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Breast Augmentation in Northern Virginia -Fairfax VA and Manassas VA

How to Achieve a Natural Look
Breast Implant Size
Silicone or Saline?
Above or Below the Muscle?
Scar Location
How we Minimize Breast Augmentation Complications
Dr. Bitar's articles on Breast Augmentation

How to Achieve a Natural Look

Breasts are the ageless sign of femininity and sex appeal. Breast augmentation is now done in ways that accentuate the natural healthy look and minimize the "done" look. Small breasts can be enlarged with saline or silicone breast implants placed under the chest muscle to create nice cleavage and give it a natural, sexy look and feel. The key to achieving a natural look is by choosing the right size implant, proper implant type, proper incision location, and proper implant placement. We will try to address some of the issues that a patient faces when looking to have breast implants. We understand that every patient is unique, and we have a wide variety of options from implant type, to scar placement to different sizes to individualize the procedure to the patient's wishes. It all starts with the initial consultation.

The Initial Consultation

An initial consultation is set-up with Dr. Bitar one of our Northern Virginia breast augmentation centers to discuss the breast augmentation procedure and to decide whether you are a good candidate for the surgery. Your medical history is reviewed and you will be asked to see your medical doctor for a physical check-up and a few labs to make sure you can undergo the surgery safely. You are given the opportunity to be seen by your own doctor to give the green light for surgery. You are given the opportunity to talk to patients who have had the same surgery you are considering. You are seen by Dr. Bitar shortly after the surgery (in a day or two usually). You are given garments, and complimentary scar management tape and cream when appropriate, all free of charge, to enhance your recuperation. You are seen regularly after your surgery. You are always welcome to come back for follow-up, even years after your surgery, free of charge.

Breast Implant Size

The decision of implant size can be a stressful decision for a woman choosing to have breast augmentation. The way to decide can be simplified and made stress-free.

In the initial consult, patient is asked to place a known sized silicone breast implants in her bra and wear a shirt that would reveal her silhouette clearly. The patient gets to try on different size implants until she finds the size she likes. We offer our patients the option to try sizes again on the second consultation. Usually they come up with either the same size or a very close size to the one of the initial consultation.

Huge implant sizes can be aesthetically unpleasant and create a higher chance of problems and complications in the future. Conversely, if a patient chooses a size that is too small, then the patient will come back asking for a bigger size implant. Therefore I encourage my patients to choose implants in the range of 150-400 cc's (325 cc's being the volume of a regular can of Coke), with exceptions in certain situations.

In the vast majority of patients, their decision on size choice turns out to be perfect!

Breast Asymmetry or Unevenness

Very rarely are a woman's breasts perfectly even, or symmetrical. Sometimes, the lack of symmetry can cause a woman to be distressed, adding prosthetic implants in her bra to achieve symmetry. This is a common situation that women do not like to discuss. The solution is straight-forward. If a woman with uneven breasts seeks a breast augmentation, it is simple to fill one breast implant more than the other to make the breasts as symmetrical as possible. Sometimes a breast augmentation is performed on one breast and a breast augmentation and lift, or a breast lift alone, or even a breast reduction is performed on the opposite breast simultaneously. The treatment plan is agreed upon during the consultation.

Silicone or Saline

The FDA has recently approved the cohesive gel silicone breast implants. I have experience with both silicone and breast implant operations, and have written a research article on silicone breast implant rupture and clean-up. I prefer saline to silicone for many reasons.

Silicone implants are advantageous in certain situations. Silicone breast implants feel more natural than saline when a woman has had many breast procedures and has very little breast tissue or muscle remaining in the breast. Silicone implants may be preferable also when a woman is very thin, in which case, silicone implants may feel more natural. In these two situations, I will offer my patients silicone breast augmentations. That is where the advantages of silicone implants end, in my opinion. If a woman's breasts are a small "B Cup" and the saline implants are placed behind the muscle, as I place them routinely, the feel of the breast is very natural, making the argument that "silicone implants feel more natural" not a valid reason for having silicone implants.

