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Breast Augmentation


Breast Augmentation (augmentation mammaplasty) is a surgical procedure performed to enlarge the breasts for a number of reasons:

  1. To enhance the body contour of a woman who feels that her breasts are too small.
  2. To correct a loss in breast volume after pregnancy.
  3. To balance breast size when the breasts are of different sizes.

The average plastic surgeon performs about 30 breast augmentations each year. In contrast, Dr. Friedman performs an average of 125 augmentations annually. He has performed well over 2000 breast augmentations.

Breast implant types

Saline-filled breast implants are widely available for breast enlargement. Saline implants are filled with the saline salt water solution used in I.V. fluids. If a saline implant leaks, the saline contents are released and absorbed by the body within hours. Saline (salt water) is harmless to the body. Saline implants are covered with a plastic shell made of solid silicone.

Silicone gel implants were restricted by the FDA in 1992 due to concern regarding possible side effects. They were approved by the FDA in 2006 following many years of study. There remains no conclusive evidence of a link between silicone gel and any autoimmune disease.

Unfortunately, there is no perfect breast implant.

The advantages of silicone gel include:

  1. More natural feel. Think jelly, instead of water.
  2. Reduced rippling. If you put water in a sandwich bag, you will notice ripples in the bag, just as you will in saline implants.
  3. Longer implant lifespan, on average.

The advantages of saline include:

  1. Lower cost. Saline implants are $1000 to $1500 less expensive than silicone.
  2. Smaller incisions. Dr. Friedman places saline implants through a 3 cm (just over an inch) incision and places silicone gel implants through a 4 to 5 cm incision.
  3. Lower risk of capsular contracture (scar tissue causing excessive implant firmness).
  4. Public perception that it is a “safer” implant. Because ruptures of silicone gel implants may be difficult to detect, the FDA recommends MRI evaluation of silicone implants at regular intervals (every other year) following surgery.

The bottom line: from a purely cosmetic standpoint, silicone gel may be a better implant than saline. From a medical standpoint, it is difficult to argue with the safety of a bag of salt water. In women with a reasonable amount of breast tissue and subcutaneous fat, Dr. Friedman feels that saline is a good choice. In women with minimal breast tissue, poor breast tone, and/or minimal subcutaneous fat (and therefore a greater risk for significant rippling with saline implants), silicone gel may be a good choice.

Breast implant position

Implants may be placed above (subglandular) or below (submuscular) the pectoralis major muscle. Dr. Friedman places the vast majority of implants in a submuscular position, as it has the following advantages:

  1. Reduced risk of interference with mammography. The muscle separates the implant (below muscle) from the breast tissue (above muscle).
  2. Reduced risk of capsular contracture (scar tissue causing excessive implant firmness).
  3. Reduced risk of long-term sagging of the implants. Muscle is more effective than skin in supporting the weight of the implants.
  4. Reduced rippling of saline implants. The additional implant coverage provided by the muscle reduces the extent of rippling along the upper and inner breast.
  5. Reduced risk of unnatural bulging of the upper breasts. The pectoralis major muscle blunts the junction of the upper implant edge and the chest wall.

On the downside, placing implants below the muscle requires greater surgical time, effort, and skill and often causes greater discomfort immediately after surgery. In athletes, implants below muscle may sometimes weaken the pectoralis major muscles.

Surgical technique

Dr. Friedman performs breast augmentation under general anesthesia on an outpatient basis. The procedure is performed in his AAAASF-accredited surgical facility, the West Plano Plastic Surgery Center, which is located on the campus of Texas Health Presbyterian Hospital of Plano. He strictly uses physicians—not nurses or technicians—to administer your anesthesia.

Most surgeons perform breast augmentation using a technique called “blunt dissection.” They use a blunt instrument or a gloved finger to tear the pectoralis major muscle off the ribs. Then they put in your breast implants. Blunt dissection is fast. (Some surgeons can complete your procedure in less than 30 minutes.) Unfortunately, it causes significant tissue trauma and bleeding and may lead to increased complication rates and reoperations. To reduce bleeding, many surgeons use surgical drainage tubes, compression bras, and/or ACE bandages following surgery.

