Breast Augmentation

How I Like to Do It 

   How I evaluate your breasts   

When I evaluate you, I will take two measurements that will help me determine what breast implant you will need to get the shape and size you are requesting.

First, I'll measure the distance from the notch at the base of your neck to the your nipple.
( see the red lines below )

  I know that the best distance is 17 - 20 centimeters (7 - 8 inches). This distance is usually found in A cup and small B cup breasts.  If your breast fits this measurement, then a submuscular implant (under the muscle) will be best for you.

As the nipple position gets lower, say 21 centimeters (8 1/4 inches), most women can still have the implant placed submuscular.

However, if your nipple position has dropped to 22 - 23 centimeters (8 1/4 - 9 1/4 inches), I might suggest you have either a subglandular Breast Augmentation (on top the muscle) or a submuscular or subglandular Breast Augmentation combined with a Crescent Lift to raise your nipple position

The second measurement I will take is the diameter of your breast ( width between the yellow lines )

Most breasts measure between 11 to 15 centimeters in diameter.  The breast looks more natural when I use an implant diameter that is similar to or slightly less than that of your natural breast.  Breast implants come in different volumes, such as 250cc or 425cc.  The larger the volume, the wider the implant.  A large volume may mean the implant diameter is to wide for you.

Let me give you an example of what I mean.  You come into my office requesting a D cup and upon examination I find your own breast measures 12 centimeters across.  To enlarge your breast to a D cup I determine I need a 475cc breast implant volume.  But because this implant is 15 centimeters in diameter, it is too big for your 12 centimeter diameter breast.

Too large of an implant can overstretch the skin and lead to bottoming out (see description below), where your breast implant seems to fall out from under your breast.  Sometimes with the skin stretching the implant can bulge into the arm pit or ride upward towards the shoulders ( high riding implant ).  Any of these scenarios can lead to a very unnatural look.

As an alternative, if you have a small breast diameter, breast implants come in narrow shapes, such as a Mentor Moderate Plus or High Profile (see description below). These narrower diameter implants will me to give you a bigger cup size.  However, in some women these implants can also take on an unnatural appearance.

Of course, if your diameter is wide, such as 15 centimeters, there is no problem using larger implants.  In general, I like the standard profile, round breast implants and reserve the narrow implants for specific circumstances.

Submuscular or Subglandular: Which is best for me?

This is the most understood concept about Breast Augmentation.
Women will come to my office requesting submuscular (under the muscle) implant placement without knowing why and whether it is appropriate for them.  If you are seeking beautiful breasts in addition to larger breasts, then sometimes it is better to place the implant subglandular (on top the muscle).

Submuscular (under the muscle)
I will place your breast implants under the muscle if your natural breast and nipple measurements are high.  An example of this would be; if you have small breasts, say an A or B cup, almost no looseness, with a nipple distance of 19 centimeters (described above)

Submuscular placement will provide you with the following advantages:

• This additional layer to cover the implant makes it less likely to see or feel the implant.

• Submuscular implants make it easier to read a mammogram for breast cancer detection.

• During normal activities the contraction of the muscle massages the implant, which can help keep the breasts softer after a Breast Augmentation.

Subglandular (on top of the muscle)
If you are a little older, heavier, had children and your breast tissue has sagged to the bottom of your breast, you may need a subglandular breast implant placement. Because your Pectoralis muscle is located high on your chest, if the breast implant is placed under your muscle it will not be low enough to shape you properly. This can result in your natural breast rolling off and falling below the implant, pushing your nipple downward. Sometimes this is called a double bubble. An example would be: if you have a small C cup, 10 pounds heavier than you want to be, with a nipple distance of 22cm.described above 

Subglandular placement will provide you with the following advantages:

• Give you a better shape than submuscular if you fit the criteria described above.

• Subglandular can help even out your breast shape more than submuscular if your breasts sag.

• You will have less pain and easier recovery.

• You may be able to avoid a full Breast Lift (Mastopexy), by placing the implant subglandular.

I frequently combine this with a Crescent Lift, as a good alternative to you getting a full Breast Lift.

TUBA or belly button incision: My thoughts!

The TUBA technique is done by making an incision in the belly button and inserting a long dissecting rod under the skin. Once the breast is reached, a pocket is made for the implant.  Through a long tube a saline breast implant is inserted and inflated.


Problems with the belly button (TUBA) incision include:

• A thick scar may develop in the belly button and be visible when wearing a bikini.