Reasons Why I Favor Saline Implants:

Safety:
Saline implants are safer, in my opinion. If they rupture, saline- or salt water- is spilled as opposed to silicone, which can cause local scarring and hardening of the breast.

Scar location:
They are more easily inserted from the armpit incision approach and then filled with saline, as opposed to the silicone implants that come pre-filled with silicone gel. The advantages of an under-arm incision are many: The scar is about an inch, the implant can be inserted behind the muscle, so the muscle and breast issue are not cut, unlike other approaches, result in less trauma and scarring, less pain, less bruising, and a shorter recovery time with minimal complications.

Scar length:
The scar is about 2cm (less than an inch) vs. a silicone implant scar, which is about 5cm.

Cost:
Saline implants are about 60% the price of silicone implants.

Long-term follow-up:
No need for MRI scans biannually to determine if there is a silicone rupture, as the FDA recommends with silicone implants. MRI costs $2,000-$3,000.

Above or Below the Muscle

Like the majority of board-certified plastic surgeons, I prefer to place the implants under the muscle for the following reasons:

- The breast feels more natural when the implant is covered by the muscle and the breast tissue.

- Implants placed behind the muscle are less likely to interfere with mammograms.

- Implants placed behind the muscle as less likely to cause rippling.

- Implants placed behind the muscle do however cause more pain after surgery as they cause the pectoral muscles to stretch. In spite of this, I personally prefer placement behind the muscle and recommend it to most of my patients. The only exception would be for women who are professional athletes and body builders in which implant placement behind the muscle might cause the implants to shift position.

Scar Location

The scar is about an inch and can be placed either in the under-arm ( axillary, or armpit scar), the crease under the breast (the inframammary fold) , or at the lower border of the areola ( periareolar incision). I prefer the under-arm scar for the following reasons, but, at the request of patients, I will perform the procedure through any of the three approaches.

Under-arm (axillary, or armpit scar):

Advantages:

- The scar is about an inch, and heals very nicely, like an under-arm crease.

- The implant can be inserted behind the muscle, so the muscle and breast issue are not cut, unlike other approaches, yielding many advantages: less time to perform the surgery, minimal bleeding, less trauma and scarring, less pain, less bruising, and a shorter recovery time with minimal complications.

- The milk ducts are not touched, so the risk of losing ability to breast-feed after a breast implant with this approach is negligible.

- The breast tissue is not touched, so there is no additional scarring that can be confusing to read on mammograms.

- The scar is relatively distant from the implant, so if there is a superficial scar infection or the scar opens up, the implant is well protected.

- A lowered probability of injuring the nerve that supplies sensation to the nipple, thus having an extremely high probability of normal nipple sensation after the breast augmentation.

- The shape and look of the breast is very natural. Critics have cited "high-riding" implants as a result of this technique. With use of proper surgical techniques and the use of a breast binder for pushing the implants down after surgery, we have not seen this problem.

Disadvantages:

The scar, although small, can be evident in the underarm area the first few months before it heals completely and fades, but it will never completely disappear.

The difficulty to remove an implant from an under-arm scar in the future if a revision is needed, so another approach may be used at that time.

The possible loss of sensation in a small area of the underarm.

How We Minimize Complications of Breast Implants:

At the Bitar Cosmetic Surgery Institute, we take pride in making sure we provide for our patients the best surgical experience possible. This is a process that includes the pre-operative preparation, the actual surgery, and the after care.

Bleeding
Bleeding after breast implants can be traumatic to a patient. It usually happens in the hours ensuing the breast augmentation, and usually happens on one side. Sometimes, a small amount of bleeding can be observed, but if the bleeding in a breast after a breast augmentation becomes significant, then the patient needs to have the bleeding removed in the operating room in a usually straight-forward procedure. The rate of hematomas, or bleeding after a breast augmentation is reported to be about 2%. Before surgery, our patients are tested to make sure they don't have any common bleeding disorders by their own physicians, and by lab tests. I use tumescent solution, similar to that used in liposuction, before starting a breast augmentation procedure to decrease the amount of bleeding. That technique plus minimal dissection, handling of the muscle during the procedure and creating the appropriate pocket size for the implant are all techniques that decrease the chances of post-operative bleeding. In my practice the rate of hematomas is about 1%.

