Tuesday, September 23, 2014

Meet Our Expert: Kevin J. Cross, M.D.

Demystifying the Breast Augmentation, Part 1
Written By: Kevin J. Cross, M.D.


The use of silicone breast implants predated saline breast implants by one year.  In 1962, first generation silicone breast implants were introduced and saline filled implants followed in 1963.  For much of the 1990's and early 2000's, as a result of a belief that silicone gel was causing autoimmune and other vague symptoms in women who had them placed, silicone breast implants were banned.  An exhaustive group of studies reviewed by the FDA found that there was no correlation between breast implants and any of those symptoms, however, and in 2006, the ban on silicone implants was lifted. Today, approximately 80% of breast augmentations nationwide, and over 90% in my practice are performed with silicone implants.  While saline implants can still provide a very effective augmentation, and some women choose saline implants simply because they prefer an implant filled with saline, most women choose silicone implants because of the more natural feel offered by the latter.  Though there was once a realistic fear that a leaky implant could lead to silicone spreading into the region around the breast, the most recent generation of silicone implants is filled with highly cohesive, or form stable gel.  These implants can actually be cut in half without any of the implant material leaving the implant shell.  Therefore, even if there is a problem with the lining of the implant, there is no risk of silicone spreading throughout the breast or beyond.  

The Basics & Image Technology
Breast augmentation procedures take, on average, between one and two hours, depending on whether a lift of the patient's own breast tissue is needed.  Often, the implant itself can be used to provide lift, and different sizes, shapes, and textures are available to customize the implant to provide the most ideal volume restoration possible for individual patients. When a significant amount of natural volume has been lost, however, especially after having children, extra shaping of the breast tissue may be needed.  In my practice, new computer software and imaging devices known as the VECTRA systems are being used to give a patient a complete visual representation of what a breast enhancement will look like on them.  The system images a patient's breasts and produces a very accurate rendering of what changes can be made with implants of different sizes and shapes.  It can even take into account any lifting procedures that may be necessary.  Unlike older technology which I feel was used as a marketing tool by plastic surgeons to try to sell the appearance of an ideal breast image, this new technology provides a very accurate representation of what the patient will actually look like, and allows the patient to move forward with confidence, knowing in advance what the goals of the procedure will be.

Since first being introduced over 50 years ago, the modern day breast augmentation procedure has undergone revolutionary changes with regard to the options available to plastic surgeons to shape the breast, the choices a patient has with regard to implant selection, and the public's understanding and perception of the procedure.


Choices that a patient and I make together in the office through a lengthy discussion and exam include size and shape of the implant to be used, whether the implant is going to go above or below the chest muscles, and what incision is used to place the implant.  Most commonly, the implant is placed under the muscle. There are certain patients with breast shapes that are better served with an implant that is placed directly under the breast tissue, but for the vast majority of patients, placing the implant under the muscle provides extra cushioning for the implant and helps create a more natural blend between the edge of the implant and the remainder of the breast and chest, thus creating the most natural shape and appearance.  

Procedural Precautions — An Expert's Advice

While placing an implant through an incision in the armpit is possible, I discourage most patients, especially patients who have had children, from using this approach.  It is less reliable as far as ensuring implant position and puts the implant at greater risk of complications.  Furthermore, an armpit incision can easily be mistaken for a biopsy incision and is visible even in a tank top or bathing suit.  For the majority of patients, placing an incision that is just a few centimeters long either in the natural under-fold of the breast or at the junction between the pigmented part of the nipple and the remainder of the breast allows for a very discrete incision that fades to the point of being imperceptible and is completely hidden in any amount of clothing or lingerie.

Post Procedure

After a breast augmentation procedure, patients spend a few hours in the recovery room and are then able to go home.  My patients wake up with a bra that we place them in at the end of the procedure.  This bra stays on for two days, after which the patient can take off the bra, shower, wash over her breasts, and start getting back to normal activities.  All sutures are absorbable and a small piece of tape is placed over the incision.  Patients feel a varying level of discomfort after the procedure, but most patients take very little to no prescription pain medicine and are able to get back to exercising within one to two weeks.  The initial discomfort is often described as feeling as if the patient did hundreds of push-ups the day before.  There is soreness in the chest when the patient moves, but relative comfort at rest.  


Common Questions, Debunked Myths

How long does an implant last? How am I protected if an implant leaks?

Common questions asked by patients relate to the "life expectancy" of an implant, and what happens if there is a leak with the implant.  Generally speaking, the risk of a breast implant leakage is about 1% per year.  This rate is less in the first few years, and increases slightly as the implant ages.  If a saline implant leaks, the implant deflates and the patient notices a decrease in volume on the side that is affected.  If a silicone implant leaks, because of the stability of the silicone, it may be harder for the patient to determine.  While there is no risk to a patient's health from a silicone implant that leaks, an MRI is used to confirm the condition of the implant.  Unlike the original procedure which requires a few days of recovery because the body has to get used to the presence of the new implants, exchanging an old or leaky implant for a new one is a short procedure with very little recovery time.  The three major implant companies in the United States are so confident of the durability of the current generation of implants that they provide a 10-15 year warranty that covers all costs to exchange an implant if there is a leak.  

Will I be able to breastfeed?  What happens when I need a mammogram?

For our younger patients, it is important to know that, contrary to popular belief, it is possible and safe to breast feed after a breast augmentation procedure.  While there is a very small measurable amount of silicone in breast milk in patients with breast implants, it is actually one-hundred times less silicone than what is found in infant formula.  For our patients who are approaching or who are at the age where mammograms are necessary, extra images are needed in patients with breast implants.  Known as the Eklund maneuvers, these extra images allow radiologists to visualize the breast tissue around an implant.  Studies have shown that there is no increased risk of being diagnosed later in the course of breast cancer as a result of having breast implants.  

Final Thoughts

Having a breast augmentation with breast implants is a commitment that a patient should not take lightly.  That being said, patients often feel that a well performed breast augmentation provides them with shape and balance that they never had in the past, or that the procedure restores form and proportion that was lost either with age, weight loss, or having children.  Patients find that they can wear clothing more comfortably, are able to fill a shirt, gown, or bathing suit more appropriately, and feel more comfortable with their body after the procedure then they ever did prior to the augmentation.  

My goal has been to give a basic understanding of breast augmentation.  With so much information to understand and so many choices to make, a successful patient experience with the most perfect cosmetic breast augmentation result ultimately depends on the dialogue and discussion between myself and my patients. More information is also available on my website: crossplasticsurgery.com under the virtual consult -breast augmentation section.  In our next segment, I will discuss the latest trend in breast augmentation – the no implant augmentation – where a patient’s own fat is acquired by a modified version of liposuction.  The fat is taken from the areas where it is least desired, and placed into the breast for a natural “autologous” augmentation.

Kevin J. Cross, MD
Cross Plastic Surgery