Studies show that one third of all women are dissatisfied with the appearance of their natural breasts.
Can a breast augmentation change this? After a breast augmentation, over 90% of women are satisfied with the appearance of their breasts.
Remarkably, over 90% of women report an improvement in self esteem after breast augmentation. No other cosmetic surgical procedure can match breast augmentation for patient satisfaction. In our survey, the average result rating was 9.3 out of 10 on a scale of 1 to 10 and the median rating was 10, meaning that over half of patients scored their result a perfect 10 (!). Breast augmentation with implants is arguably the most important advance in the history of cosmetic plastic surgery. Not surprisingly, over two million American women have had breast implants. It is also one of the most satisfying procedures for both the patient and surgeon, in its almost magical ability to transform human shape. Gratification is almost immediate. It is an operation that reliably meets expectations and exceeds them in almost half of patients. While rejuvenation of the face and body faces practical limitations, even older women can enjoy youthful looking breasts with the right combination of implants and lifts. No wonder this is a favorite procedure for cosmetic surgeons.
No plastic surgical procedure has received as much public attention, and scrutiny, as breast augmentation.
Breast augmentation decreased in popularity in the early 1990's due to media attention regarding the safety of silicone gel implants, and the 1992 FDA decision to make silicone gel implants unavailable to women desiring cosmetic augmentation (but allowed back on the market in the United States in 2006). Breast augmentation has resumed its place as one of the most popular cosmetic procedures today, recently overtaking liposuction as the most popular cosmetic operation.
The procedure is not perfect and there are problems. However, even when complications are encountered, almost all women are still satisfied with their decision to have the procedure and would do it again. Fortunately, provided there is excellent communication and trust between patient and surgeon, almost all complications can be managed successfully. Very few women decide to have their implants removed and not replaced. These are usually older women who have had their implants removed and a simultaneous breast lift. But even this situation is unusual. Most women of all ages will have replacement implants. To this date, I have never had to tell one of my patients: "I'm sorry. We have to take out your implants and you cannot have replacements."
It is important for the surgeon to try his or her best to reach an acceptable outcome with implants because the alternative, "deflated" breasts, is unattractive. Excellent communication, trust, skill and patience are needed between patient and surgeon because revisions are not without risk, and several procedures may ultimately be required. Like a marriage, the patient-physician relationship is tested when there are problems.
The outcome is different from patient to patient, depending on what is there to start with. Human tissues are not like clay and this is the difference between a sculptor and a plastic surgeon. A plastic surgeon has to work within the limits of real materials (the nature of the skin, existing breast tissue, the shape of the chest, implants). Fortunately, there is a range of breast shapes that are aesthetically pleasing. A breast need not be perfect, and perhaps there is some advantage in not having every woman resemble a BarbieTM doll. Although gross asymmetry is distracting and unappealing, small differences are well-tolerated. Within general guidelines, such as appropriate nipple level on the breast mound, more upper pole fullness than lower, and a tight lower pole, various breast shapes, even slightly pendulous breasts, can be attractive.
Breast augmentation – Usually a One-Way Ticket
Furthermore, most changes are one-way. There is simply no "back button" on the computer to push and get you back to where you were before. A breast augmentation creates irreversible changes by stretching the skin and breast tissue. However, the change is so pleasing that few patients would reconsider their decision. In our own survey, 99% of women would have the surgery again.
Alternatives to breast implants
Photographs – Products marketed that claim to enlarge breasts.
Before coming to see the plastic surgeon, some women consider alternatives to surgery. Many women are understandably nervous about having surgery. It is amazing to see advertisements for creams that are supposed to enlarge the breasts, even in the 21st century. Such creams have no scientific basis for effectiveness. A "BRAVA®" bra was promoted about a decade ago as a means to enlarge the breasts about a cup size. Women would have to wear this cumbersome device for ten hours a day for ten weeks. The concept was that sustained negative pressure to the breasts would enlarge them. It never caught on because of the impracticality of wearing the device and results that were unimpressive.