Infection
Breast implant infections occurs in general in about 1-2% of cases. The most important step in avoiding infections, in my opinion, is to perform the surgery at a first-rate surgical facility such as INOVA Fairfax Hospital. Patients are given the appropriate intravenous antibiotics coverage throughout the actual surgery. During the surgery, the skin surface of the patient is cleaned properly. Next, I change gloves multiple times during the operation, and I am the only one who handles the implant in the operating room to ensure total sterility and avoidance of infection. After the procedure, my patients are prescribed a one-week course of antibiotics to minimize infection. As a result of these extra precautions, my implant infection rate is significantly lower than the national average.

Capsular Contracture
Capsular contracture is the hardening of the scar tissue around the implant, and occurs in 10%-15% of women with breast implants. It can also be a factor of time elapsed since the implant placement. Every implant will have scar tissue around it; that is totally natural. What is undesireable is for the scar tissue to harden and cause the patient pain or unnaturally-looking breasts. The theories behind the cause of capsular contractures vary. Capsular contractures may be caused by a sub-clinical infection, by significant bleeding during the operation, or by time alone. In the previous section, I discussed how to minimize the risk of infection. In order to minimize the risk of bleeding, I inject the breasts with a tumescent solution, similar to that used in liposuction. The reason for the tumescent solution is to decrease the bleeding during and after the operation and to provide for local anesthesia to decrease post-operative pain. As a result, my rate of capsular contracture has been less than 1%.

Rippling
Rippling is the formation of small waves or folds of the breast surface due to a breast implant. Sometimes rippling is visible, other times it is palpable, or both. In the case of breast augmentations, especially with saline implants, this potential result can lead to patient dissatisfaction in up to 10% of breast augmentation patients. In order to avoid rippling, one must understand what causes it. The chest muscle, or pectoralis major, does not cover the chest totally; the lateral edge of the breast is not covered by that muscle, which is used as coverage for a breast implant. Rippling can be avoided or minimized by giving the breast implant maximum coverage with breast tissue and muscle. For that specific reason, rippling is minimized by placing an implant under the pectoralis major muscle and by selecting an implant size that would be covered almost completely by the muscle. As a result, the implant cannot be felt from the lateral edge of the breast. Because of these two guidelines, the rate of rippling among my patients is less than 2%.

Deflation or Rupture
Breast implants are devices. Their lifespan of "looking good" varies between different types, the patient's conditions, and the technique used, but that lifetime is not indefinite. The younger the age of a woman seeking breast implants, the higher the probability that they may have to be adjusted or replaced at some point in the future. The good news is that newer breast implants are made of better material than the old ones and have a longer lifespan, with less complications. It is difficult to quote rates of breast implant rupture or deflation because it is a function of time. The best way to minimize this risk is by paying attention to each step in the pre-operative evaluation of a patient, the actual surgical procedure, and the follow-up care. If an implant ruptures or deflates, it needs to be exchanged. Saline implants ruptures are easier to diagnose, but silicone implant ruptures may need MRI imaging to make that diagnosis.

Ability to Breastfeed
Women are sometimes concerned that if they get a breast augmentation, they will not be able to breastfeed afterwards. The likelihood of losing the ability to breastfeed after a breast augmentation is very small, since the dissection occurs away from where the milk ducts are located. With the breast augmentation operation described above, inability to breastfeed after a breast augmentation that I have performed has not occurred with any of our patients to my knowledge.

Loss of Nipple Sensation
Similar to what has been said about ability to breastfeed, loss of nipple sensation is a potential complication that due to the technique with which I perform this procedure is a minimal complication, with less than 1% occurrence. Temporary loss of sensation from a "stunned" nerve or a bruised nerve may occur in the time period after surgery, but sensation in the vast majority of cases returns within a few weeks.

Dr. Bitar's articles on Breast Augmentation

Read Dr. Bitar's Article on Axillary Breast Augmentation Here

Information on this web site is for information only. Do not use the information to diagnose or treat your plastic surgery or cosmetic surgery problems. Please contact your plastic surgeon with all questions and concerns.