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Breast Augmentation

What is breast augmentation?

Breast augmentation involves using breast implants to increase the size and improve the shape of the breasts.

Who seeks breast augmentation?

Breast augmentation is desired by women who wish to enhance their breasts because they are too small, or by women who have lost breast volume and shape after pregnancy and breast feeding. (Fig. 1)

breastfig01
(Fig. 1)

Silicone or saline?

Silicone breast implants are the preferred choice of implant material, as they look and feel more natural compared to the alternative, saline implants. Silicone implants are safe, and do not increase the risk of breast cancer or other diseases.

What kind of silicone implants?

Dr Huang uses high quality, current generation silicone breast implants from the U.S. These implants contain silicone gel that is highly cohesive, meaning that they retain their shape well in the long term (i.e. they are form stable). The fact that the silicone is a gel and not a liquid also means that in the extremely unlikely event of rupture of the implant shell, the silicone gel will not leak out of the implant. The implant will therefore not lose any volume or shape. Thus, implant rupture, a rare event in any case, will have no adverse consequences.

Round or anatomical?

Silicone breast implants are available in two basic designs: round and anatomical. The round implant is shaped like a dome, equally full in its upper and lower parts (poles). The anatomical implant is shaped like a tear drop, less full in its upper pole and more full in its lower pole. (Fig. 2)

breastfig02
(Fig. 2)

The round implant tends to produce additional fullness in the upper pole of the breast that a natural breast does not have. (Fig. 3)

breastfig03
(Fig. 3)

On the other hand, the anatomical implant is shaped more like a natural breast, therefore it produces a natural profile in the upper pole of the breast without excessive fullness. Most of the fullness is in the lower pole of the breast, just like in a natural breast. (Fig. 4)

breastfig04
(Fig. 4)

Therefore, Dr Huang recommends anatomical implants for patients who want the most natural looking result. As most of his patients fall into this category, he uses anatomical implants in the majority of patients.

In fact, in recent years, breast augmentation has undergone a paradigm shift with the emphasis now on shape rather than just volume, thanks to the availability of the tear drop shaped anatomical silicone implant.

Anatomical implants have given an unprecedented degree of versatility, because for each size (volume), there is a wide range of shapes available. Three dimensions determine the shape of the implant: width, height, and projection. Each of these parameters can be varied so that the implants selected can be highly customized for each patient according to her own unique breast and chest wall anatomy. Furthermore, this versatility allows us to correct asymmetries between right and left sides much more effectively than before. (Fig. 5)

breastfig05
(Fig. 5)

Dr Huang uses high quality Natrelle anatomical breast implants from Allergan. Please visit the Natrelle website below for information on these implants. Note that these implants come with a lifetime warranty for defects and wear and tear.

http://www.natrelle.com

How do we decide on size and shape?

Preoperative planning and implant selection are key steps in determining a successful outcome. In this detailed process, your chest and breasts will be carefully examined qualitatively and quantitatively. Several key dimensions of your chest and breasts will be measured. (Fig. 6)

breastfig06
(Fig. 6)

Based on these measurements as well as your own desires in terms of bra cup size, Dr Huang will select the most suitable design and size of anatomical implant so that your breasts will be enhanced with a natural looking shape and an appropriate volume, and will be proportionate to the rest of your body. You will then get to try on these implants by placing them in your bra and evaluating your appearance the mirror. This helps you to decide if you are comfortable with the implant size and shape that has been selected.

What about Vectra?

Vectra is an advanced three dimensional breast imaging system that photographically captures your breast images, then produces new images to show what your breasts will look like with different sets of implants selected by you and your plastic surgeon. This allows us to compare different choices of implant (different sizes and shapes) before deciding which pair of implants is preferred. Vectra therefore performs virtual surgery on your breasts and shows you the virtual results to help you with your decision making.

 Breast Augmentation VECTRA X3 BreastSculptor Capture RGB Breast Augmentation X3 oblique-1-LoRz-RGB

Vectra is thus a very useful virtual tool to help us decide on the choice of implant, and it complements the physical sizing process using real implants.

How do we use these implants?

Surgical technique is the next important process in producing an optimal result. Anatomical implants are actually more demanding to use, since their specific shape dictates that they must be positioned correctly and this correct position must be maintained postoperatively. To ensure this, Dr Huang creates a precise pocket of space for the implant that matches the width and height of the chosen implant, so that the implant will fit tightly like a hand in a glove, with no room to move out of position. In addition, the surface of the implant shell is textured, making it rough, not smooth. This prevents the implant from becoming slippery and helps to ensure that it does not rotate into the wrong position.