Fat injection is a more feasible alternative to breast implants. Fat injection has been a valuable addition to our armamentarium in facial rejuvenation and body contouring, such as buttock augmentation. It makes sense to consider using our own fat for breast enlargement. Traditionally, the plastic surgery community has frowned on fat injection for breast augmentation. However, there is little doubt that it works. The problem is that several treatments may be needed. Only limited increases in volume are possible with a single treatment. It is time consuming, and there must be sufficient donor fat tissue available, which can be scarce in thin women. It is likely to be more expensive and time consuming than a single breast augmentation procedure. It would be a more popular treatment if the results from breast augmentation using implants were not so consistently satisfactory. I have found it a useful technique to fill in small breast defects after lumpectomies or after breast reconstruction.
The Desire for Larger Breasts
The desire to have fuller breasts is quite understandable in view of the importance of the breast to a woman's sense of femininity and attractiveness. To deny this is to deny the reality of female form and sexuality. Fortunately, we live in a time when it is possible to safely enlarge breasts, so that women with small breasts need not be at a social disadvantage. With breast implants an option since the mid-1960's, it is hard to imagine a time when this was not available for women who were under-endowed. We live in a time when the "playing field" can be leveled (or perhaps "unleveled") so breast-challenged women can compete.
Women who come to see the plastic surgeon have done so after considerable reflection. There is an element of embarrassment coming to a plastic surgery office and disrobing. Women are already dealing with some guilt about considering such a "self indulgence." Often, they are thinking about how friends and family are going to react. In the back of the mind are horror stories they've read or heard about. It is a wonder they work up the nerve to come in at all! And, yet they do, which shows the strength of the emotional need. In the past, women have endured really awful treatments, such as silicone injections that led to painful lumps ("granulomas"). This was the only option for women who were born just a decade or two too early or in a country without modern standards of practice.
Contrary to popular belief, most women are not having a breast augmentation to satisfy others. Our survey found that 89 percent of women are having the surgery for their own reasons, ten percent for both themselves and an "other," and less than one percent just for the "other." And, it is not a snap decision- they have usually been thinking of it for years. On average, our patients have considered it for five years before having the surgery. Sometimes they have been saving up for a long time, or waiting until the kids are off to college and they feel they can reward themselves. I am reassured by consistently hearing women tell me that their husbands are supportive, but in most cases, not pressuring them to do it- "he loves me whether I do it or not." But, if I want to do it, he's all for it." Of course, the procedure is such that both partners can enjoy the result. Usually, husbands sit quietly and a little timidly in the examining room. - I have never heard a husband object to the concept of larger breasts.
Common Reasons Women Choose Breast Augmentation
Of course, like other areas of cosmetic surgery, I see women who are newly single, due to a marital breakup or death. They are “back on the market.” Women who are divorced, and whose bodies have suffered the effects of childbirth, want to look as attractive as possible, mainly for their own sense of confidence. They are working out, toning their bodies, and this is just one of the self-improvement items on their list.
Some women do not want to have their partner's attention wandering. One patient told me, "I was at the racetrack with my boyfriend, and there was no denying that full-chested women caught his eye. I just don't want to have to deal with it."
Breast Appreciation
A breast augmentation typically improves a woman's sense of femininity, which can boost her own feelings of sexuality. Although the priority for most women is an improved body image, almost half report a positive effect on their romantic life. Their breasts are no longer a source of feelings of inadequacy, but a source of feminine pride and enjoyment. One patient told me after her breast augmentation, "This is how a woman is supposed to look." It is an appreciation she experiences every day, looking in the mirror, putting on clothing, shopping for clothing, wearing an evening gown, and fitting a bathing suit.