• Visible rippling of the abdominal skin may develop from passing the dissector rod under the skin.

• It is more difficult to position the implant properly under the breast with this incision.

• Testing different sizes to see which look better on you is not done through this incision.

• Silicone implants cannot be inserted through this incision.

Instead, I would suggest a Transaxillary (arm pit) approach, if you do not want an incision on your breast.

Smooth or textured implant surface: What implant surface I like to use?

For Subglandular - Textured coating:  Generally, I use the textured coating which is designed to adhere to the implant capsule and inhibit the capsular contraction (hardening of the tissue around the implant).

For Submuscular - Smooth coating:  I like to use smooth implants because they move around in the implant pocket and are less likely to be visible.  Textured coating is unnecessary because the contraction of the muscle massages the breast implant and helps to keep it soft. Smooth implants also last longer than textured implants.

I like to replace ruptured textured implants that are subglandular with new smooth surface implants.   I won't have to use textured implants again because the implant capsule has already formed.

Different shaped implants: Which shape is best for me?

Teardrop, Anatomical and Contour:  These are some of the names given to implants that were designed to create a more mature or sloping look at the top of the breast.  I rarely use these implants because once inserted under the muscle they don't seem to maintain that sloped look and don't appear as natural looking as the round implants. 

Round or Standard:  These implants look the most natural and I use these most of the time.

Size: What is the best size for my body?

The most common requested cup size is a C.    However, if you are a petite woman or a large woman, than a full B cup or D cup respectively, may produce a more natural look.

What I like to do is first hear what shape and cup size you are looking for and then describe what implant I need to use to give you the best results.

Breast diameter: Mine is small, I want to be rather full.  What can I do?

Both saline and silicone Mentor brand breast implants now come in several profiles; moderate, moderate plus and high.  If you take each breast implant profile with the same volume (e.g. 300cc) and set them all on a table next to each other, you would notice that the moderate profile breast implant is the widest and lowest and that the high profile breast implant is the narrowest and tallest.  The moderate plus profile breast implant falls in between the other two. 

If you have a small diameter breast and ask for a bigger cup size, than I may need to use one of these narrower implants. 

Large breasts: I have them and still want breast implants?
 

If you have larger breasts, say a full C or D cup and you want to be a larger cup size, it is very common to need shaping first (see my Breast Lift and Breast Reduction pages to determine this). That's because large breasts usually have fallen, lost support and have very wide diameters. These combined features are not ideal for using breast implants.

Here are some options if you have fairly large breasts and what implants: 

Probably the best choice in most cases is to do the Breast Lift first, before placing an implant under the breast at a later date.  That is because implants will be under yours breasts pushing them outward.  If you have poor shaped breasts to begin with and get implants, you will have poor shaped breasts that a bigger.

Sometimes after a Breast Lift, the shape is so great, some women opt not to get implants at all.

Another option is to perform a Breast Lift, while placing an implant at the same time. 

I would only suggest this if you have a great deal of loose skin.

 

Lastly, sometimes I suggest a Breast Reduction first.  If your own breast in rather large, heavy with very projection outward, then a Breast reduction will remove this non-supportive tissue and shape you.  This is followed months later by a Breast Augmentation to build the breast back up to a bigger cup size.

This procedure is particularly advantageous if you have rather large and wide breasts.

Safety: Are breast implants safe?

All breast implants have a silicone outer shell and some type of filler.  The filler material is either saline used in intravenous solutions or silicone gel. 

Although there has been much controversy about silicone gel, current studies do not demonstrate a causal relationship between silicone and diseases such as Rheumatoid Arthritis or cancer.  The FDA released silicone implants for general use in November of 2006, after years of restrictions and further testing.

Saline or Silicone - What are the pros and cons of each type?

Silicone:

• Tends to be softer and more natural in feel and appearance.
• Costs more money, but tends to last longer.
• More difficult to replace if there is a rupture of the outer shell.
• Can provide less fullness at the top of the breast, for women who like a more sloped look.
• Should be inserted through an incision large enough to avoid fracturing the gel.

Saline:

• Adjustable, which especially valuable in those women with two different size breasts.
• Very easy to replace if the implant deflates or ruptures.
• Easier to see the breast when performing a mammogram.
• Can be inserted through any incisions

What about Silicone breast implants and Gummy Bear breast implants?

