Breast Augmentation in Louisville, Lexington, Kentucky

I have been doing “Quick Recovery Breast Augmentation” and “No-Touch” techniques for placing implants during breast augmentation for 25 years. The recovery phase of a breast enlargement has more to do with the talent and philosophy of the surgeon than any other factor. The breast augmentation method that I perform on my patients has evolved over time. We know that if less blunt tearing of tissues is accomplished, and only sharp electric dividing of the space needed to accommodate the implant is used, then the amount of bleeding and swelling are reduced, thus making the recovery less painful. I have used a forceps electrocautery device for 20 years that allows for grasping and coagulation of small blood vessels prior to dividing them so that no blood enters the space where the implant will be placed. This has significantly reduced bruising, pain, and recovery for my patients. Using ultrasound guidance, after you are asleep, I now place a long-acting numbing medicine to relax the pectoralis major muscle, resulting in fewer spasms and pain in the early postoperative phase.

BLOG: Quick Recovery Breast Augmentation 

The philosophy of the surgeon also matters a lot. I do not believe in placing a lot of restrictions on lifting, bathing, stretching, or the wearing of fancy post-surgical bras. None of these modalities are based on solid scientific principles. If a muscle is sore, resting it makes sense, but immobilizing it makes for more stiffness. We tell our patients to stretch their pectoralis muscle but don’t exercise to the point where extra blood flow will add to the swelling of the area.

I place a waterproof dressing over the small incision and allow for immediate bathing. The incisions are almost completely sealed off from the outside for 24 hours. I do not believe in custom post-op bras. If the pocket is made correctly, no bra is necessary to immobilize the implant. If the implant is improperly immobilized by a poorly fitting bra, however, it may not allow the implant to access the bottom of the pocket as the pectoralis relaxes and gravity allows the implant to drop. This can lead to a high-riding implant. We tell our patients that the recovery is one to two days and that they can return to regular activities within a week. Most people go back to work in a few days.

The “No-Touch” technique helps in reducing possible contamination of the implant and the pocket during the procedure. The premise is that small amounts of bacteria that live in the ducts of the breast can gain access to the fluid that naturally occurs around an implant and form into a biofilm. In this biofilm state, these bacteria can cause more inflammation to the naturally-occurring scar that forms around an implant. We call this capsular contraction. Some foreign bodies, like the powder on surgical gloves, have likewise been implicated in being causative of capsular contracture.

For these reasons, it seems prudent to me to lessen the contact of the implant and the skin, and prevent glove powder from touching the implant prior to its placement in the pocket. I will glue a plastic-wrap-like dressing over the prepped area of the incision in the crease so that the implant never touches the skin while it is being placed. We use the Keller Funnel to help place silicone gel implants through the areolar approach into the pocket. This funnel-shaped, lubricated sac allows for the smooth introduction of the implant into the pocket, reducing stress on the shell wall and completely isolating the implant from the skin. Glove powder is removed before touching the implant as well. By utilizing these “No Touch” techniques in breast augmentation, I can offer my patients a rapid return to daily activities and a nice, soft, and natural result.

The surveillance of silicone gel breast implants is important, since routine mammography and physical examination may not be able to detect a small tear in the implant shell. Due to the very cohesive nature of the newer silicone gels, this “broken” implant may not leak gel very far away from the shell. The mainstay of evaluating breast augmentation patients for the integrity of their silicone gel implants has been MRI. These studies are recommended by the FDA at three years after surgery and every two years after that. At a cost of $1500 to $2500, this seems unreasonable to me, especially since the chance of finding a broken implant when nothing else seems wrong is less than 1%. We have been using diagnostic ultrasound for over four years now in an attempt to help patients avoid this costly exam.

I participated in the FDA-approval studies for two of the three brands of silicone gel implants in the United States, and we had access to the MRI cohort of patients that we had operated on. These patients were randomly selected to have an MRI study at a set interval of time. I was then able, on the day before or the morning of the MRI, to do the ultrasound study in the office. I’m proud to say that the correlation of my ultrasound findings was 100% to that of the MRI. In my hands with ultrasound technology, the chance that the implant has been correctly identified as being ruptured has been extremely high. For our patients, there is no cost to having a breast ultrasound, and it takes less than five minutes to complete. If patients are worried, have car accidents, falls, or experience trauma to the chest wall, it has been quite a relief for them to know, in a very short amount of time, that everything’s okay with their implant. Very few plastic surgeons in the US have embraced this in-office ultrasound technology. I believe, over the next 3 to 5 years, this will be the mainstay of surveillance.

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Indications

Smaller than desired breasts. One breast is noticeably smaller than the other. Breasts have lost volume after weight changes or childbearing.

BLOG: Thinking about a Breast Augmentation by Dr. Salzman

Intended Results

Larger and more shapely breasts. A more confident and positive self-image. More proportional body shape.

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Consultation

There are many choices in breast enlargement, and we believe it is important to be given all of the options at the time of consultation. There are saline and gel implants, as well as expandable implants and shaped implants. The gel implants come in different consistencies with smooth or textured surfaces. The placement of the incision can also be in numerous locations. We take these considerations, as well as the preoperative state of the breast, the size of the patient, her desires, and activity levels, and address all of these at each and every consult.

BLOG: Breast Ultrasound

Using Vectra 3D computer imaging, we can show the result that will be both pleasing to the patient and achievable surgically. This is a truly customized approach for each individual patient. Dr. Salzman’s surgery technique is likewise different than most. Having done thousands of breast enlargement procedures, he has been able to streamline these operations to allow an easier recovery for his patients. There is very little blunt tearing of tissues since all separating of tissues is done with an electric forceps. We find that under-the-muscle patients can get back to regular activities in just a few days. We don’t put a lot of restrictions on what our patients can and cannot do. We also don’t place large constrictive bandages. We only place a small Band-Aid-type dressing that is waterproof and will allow for bathing right away. There are questions that seem to come up a lot during consultation for breast augmentation and we can address those here.