IMAGE/TESTIMONIAL: S.F. and Suzanne
Women have told me they have developed a new appreciation of their breasts and have a different attitude after breast augmentation. Many are more open and confident about their sexuality. They may wear clothing that they hadn't considered before. They seem to stand taller and exude more confidence. One of the pleasures of being a plastic surgeon is having these women come back and tell me how delighted they are and what a difference it has made.
Restoring Breast Volume after Pregnancy and Nursing
Many women decide to have their breasts enlarged after losing volume after pregnancy. They enjoyed the enlargement that came with pregnancy and are disappointed to lose it. Many women find their breast size after having children is less than what they had to start with. Ironically, after bearing children, and often breast-feeding, the dubious reward for these maternal duties are shrunken breasts, and, as if that were not enough, a stretched out tummy! I often ask a patient if she liked her breasts more during pregnancy. If the answer is yes (and I don't remember it ever being no), this is a good indication that she is going to be pleased with an augmentation. E.D.'s and J.B's Testimonials
Breast Augmentation and Age
The average age of a woman having a breast augmentation in my practice is 34, with a range of 18 – 71. Traditionally, most women are in their twenties and thirties, but I have noticed a growing number of women having breast augmentations in their forties and fifties.
Undoubtedly, many teenage girls would like to have a breast augmentation, and there is no denying the social pressures. Ours is a society in which, in 1994, Pamela Lee Anderson was the most recognized Canadian in the world, and not because of her acting prowess. Most eighteen year-olds do not have a breast augmentation because they cannot afford it (and their parents find it less important than a college education), and perhaps that is not a bad thing for the time being, until they are sufficiently mature, physically and emotionally.
High Patient Satisfaction Despite Cost
Partly by the process of financial selection, women tend to be in their twenties by the time they arrive in the plastic surgery office. These young women are generally not in a high income category. They are making a sacrifice to have this surgery. It is a sacrifice not to be taken lightly by the surgeon. For many young women, the first question is: "How much does it cost?" A few hundred dollars makes a difference.
I often ask patients after surgery "Are you glad you did it?"
Of course, they are being put on the spot by their plastic surgeon, but I can tell in their spontaneity and enthusiasm and lack of hesitation in their response, that they feel it was worth it. The psychological benefit they will enjoy every day and for years to come compares favorably to discretionary income spent elsewhere.
Women over 50 sometimes ask if they're too old for a breast augmentation. Of course, there is no real age limit and the results of breast augmentation are appreciated by patients of all ages. In fact, our capabilities of breast rejuvenation, which may include a breast lift in patients with sagging, compare favorably to results from other body contouring surgery, where we often have to settle for skin laxity and cellulite that cannot be completely corrected using presently available techniques. We may as well take advantage of superior results where we can get them. Youthful looking breasts can help compensate for aging elsewhere.
Breast Asymmetry
In fact, about half of women who present for breast augmentation have breasts which are asymmetrical in size and about half have nipples that are at different levels. Including asymmetry in the shape of the chest, nipple/areola size, and level of the crease under the breast, 88% of women have asymmetrical breasts before surgery! Women are often unaware how common this is. We have all seen women's breasts portrayed in the visual media in various poses and amount of cover. But, most of us are not in the habit of critically inspecting large numbers of naked, unretouched women's breasts. And, I am at a loss to think of anybody who is in such a habit, apart from a medical doctor or mammographer!
Breast Asymmetry
As part of the examination, plastic surgeons look for asymmetry before surgery. One reason we do this is to bring any existing asymmetry to the patient's attention. She may have never noticed it before. But, she will look more closely at her breasts after surgery and, unless she knows about it beforehand, she may notice for the first time that one nipple is slightly lower or higher, or points outward more, than the other.