The silicone gel breast implant is different now, then prior to 1990.  That is because the gel is cohesive, rather than liquid.  Cohesive gel breast implants are semi-solid and range in viscosity from a soft pliable gel to a very gummy consistency. The most widely used Cohesive Gel breast implants are Mentor Corporation's Memory Gel implant and Inamed Corporation's Matrix filled Silicone implant.   I like to use either of these two companies because they have been manufacturing breast implants for many years.

Gummy Bear breast implants, marketed by Silimed is their form of Cohesive Gel breast implants.  This company does not yet have FDA approval to use their breast implants in the USA.  So you have to be enrolled in an experimental study.  This implant may ultimately be approved or rejected for use for women in the USA.  I don't like the name, because who would want the hardness of a Gummy Bear in a breast implant.

We all know that a Gummy Bear doesn't change shape no matter if it stands on end or lies down.  Not the ideal quality to have under your breast.

So think Cohesive, (not Gummy Bear), which makes the gel stay together while allowing the breast implant to change shape when you change positions.  Having seen many experimental breast implants come and go over the years due to poor quality and high rupture rate.

I will continue to use either Mentor's Memory Gel or Inamed's Matrix Silicone filled gel breast implants.

Cohesive Memory Gel Silicone breast implants, what should I know?

These gel implants tend to feel softer and more natural than saline breast implants. 

These gel implants differ from the earlier generation silicone breast implants, because they do not leak if the breast implant shell is ruptured.

Because they are jello like in consistency, on rare occasions a piece of this gel can break off inside the implant and show as a visible indentation on your breast.

Breast feeding: Is it possible after breast implants ?

The answer for you is most likely. However, some women are unable to breast feed after having an enlargement.

I do think it is best not to get a periareolar incision if you are thinking about breast feeding, because this incision requires more cutting of ductal breast tissue needed during milk distribution.

Mammogram: What will happen ?

Most of the time breast implants make it slightly more difficult to read a mammogram.  Saline implants are easier for the radiologist to interpret your mammogram, because they block the x-ray less than silicone.

In some women who are very flat, a breast implant will actually aid in performing a mammogram by allowing the x-ray unit to hold, compress and position the breast better.

I may have you get a screening mammogram prior to a breast augmentation, generally around 35 years of age.  After surgery it may take up to 6 months before the effects of surgery will allow for an accurate reading of a mammogram.

Rupture: Why does this happen?

Implant failure or deflation can result from the following: normal wear and tear as the implant folds on itself with movement of the body.

Failure of the valve to hold the saline in the breast implant shell.

Trauma or injury to the breast and compression during a mammogram.

Capsular contraction: What is it ?

After placement of an implant, your body will form a barrier around the implant called a capsule.  This natural tissue is your bodies normal response to breast augmentation.   If the capsule stays soft and pliable, your breast implants will feel soft to touch.  If the capsule tightens a little, your breast implants may feel a little firmer to you, while still maintaining a good shape.  Severe tightening of the capsule, is most often associated with the term "capsular contraction" and can lead to distortion of breast shape and hardness to touch.

The good and bad of varying degrees of capsular tightness:

• Sometimes it is beneficial to have a little capsular tightness, even though it may feel a little firmer. Some of the women like how it creates more fullness in the upper breast.

• Severe capsular contraction can make the breast shape distorted or too round and unnatural looking, requiring additional surgery.

Treatment of severe capsular contraction:

• Surgical release (capsulotomy) or removal of the capsule (capsulectomy) around the breast implant.

• Accolate - an asthma drug which can be effective in treating capsular contraction following a capsulotomy or capsulectomy. This drug should be taken for 6 months.

Rippling: What is rippling and how does it happen?

Rippling or visible waves in the breast skin can happen on rare occasions.  This rippling is caused by the implant folding as you move or lean forward.  If you are extremely thin and have very little breast tissue to cover the implant when it is folding, you have a greater chance of developing rippling.

Ways to minimize rippling:

• Smooth implants, unlike textured implants move around in the breast pocket and are less likely to show a visible fold.

• Overfilling saline implants helps to avoid implant folding.

• Submuscular placement:   This extra layer of coverage over the implant may also help to hide the implant folds.

• Silicone implants have a thicker inner core and are less likely to be visible.

Double bubble: What is it?

A double bubble is seen when the implant is placed under the muscle in sagging breast.  The breast tissue rolls off the top of the implant and implant is seen as a bulge under the natural breast at the very bottom. Sometimes accepting a small double bubble is a reasonable compromise, if you do not want to have additional scars from a Breast Lift.