In contrast, Dr. Friedman uses electrocautery to perform your surgery. This involves use of a thin, long, matchstick-shaped instrument that heat-seals the tissues as they are elevated. This reduces bleeding (Dr. Friedman’s average blood loss is under an ounce), virtually eliminates bruising, and makes drainage tubes, ACE bandages, and compression bras unnecessary. All stitches are internal. There are no stitches to remove. In addition, Dr. Friedman uses “sizers,” which are sterile sample implants, to preview your results before selecting your final implants. These maneuvers add time to the surgery but reduce reoperation rates. It takes Dr. Friedman about 1.5 to 2 hours to perform breast augmentation. He believes that there are no shortcuts to obtaining a good result.

Complication and reoperation rates

According to data submitted to the FDA by breast implant manufacturers:

2% of women undergoing breast augmentation experience postoperative bleeding
2% of women undergoing breast augmentation experience postoperative infection

Dr. Friedman’s numbers are:

0.2% bleeding
0.5% infection

According to the same data, among women undergoing breast augmentation with saline implants, 26% underwent further breast surgery within 5 years. Dr. Friedman’s 5-year reoperation rate is 8%.

Many physicians also refer patients to Dr. Friedman for breast implant revision. Dr. Friedman performs revisions to increase or decrease implant size, remove and replace deflated or ruptured implants, soften breasts that have become hard (capsular contractures), and improve breast implant position and shape.

When you visit our office, we will be happy to show you a variety of “before and after” photos of breast enlargements performed by Dr. Friedman. You will also be able to see and feel the differences between saline and silicone gel implants. If you wish to speak to other women who have undergone the procedure, we will be happy to provide phone numbers.

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Dr. Friedman explains breast augmentation, and a patient describes her experience.

Dr. Friedman explains breast augmentation techniques.

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Q & A: Breast Augmentation

How long will my implants last?

Your implants will probably not last as long as you do. It is likely that one or both of your implants will require replacement at some point in your lifetime due to deflation (saline) or rupture (silicone gel). Most implants will last at least 10 to 15 years. In the absence of an implant-related problem, there is no need to "change out" your implants (i.e. if it isn’t broken, don’t fix it).

Are ruptured implants dangerous?

Saline implants are filled with sterile saltwater. Upon deflation, the saline is absorbed harmlessly. There is no known health risk associated with deflated saline implants.

The FDA has determined that intact silicone gel implants are safe. However, they have not made a determination regarding the safety of ruptured silicone gel implants. Therefore, the FDA currently recommends that any ruptured silicone gel implant be removed.

Can implants cause breast cancer?

Multiple published studies demonstrate absolutely no link between breast implants and the development of breast cancer.

Can implants interfere with mammograms?

Implants may reduce the sensitivity of mammograms. This is a greater concern for implants placed above muscle than those placed below muscle. In order to better visualize the breast tissues, additional mammography views (such as the Eklund displacement view) are recommended. Of interest, implants may actually make it easier to detect breast lumps on physical exam.

What is "overfilling" an implant?

All saline implants ripple. Most surgeons overfill implants (for example, fill a 300 cc implant to 330 cc) to reduce rippling. Overfilling does not compromise the integrity of the implant. However, overfilling a 300 cc implant to 450 cc is not reasonable, as it will make the implant look and feel "hard."

How much does breast augmentation cost?
How do I figure out the right breast implant size?
Saline or silicone gel: Which breast implants should I choose?
Which are better? Smooth breast implants or textured breast implants?
Breast augmentation with breast lift: Can I get away with implants or do I need a lift too?
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Breast Augmentation: Instructions

One week before surgery

  1. Do not take aspirin-containing products, as these may increase your risk of bleeding. Use extra-strength Tylenol for any headaches or other minor pains.
  2. Please notify Dr. Friedman's staff if you become sick with a fever, significant cough, etc. If necessary, your surgery can be rescheduled to a time when you are feeling better.
  3. Do not smoke at all or use a nicotine patch for at least two weeks (and preferably 4 weeks) prior to surgery and 4 weeks after surgery. Smoking interferes with wound healing and increases your risk for anesthetic and surgical complications.
  4. Arrange to have a relative or friend drive you home after surgery and stay with you for the evening. You cannot drive yourself home.