Nipples naturally point slightly outward due to the curved contour of the chest. A breast augmentation will not change this. It will not alter nipple placement on the skin. Sometimes, an optical illusion is created after surgery by the low position of the nipple on the breast mound - it appears that the implant is too high, when in fact the implant is correctly positioned on the chest, but the nipple is too low. Patients wonder, "Can't you just put the implant lower?" But to lower the implant in such a situation, would make the whole breast appear too low. It would sit lower on the chest, look unnatural and would displace the natural crease under the breast ("inframammary crease") downward. The implant has to be in the right position for the breast, not for the nipple. The logical way to correct a lowered nipple position is to elevate the nipple with the saggy lower breast tissue, and a breast lift is the operation that does this. Women cannot expect breast implants alone to significantly raise the nipple position on the breast.
Breast Volume
The final breast volume represents a combination of the breast tissue that is there to start with, plus the implant, which explains why two women with the same size implants may have different breast sizes. The implant simply fills out the breast envelope, so that characteristics of the breast (amount of existing breast tissue, nipple size and position) remain unchanged. With saline-filled implants, size asymmetry may be reduced by simply adding more fluid, or using a slightly larger implant, or both, on the smaller side. The prevalence of existing volume asymmetry explains why the implant volumes are often not identical in the patients shown in this section. Of course, any small size discrepancy is minimized anyway as the volume of both breasts is increased by the presence of the implants.
Perfect symmetry is virtually impossible and, fortunately, unnecessary to get an ideal result- one that is very pleasing to both the patient and her surgeon.
Breast Augmentation in Asymmetrical Breasts
In patients with greater degrees of asymmetry, the breast "envelope" is tighter on the smaller breast and looser on the larger one. The nipple on the larger breast is lower and the areola is usually larger, because the nipple and areola are part of the same expanded ectodermal appendage that forms the breast. We need to use a larger implant on the smaller side to help correct the size discrepancy. Ideally, we would like to take up the slack more on the larger side, which tends to be saggier, but we have to use a smaller implant (so this side is not too big) on the larger side. A small implant does not take up much slack in the breast tissue, so the nipple will remain lower on the larger side. This explains why a breast augmentation will not correct significant asymmetry in which one breast is significantly larger and saggier than the other. In this situation, a simultaneous breast lift is usually the better option. This way, the breast envelope can be tightened as necessary. The nipples can be more symmetrically placed at the same level and the areolae can be reduced to provide a better match.
In most cases, however, a mild degree of asymmetry does not bother women enough to have the additional scars that come with a breast lift. It is unusual for me to perform a breast lift on just one side. Usually, it is better to do it on both breasts. The breasts and nipples appear more symmetrical this way, because a lifted nipple looks different from a natural one. The border of the areola, which has been incised with a scalpel, is more distinct than a natural areolar border. It does not fade away into the surrounding skin like a natural areola. Better to have matching areolae. Additionally, many women, whose nipple is low enough on one side to justify a breast lift, benefit from having both breasts lifted anyway because even the smaller breast is a little saggy.
See patients with asymmetry S.S. and B.S.
Sagging Breasts (Ptosis)
You might think that breast implants would help take up the slack of the breast and correct sagging. The nipples would rise back up as the breast volume is restored. However, measurements show that the nipple level does not change significantly after breast augmentation. Although implants help fill out the upper poles, they are of limited benefit for the lower poles, where the extra breast tissue persists. Because of this limitation, breast implants alone will not overcome significant sagging. Of course, what constitutes "significant" sagging is the question. I explain to patients that the effect of the implants in providing lift will "never be as great as she would like it to be." Many women accept this and are not overly concerned about it. They may say: "Well, I'm not trying to look like I'm eighteen anyway. But, I would like to look good in clothing." Or, "I can wear a bra for that." For other patients, who do place importance on perky breasts, correction of sagging is a priority and we proceed to discuss the breast lift procedure.
IMAGES/CASE STUDIES:
Breast sagging, Hispanic: T.S.
Breast augmentation (Sagging): N.B.
Breast augmentation (Stretched Out): W.B.
Breast sagging, Asian: T.H.
Breast sagging, Black (Combined Makeover): G.B.