Which incision is best? (Fig. 7)

breastfig07
(Fig. 7)

To achieve this degree of surgical precision, it is best to perform the operation through an inframammary incision, made in the crease just below the breast where it joins the chest. This allows easy and direct surgical access so that an accurately dimensioned implant pocket, which is key to the successful use of the anatomical implant, can be created.

The underarm incision (the trans-axillary approach) is too distant from the breast, making it difficult to achieve this level of surgical precision.

The periareoalar approach (incision around the areola) affords good  access, but it results in some milk ducts being cut in the process. This has two adverse consequences. First, this may compromise future breast feeding. Second, it releases bacteria that reside in the milk ducts, causing contamination of the implant. While the level of bacterial contamination is too low to cause infection, it will cause some degree of inflammation, which increases the risk of capsular contracture (see below).

For all of the above reasons, the infra-mammary incision remains the incision of choice for Dr Huang.

Above the muscle or below the muscle? (Fig. 8)

breastfig08
(Fig. 8)

Breast implants can be placed under the breast and on top of the pectoralis major muscle of the chest wall, (Fig. 9)

breastfig09
(Fig. 9)

or they can be placed under the muscle. (Fig. 10)

breastfig10
(Fig. 10)

Placing them under the muscle provides additional tissue padding over the implants, and helps to make the implant margins less obvious. This is especially useful in the upper inner part of the breast, where the patient’s own tissues are often thin.

However, placing the implant totally under the muscle has a significant disadvantage. This muscle, which is very strong, will gradually pull the implant upwards and outwards as it contracts, causing the implant to sit too high up on the chest and too far out to the side. The breast will then look too full in its upper pole and its shape will be distorted.

Therefore, Dr Huang prefers to place the implants partly under the muscle and partly under the breast. This is known as the dual plane approach. (Fig. 11)

breastfig11
(Fig. 11)

They are placed under the muscle in the upper inner area and under the breast in the lower outer area. This provides muscle padding for the implant in the area that needs it most (the thin upper inner zone), but avoids muscle coverage elsewhere (where it is not needed anyway), so that the muscle cannot pull the implant out of position.

What is the operation like?

The operation takes about 1.5 hours. It is done under total intravenous anesthesia (a short acting general anesthesia) as a day surgery procedure with quick post-anesthesia recovery. The surgical dissection is carried out cleanly and accurately with great attention to technical detail, and bleeding is meticulously controlled. No surgical drains are used. The inframammary incision is closed using specific stitching techniques that maximize the chance of a fine scar.

What is the recovery like?

Postoperative pain is mild and well controlled with oral pain medication. Bruising and swelling are also mild, and are reduced by appropriate medications and a special recovery device that is worn on the chest. Normal activities can be resumed within one or two days. Downtime from work is usually two or three days. A compression band is worn around the upper chest above the breasts for the first one to two weeks. This helps to reduce swelling and keeps the implants in the correct position. The stitches are removed after two weeks.

A proactive scar management program is then commenced to ensure the best possible scar. Bras are avoided for the first one month so as not to push the implants upwards and allow them sufficient time to stabilize in the correct position. Exercise can be restarted after one month, but strenuous upper body exercise should be avoided for three months.

How often will I need checkups?

Postoperative care by Dr Huang’s nurses and will be attentive and detailed and checkups by Dr Huang will be frequent. Typically, reviews are scheduled on the second postoperative day, at the end of the first week, then weekly till the end of the first month. Thereafter, reviews are scheduled very two weeks till the end of the second month, then at three months postoperatively. Subsequently, reviews are carried out every three months till the end of the first year. The interval is then increased to six months till the end of the second year, after which reviews become yearly.

If the patient is a foreigner who can only stay in Singapore for a limited time, the schedule for postoperative reviews is modified accordingly, and her recovery is monitored long distance through email communication and photos taken of the patient at appropriate intervals and sent to Dr Huang for review.

What are the risks and complications?

The risks of surgical complications such as bleeding and infection are extremely low. The main long term risk is capsular contracture. This refers to hardening and distortion of the implant caused by thickening and contraction of the capsule of scar tissue that normally forms around it. Anything that causes inflammation, such as the presence of blood or bacterial contamination can cause thickening of the capsule and therefore increase the risk of capsular contracture. If it occurs, the aesthetic result is compromised, and further surgery may be required to correct it. However, it is not a dangerous complication. The risk of capsular contracture in Dr Huang’s practice is less than one percent. This very low incidence is due to his careful surgical technique and the textured, form stable implants that he uses.

There is also a small risk of losing some nipple sensation. This is due to the fact that the sensory nerves of the nipple can sometimes get in the way of the surgical dissection when the implant pocket is being created. Most of the time, however, any sensory loss that occurs is temporary.