The evening before surgery

  1. Do not eat or drink anything for at least 8 hours prior to your scheduled surgery time.
  2. Make some jello and/or soup for after surgery. Have some juice in your refrigerator.
  3. The anesthesiologist will contact you by phone to discuss your medical history and to answer any questions.

Day of surgery: before you leave home

  1. Remember not to eat, drink, or smoke. This includes no chewing gum, mints, etc.
  2. Make sure someone is available to drive you home. Put a pillow and blanket in the car.
  3. Wear loose, comfortable clothing. Avoid heavy make-up, jewelry, or contact lenses. Please do not use any lotion, baby oil, perfume or powder. LEAVE ALL VALUABLES AT HOME!

Day of surgery: at the facility before surgery

  1. Dr. Friedman will talk to you before surgery to answer any last-minute questions. He will place drawings on your chest to help him accurately plan your surgery.
  2. You will meet the anesthesiologist and surgical nurses.

Day of surgery: at the facility after surgery

  1. You will be taken to the recovery area to wake up after surgery. Dr. Friedman will go to the waiting room to speak to your family/friends.
  2. Approximately 1 hour later, your family can visit you. Once you are feeling well enough, you may go home.

At home after surgery

  1. Have someone stay with you for the first night. You may be weak and drowsy.
  2. Take the antibiotics, pain medication (as needed), and anti-nausea medicine (if needed) that Dr. Friedman has prescribed for you.
  3. Sleep with your head elevated. Sleep on your back (not your stomach or side).
  4. Keep your dressings (gauze and tape) clean and dry. Do not remove the dressings. You may shower only from the waist down. You may wish to sponge bathe.
  5. You may remove the gauze and tape over the incisions and begin light showers four days after surgery. Avoid immersing the breasts under water.
  6. Take at least 10 deep breaths every hour. This will help keep your lungs expanded.
  7. Do not be a couch potato. To reduce the risk of blood clots in the legs, get up and walk anytime you eat or need the bathroom. While you are in bed, repeatedly flex your ankles (moving your toes up and then down) and/or have your family massage your calves.
  8. If you experience a prolonged fever (oral temperature greater than 101), contact Dr. Friedman. Feel free to call our office or to page Dr. Friedman for any other problems or concerns.

Instructions for your first postoperative visit (about one week after surgery)

  1. Activity level

    1 Week after surgery: you may resume casual walking but must not engage in vigorous exercise that increases your blood pressure or heart rate. You may resume driving once you are off of your pain medication. Avoid freeways until you are comfortable with city driving.

    3 Weeks after surgery: you may resume jogging (with a jog bra) or an elliptical trainer but must avoid vigorous use of your chest or arms.

    6 Weeks after surgery: you may gradually resume exercise involving the chest and arms. Only now you may lift more than 5 pounds.

  2. Sleeping position

    Please sleep on your back (flat or elevated) or part way over (pillow under your shoulder and hip). Do not sleep on your side until about 3 weeks after surgery. Unless otherwise instructed by Dr. Friedman, do not sleep on your stomach until about 6 weeks after surgery.

  3. Incision care

    You have a layer of tissue glue to seal your incision. After this peels off (about 2 weeks after surgery), begin scar massage with Mederma twice daily. Mederma is available at our front desk or over-the-counter at your pharmacy. If you prefer, you may use Vitamin E or Aloe Vera. Continue scar massage for about 3 months.

  4. Breast exercises and bra usage

    Your implants are high and tight, as expected. Dr. Friedman will instruct you on exercises to mobilize the implants (usually up and in) until they have softened and settled to some degree. Final settling will take about six months. Once you feel that the implants are no longer "way too high," you begin use of a bra to reduce further downward settling of the implants. If you have an incision in the breast crease, you should avoid an underwire bra for at least 3 months. Even after the implants have settled, you should push them up and in about 2 to 3 minutes per week (for the rest of your life) to help keep them soft.

