administration (FDA) recommends MRI at 3 years after implantation and every 2 years after that to screen for rupture. Silicone gel that leaks outside the capsule surrounding the implant may travel (migrate) away from the breast. The leaked silicone gel may cause lumps to form in the breast or in other tissue, most often the chest wall, armpit or arm. It may be difficult or impossible to remove silicone gel that has traveled to other parts of the body. The FDA recommends removing both saline-filled and silicone gel-filled breast implants if they have ruptured. You and your plastic surgeon will need to decide whether or not your implant has ruptured and if you should have it replaced or removed without replacement.    

 

 

Small Risk of Lymphoma Associated with Textured Breast Implants

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a T-cell lymphoma that can develop following breast implants. ALCL is a type of non-Hodgkin's lymphoma, a cancer of the cells of the immune system. It can occur in many different parts of the body, including the lymph nodes and skin. Even though BIA-ALCL is found in the breasts of some individuals with breast implants, it is not breast cancer. Considering the many thousands of breast augmentation with implant procedures that are performed every year in America (300, 378 in 2017), the compiled data issue by the US Food and Drug Administration (FDA) show that there is a small risk of developing lymphoma. Approximately, 3 in 100 million women per year in the United States are diagnosed with ALCL in the breast, according to the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Because the risk of ALCL appears very small, FDA-approved breast implants continue to be considered safe and effective when used as labeled. Despite the likelihood that Dr. De La Cruz may never encounter a patient with this disease, he feels the responsibility to educate himself and fully inform his patients about the potential risks of lymphomas associated with breast implants.         

Up to date, there is no certainty about the specific cause-and-effect relationship between breast implants and ALCL. Most data comprised in medical device reports submitted to the FDA and published on September 2017 suggests that BIA-ALCL occurs more frequently following implantation of breast implants with textured surfaces rather than those with smooth surfaces. Currently, it is not possible to identify a type of implant (silicone versus saline) or a reason for implant (reconstruction versus aesthetic augmentation) associated with a smaller or greater risk. Half of the reported cases were diagnosed within 7-8 years post-implantation. Moreover, more patients were diagnosed when they sought medical treatment for implant-related symptoms such as persistent seromas, capsular contractures, or peri-implant masses warranting breast implant revision operations. In each case, lymphoma cells were found in the effusion fluid (seroma) surrounding the implant, in the fibrous capsule into the breast parenchyma. Because BIA-ALC has generally only been identified in patients with late onset of symptoms such as pain, lumps, swelling, or breast asymmetry, prophylactic breast implant removal in patients without signs or symptoms is not recommended. 

Dr. De La Cruz always emphasizes to his patients the importance of returning for follow-up visits since plastic surgeons may be the specialist most knowledgeable about this rare disease process as well as the person most appropriate to coordinate the necessary evaluation and treatment. If you have ALCL around a breast implant, your plastic surgeon will discuss the best treatment options with you. The type of treatment depends on several factors, including: type of ALCL. stage of the disease, location of the cancer, your age and general status, among other cases. In many cases, surgical treatment by itself is sufficient to treat implant-associated ALCL. The main purpose of surgery for implant-associated ALCL is to remove the cancer and any inciting antigen that may be present stimulating the lymphoma. In cancers that are more difficult to treat, additional therapy such as chemotherapy or targeted agents may be required. Fortunately, BIA-ALCL tends to remain confined around the breast implant and most patients have a god prognosis when they receive the appropriate treatment. 

 

   

Contact Us!

Emmanuel De La Cruz MD, PLLC

» Contact Dr. De La Cruz today for more information by calling 832.520.1844

 

 

 

 

 

 

Figure 1: Before and After Dual-Plane breast augmentation performed by Dr. De La Cruz

Figure 2: Traditional silicone gel-filled breast implants.

Figure 3: Before and After Dual-Plane breast augmentation performed by Dr. De La Cruz. 

Figure 4: Before and After breast augmentation revision surgery to correct synmastia, performed by Dr. De La Cruz. 

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The Woodlands Clinic (North Houston)

2219 Sawdust Road Unit 1203  The Woodlands, TX

77380

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15016 FM 529 Road

Houston, TX 77094

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