Finally, there is a very low risk of a complication known as a delayed seroma. A seroma is a collection of fluid known as serum that partly surrounds the implant and is produced by the inner surface of the capsule. Serum is a clear yellowish fluid that is actually blood without the red blood cells. A delayed seroma can occur as a rare and late complication many months or years after breast augmentation, most likely as a result of significant blunt trauma (e.g. blunt traumatic impact to the breast, extremely vigorous exercise, or extremely rough handling of the breast). The breast becomes swollen and firmer as a result of this fluid. The diagnosis is confirmed on ultrasound examination. Treatment is rest and anti-inflammatory drugs. The seroma usually subsides with this treatment.

Do I need to replace the implants after many years?

While the high quality breast implants used by Dr Huang are not promoted as being lifetime devices, as long as there is no capsular contracture, it is not necessary to replace the implants after a certain number of years. Therefore, the implants can usually remain in your body indefinitely.

Can I still do breast screening examinations?

After the surgery, the breasts can still be screened with ultrasound scans and mammograms.

Will I still be able to breast feed after breast augmentation?

Breast feeding is still possible after breast augmentation because the milk glands and mild ducts are not damaged by the procedure.

Summary

Breast augmentation is one of the most sought after cosmetic operations by women who desire breast enhancement. Dr Huang uses careful, measurement based preoperative planning to select the most suitable high quality anatomical breast implant for you based on your existing chest and breast dimensions as well as your own desires. He carries out the procedure meticulously and with great attention to technical detail using advanced surgical techniques and the inframammary dual plane approach. Postoperative care is equally detailed, attentive and proactive to ensure a smooth, pain free and quick recovery. His ultimate goal is to deliver to his patients a high quality, natural looking aesthetic result with a high level of safety and low complication rates.

Who can perform breast augmentation?

According to the Singapore Medical Council (SMC), only plastic surgeons are allowed by regulations to perform breast augmentation. This regulation is found the SMC’s Guidelines for Aesthetic Practices for Doctors, which can be accessed in the link below:

Download PDF

But some general surgeons are offering and performing breast augmentation…

Yes, that is true. Therefore, patients need to be aware that this practice violates the SMC’s guidelines.

Why are these doctors able to continue to offer and perform this procedure if they are not allowed to?

Because of inadequate enforcement of regulations to ensure compliance of these regulations by doctors.

How do I tell if the doctor offering breast augmentation is a plastic surgeon or a non-plastic surgeon?

The safest way is for you to verify this yourself by checking if the doctor in question is on the list of recognized specialists on the Ministry of Health’s website (see link below):

http://mservices.moh.gov.sg/eservices/doctorSearch.do

You can perform this search according the doctor’ name or search by specialty. Either way, you will be able to determine if the doctor is a plastic surgeon or not.

If your search reveals that the doctor is a plastic surgeon, you can be assured that your doctor is a bona fide specialist in plastic surgery. Otherwise, he or she is not, no matter what appearances may otherwise suggest.

International recognition

Dr Huang was one of the first plastic surgeons in Singapore to acquire the advanced surgical techniques required for using these implants in 2007. He learned them directly from Dr Charles Randquist, an eminent plastic surgeon from Sweden who has developed methods and techniques to produce outstanding results using anatomical implants. Dr Randquist in turn was mentored by renowned U.S. plastic surgeon John Tebbets, who is known as the original guru of the anatomical implant.

Since that time, Dr Huang has accumulated a significant experience with these implants, and they are now the preferred choice of breast implant for him and his patients. He is a key opinion leader in this field, and his work with anatomical breast implants has received international recognition. This is reflected in his role as a founding board member of the Allergan Asia Council of Breast Esthetics (AACE) together with Dr Randquist. In addition, he is a sought after speaker on breast augmentation using anatomical implants and has given invited presentations on this subject in plastic surgery professional meetings across Asia, in such countries as Korea, China and Japan, as well as South East Asia. At some of these meetings, Dr Huang has worked closely with Dr Randquist in presenting his own work that validates the benefits of the Randquist techniques. In Asia, Dr Huang has been one of the most visible and vocal proponents of Dr Randquist’s philosophies and methods.

Please visit Dr Randquist’s website below to see before and after photos of Dr Randquist’s breast augmentation patients using the same anatomical implants and performed with the same technique that Dr Huang has adopted from Dr Randquist.

http://www.victoriakliniken.com/en

You can therefore be assured that you will be in the expert hands of an internationally recognized expert as his breast augmentation patient. This will be true whether you are an Asian or a Caucasian patient, as Dr Huang has a large experience with both groups of patients, and is intimately familiar with the racial differences in tissue quality that make a difference.

Cosmetic Surgery Clinic