  5. Water exposure

    You may begin light showers but should avoid scrubbing your incisions. Do not immerse your breasts under water in a bathtub for 4 weeks. Avoid immersing your breasts in a pool, lake, or ocean for 6 weeks.

  6. Medications

    One week after surgery, you may resume use of any medications or supplements that you discontinued prior to surgery. However, for at least 3 weeks, you should avoid Motrin, aspirin, and any other product that may thin your blood.

  7. Smoking

    Do not smoke for at least one month (and preferably much longer) after surgery. Smoking may increase your risk of infection, lung problems following anesthesia, and wound healing problems.

  8. Tanning

    You may tan your breasts whenever you like. However, you should avoid tanning directly over your incisions for at least 6 months. Premature tanning of the incisions may cause them to darken permanently.

  9. Sex

    You may resume intercourse in a non-weight bearing position (i.e. on your side) about 3 weeks after surgery. You may not bear weight on your chest for at least 6 weeks.

  10. Dental visits

    Avoid dental cleanings/fillings for 6 weeks, as bacteria in your gums can be transmitted to your implants via your bloodstream.

Please feel free to ask Dr. Friedman or his staff about any additional questions or concerns.

Plano Breast Augmentation Specialist

Plano breast surgery physician, Dr. Ronald M. Friedman, is one of the top 10 breast implant specialists in the Dallas Fort Worth (DFW) area. D Magazine has repeatedly selected Dr. Friedman as a "Best Plastic Surgeon" in both Dallas and Collin County. Texas Monthly Magazine named him a "Texas Super Doctor" for four consecutive years. He has more than 17 years of experience and is board certified by the American Board of Plastic Surgery (ABPS). Dr. Friedman is also a member of the American Society of Plastic Surgeons (ASPS), the Texas Society of Plastic Surgeons (TSPS), and the American Society for Aesthetic Plastic Surgery (ASAPS). Furthermore, Dr. Friedman is the former Chief of Plastic Surgery at Parkland Memorial Hospital, has made various media appearances that include FOX-4 TV,, and the "Dallas Morning News," and has earned multiple awards.

Many women with small, drooping, and/or asymmetric breasts turn to plastic surgery in order to achieve a more aesthetic appearance. Those who wish to undergo breast augmentation in Plano may consult Ronald M. Friedman, M.D. of the West Plano Plastic Surgery Center. Located on campus at the Presbyterian Hospital in Plano, patients are provided with quality care in a safe environment. He also has a Flower Mound office for your convenience. Prospective Plano and Frisco breast augmentation patients may view before and after plastic surgery photos to see examples of Dr. Friedman's results. To gain insight to the care provided at the West Plano Plastic Surgery Center, patient testimonials are available. Q&As and educational videos provided offer further breast surgery information. Every year in the thriving southern metropolis of Plano, thousands of women choose to have breast enlargement surgery. As an experienced plastic surgeon, Dr. Ronald Friedman performs breast implant procedures in Plano, for both cosmetic and restorative purposes. As a wood and marble sculptor, Dr. Friedman brings an artistic eye to breast augmentation ("augmentation mammaplasty") in order to help patients achieve the look they desire. In addition to breast augmentation, some patients may wish to undergo breast lift surgery ("mastopexy"). This procedure is designed to lift the breasts to a higher position on the chest wall in order to provide patients with a more youthful appearance. Dr. Friedman can perform this surgery with the combination of breast implants surgery or by itself. Dr. Friedman is also well-regarded as a breast implant revision specialist. Read more about breast augmentation from the American Society of Plastic Surgeons.

Those in the Plano and Frisco area who are interested in breast augmentation may call (469) 467-0100 to schedule a complimentary cosmetic consultation. Contact Dr. Friedman regarding your plastic surgery questions about breast augmentation procedures.

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