 

Types of Breast Implants

Today there are many types of breast implants. We will summarize each below:

SALINE IMPLANTS:

The saline implant has a rubberized silicone shell and is filled in the operating room with sterile salt water. It has some advantages over the gel-filled devices. Because the implant comes with no volume in it, the amount of fill volume can be customized to the patient’s individual needs during the implant placement. Breasts that are different sizes can then be made more symmetric by adding different amounts of saline to each implant. Saline implants, because they are filled with salt water, feel less breast-like than silicone, are shorter lasting and wrinkle more than their silicone counterparts. They cost less than silicone implants. They can be placed more easily through remote incision sites like the underarm or belly-button. Learn more about saline implants.

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SILICONE GEL IMPLANTS:

Silicone breast implants are the most studied implantable medical devices on the planet. Multiple peer-reviewed journal articles have attested to their overall safety and lack of correlation in causing systemic diseases. The American Society of Plastic Surgeons provides this FDA data on the website breastimplantsafety.org. Silicone implants have the advantage of feeling more breast-like, being less prone to wrinkling, lasting longer, and providing more upper breast fill than a properly-filled saline implant. The silicone breast implant comes pre-filled. No adjustments in the operating room can be made. However, using the precision analysis of the Vectra™3D computer imaging, as well as the experience and keen eye of a skilled and experienced plastic surgeon, good symmetry can usually be obtained. Silicone implants, when using larger sizes, may necessitate a slightly longer incision. Silicone implants have a higher cost than saline implants. Learn more about silicone breast implants.

GUMMY BEAR IMPLANTS:

This term is confusing to most people. Plastic surgeons refer to this implant as “form stable,” meaning that even if the shell were stripped away from the silicone filling, the shape of the silicone filling would remain. These are usually shaped implants. The shaped implants, rather than being round, have different height, width, and projection ratios. For instance, the implant can be moderate in height, moderate in width, and extra projecting. Three different heights, widths, and projections are possible for the same volume of the implant. Dr. Salzman was involved in the FDA trials of this implant (style 410 Inamed) and has used it extensively in his practice. It is not presently available for free and unrestricted use. All silicone gel implants today contain a “cohesive gel.” Unlike the gel implants of the ’70s and ’80s, these newer implants have a thicker gel and are sometimes known as “gummy bear” implants.

TEXTURED IMPLANTS:

Textured implants mean that the shell of the implant feels rough. Several manufacturing methods are used to create this surface texture. The reasoning behind using these textured implants is that they may be more resistant to capsular contracture, or hardening of the scar tissue that naturally occurs around a breast implant. With the older implants of the ’70s and ’80s, where the gel inside was runnier and could leak out of the implant, it was thought that this textured surface could resist the formation of a capsule better than a smooth surface implant. With the newer forms of gel implants, and with most implants placed below the muscle where there is natural movement of the implant, the textured surface is unnecessary. Textured implants feel stiffer and, when filled with saline, have a higher rupture rate than their smooth-shelled counterparts.

SMOOTH IMPLANTS:

The smooth implant shell is just that: smooth in feel. It feels better than textured shells, wrinkles less, and lasts longer, particularly in saline-filled devices.

 

FDA APPROVES THE USE OF SILICONE GEL IMPLANTS

Dr. Salzman has performed thousands of successful breast augmentations in his 20+ years of private practice. During the FDA moratorium on the use of silicone breast implants, Dr. Salzman was one of a few select plastic surgeons in the US to be authorized to use the new silicone gel implants. He was chosen by both Allergan and Silimed as a lead investigator for the pilot study of these new implants prior to their FDA approval. In November of 2006, the FDA reinstated the approval of silicone breast implants, declaring that they are safe and effective for women aged 22 and older. Silicone gel breast implants are a wonderful alternative to saline and offer a much more natural look and feel.

Procedure Description

Breast enlargement is performed in an outpatient setting under a general laryngeal mask with adjuvant local anesthesia. During the procedure, which takes less than an hour, an incision is made either on the breast or in the underarm, and a breast implant is placed either below or on top of the pectoralis muscle. The separation of the space (pocket) is completed with electric cautery forceps to facilitate healing and make for a smoother recovery. We sit the patient up in the operating room after both implants are in place and make any adjustments necessary to achieve the best symmetry. The incisions are closed with absorbable sutures hidden under the skin. A small dressing is placed and the patient goes home.

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Recuperation and Healing

Breast augmentation patients can have mild to moderate discomfort that lasts several days. Pain is controlled with oral medications, and muscle relaxers are given if the implant is placed below the muscle. We ask that the patient either wear no bra, an athletic bra, or the bra that we will supply for the first few weeks. No underwire bra should be worn for 6 weeks. Under-the-muscle implants will appear high on the chest wall for a few weeks before they drop into the proper location in the pocket. Patients may shower the next day. Most patients with non-physical jobs may return to work in a few days.

Other Options

Another option if the breasts are droopy and low on the chest wall is a breast lift (mastopexy). There are several different types of breast lifts that can be done with an implant placement at the same time.

Incision Options

Learn more about the different types of incision options for breast augmentation.

Note

The specific risks and suitability of this procedure for a given patient can be determined only at a consultation. All surgical procedures have some degree of risk. Minor complications that do not affect the outcome occur occasionally. Major complications are unusual.

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