   Ways to minimize a double bubble:

• A subglandular (on top the muscle) placement may avoid this

• A Breast Lift first, with good shaping, followed a few months later with a breast implant.

• Sometimes a sub-pectoral placement with 1/2 the implant under the muscle will avoid this.

Synmastia (One Boob look): How does it happen?

Synmastia, sometimes call Uni-Boob is the result of trying to gain cleavage by moving the implants close together.  The implants should never be placed on top of the sternum or breast bone, which results in the skin being lifted off of the bone and creating this condition.

   Way to avoid Synmastia:

• If your breasts are wide apart or you have a wide sternum, you will have to be accepting of the fact that the implants cannot be placed close together.

Bottoming out: Tell me about it?

Bottoming out of the breasts is when the implants stretches out the skin too much.  This results in the implant looking too low on the chest and the nipple being pushed too far up on the breast mound.

   Ways to avoid bottoming out of a breast implant:

• Do not request larger implants than your body can handle.

• Sometimes going under the muscle can help.

• This is not always preventable.

5 Things you must know prior to a Breast Augmentation - by Dr. Costanzo

You must know:

• The Doctor

I rank this as number 1, because picking the right Plastic Surgeon will assure you a great outcome and happy results.

Some tips on getting to the right Breast Augmentation surgeon are:  Ask around, I've found the best referrals come from nurses who work with different doctors and can compare their surgical skills.

Also, make sure your Breast Augmentation surgeon is Board Certified by the American Board of Plastic Surgery.  Most persons don’t realize that there is "NO" recognized Board Certification for Cosmetic Surgery by the American Board of Medical Specialties or the State of California.  This is important, because only Plastic Surgeons certified by the American Board of Plastic Surgery learn how to perform Breast Augmentation surgery while in hospital residency training prior to starting private practice.

An additional factor to help find the right Plastic Surgeon is to inquiry of about length of time in practice.  An experienced surgeon is a valuable asset.

• If you need a Breast Lift

This is important because breast implants look the best if you have good shape to your breasts.  If your breasts have stretched out or fallen, then a shaping lift may be necessary before or at the same time as a Breast Augmentation.  Go to the Breast Lift page on my website for information on the Breast Lift.

• What size and shape implant is right for you

The more detailed in your discussion with me, the easier it is for me to match the breast implant size and shape to your new look.  Specific things I find important include, a cup size, whether you want to be on the fuller or smaller side and photos of women who have already had Breast Augmentation.

• Whether the implant should be placed subglandular or submuscular

If your nipple position is high and your breasts have not stretched out, then I will place the implant under the muscle. This places an additional layer over the implant to reduce visibility.  However, if your breasts have dropped somewhat, your skin is loose and you are not very thin, then I will place the implants on top of the muscle.  This subglandular placement of the implant may mean you can avoid a Breast Lift.

• What type of implant, saline or silicone is right for you
  
  Here are some of the differences:

Saline implants have the following advantages; lower cost, ease of replacement, less interference with a mammogram reading and the most important of all, overfill and adjustability.  Overfill means I can add more saline if you're petite and want more fullness. Adjustability on the other hand gives me the ability to add more saline to one implant, if one of your breasts is smaller that the other.

Silicone implants have these advantages; softer and more natural feel, less chance of visibility of the implant edge and better durability.  Silicone implants on average last longer than saline implants.

Thousand Oaks Breast Augmentation and Breast Enhancement, Saline Breast Implant, Silicone Breast Implant, Cohesive Silicone Memory, Gel Breast Implant, Gummy Bear Implant - TUBA Incision Thousand Oaks Breast Augmentation, Beverly Hills, Los Angeles, Calabasas, Ventura, Santa Barbara by Thousand Oaks Board Certified Plastic Surgeon Dr Costanzo. Mayo Clinic trained and Board Certified in Plastic Surgery in 1987, Christopher Costanzo MD performs Cosmetic Surgery and Breast Augmentation Beverly Hills Style for patients in California, serving Thousand Oaks, Beverly Hills, Los Angeles, Calabasas, Ventura, Santa Barbara, Encino, Sherman Oaks, Tarzana, Chatsworth, Canoga Park, Granada Hills, Woodland Hills, West Hills, Malibu, Agoura, Oxnard, Moorpark, Simi Valley, Camarillo, Westlake Village, Los Angeles County, Ventura County and Santa Barbara County. View Beverly Hills Style Breast Augmentations with Breast Implants