Breast enlargement, or augmentation, technically known as augmentation mammoplasty, is a surgical procedure to enhance the size and shape of a woman's breast for a number of reasons:

To enhance the body contour of a woman who, for personal reasons, feels her breast size is too small.

• To correct a reduction in breast volume after pregnancy.
• To balance a difference in breast size.
• As a reconstructive technique following breast surgery.

By inserting an implant behind each breast, surgeons are able to increase a woman's bust line by one or more bra cup sizes. If you're considering breast augmentation, this will give you a basic understanding of the procedure - when it can help, how it's performed, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please ask Dr. Freedland if there is anything about the procedure you do not understand.

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Breast augmentation can enhance your appearance and your self-confidence, but it won't necessarily change your looks to match your ideal, or cause other people to treat you differently. Before you decide to have surgery, think carefully about your expectations and discuss them with Dr. Freedland.

The best candidates for breast augmentation are women who are looking for improvement, not perfection, in the way they look. If you're physically healthy and realistic in your expectations, you may be a good candidate.

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A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.

Because of concerns that there is insufficient information demonstrating the safety of silicone gel-filled breast implants, the Food & Drug Administration (FDA) has determined that new gel-filled implants, at the present time, should be available only to women participating in approved studies. Some women requiring replacement of the implants may also be eligible to participate in the study.

Saline-filled implants continue to be available to breast augmentation patients on an unrestricted basis, pending further FDA review. You should ask Dr. Freedland more about the specifics of the FDA decisions. (Above guidelines are current as of July 1992.)

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Breast augmentation is relatively straightforward. But as with any operation, there are risks associated with surgery and specific complications associated with this procedure. You can reduce your risks considerably by having your surgery performed by a qualified plastic surgeon.

The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or "scoring" of the scar tissue, or perhaps removal or replacement of the implant.

As with any surgical procedure, excessive bleeding following the operation may cause some swelling and pain. If excessive bleeding continues, another operation may be needed to control the bleeding and remove the accumulated blood.

A small percentage of women develop an infection around an implant. This may occur at any time, but is most often seen within a week after surgery. In some cases, the implant may need to be removed for several months until the infection clears. A new implant can then be inserted.

Some women report that their nipples become oversensitive, under sensitive, or even numb. You may also notice small patches of numbness near your incisions. These symptoms usually disappear within time, but may be permanent in some patients.

There is no evidence that breast implants will affect fertility, pregnancy, or your ability to nurse. If, however, you have nursed a baby within the year before augmentation, you may produce milk for a few days after surgery. This may cause some discomfort, but can be treated with medication.

Occasionally, breast implants may break or leak. Rupture can occur as a result of injury or even from the normal compression and movement of your breast and implant, causing the man-made shell to leak. If a saline-filled implant breaks, the implant will deflate in a few hours and the body will harmlessly absorb the salt water.

If a break occurs in a gel-filled implant, however, one of two things may occur. If the shell breaks but the scar capsule around the implant does not, you may not detect any change. If the scar also breaks or tears, especially following extreme pressure, silicone gel may move into surrounding tissue. The gel may collect in the breast and cause a new scar to form around it, or it may migrate to another area of the body. There may be a change in the shape or firmness of the breast. Both types of breaks may require a second operation and replacement of the leaking implant. In some cases, it may not be possible to remove all of the silicone gel in the breast tissue if a rupture should occur.

A few women with breast implants have reported symptoms similar to diseases of the immune system, such as scleroderma and other arthritis-like conditions. These symptoms may include joint pain or swelling, fever, fatigue, or breast pain. Research has found no clear link between silicone breast implants and the symptoms of what doctors refer to as "connective-tissue disorders," but the FDA has requested further study.

While there is no evidence that breast implants cause breast cancer, they may change the way mammography is done to detect cancer. When you request a routine mammogram, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast with an implant. Additional views will be required. Ultrasound examinations may be of benefit in some women with implants to detect breast lumps or to evaluate the implant.

While the majority of women do not experience these complications, you should discuss each of them with your physician to make sure you understand the risks and consequences of breast augmentation.

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In your initial consultation, Dr. Freedland will evaluate your health and explain which surgical techniques are most appropriate for you, based on the condition of your breasts and skin tone. If your breasts are sagging, Dr. Freedland may also recommend a breast lift.

Be sure to discuss your expectations frankly with Dr. Freedland. He will be equally frank with you, describing your alternatives and the risks and limitations of each. He invites you to view Before and After photos of his patients.

You may want to ask Dr. Freedland for a copy of the manufacturer's insert that comes with the implant that he will use - just so you are fully informed about it. And, be sure to tell him if you smoke, and if you're taking any medications, vitamins, or other drugs.

Dr. Freedland will explain the type of anesthesia to be used, the type of facility where the surgery will be performed, and the costs involved. Because most insurance companies do not consider breast augmentation to be medically necessary, carriers generally do not cover the cost of this procedure.

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Individuals considering breast enlargement often feel a bit overwhelmed by the number of options and techniques being promoted today. However, Dr. Freedland can help. In deciding which the right treatment approach is for you, Dr. Freedland will consider effectiveness, safety, cost and appropriateness for your needs. This is called surgical judgment, a skill that is developed through surgical training and experience. Dr. Freedland also uses this judgment to prevent complications; to handle unexpected occurrences during surgery; and to treat complications when they occur.

Dr. Freedland's education and training, which he received at the University of Michigan, has helped to form his surgical judgment. Patients are encouraged to consider a doctor certified by the American Board of Plastic Surgery ("ABPS"). By choosing a plastic surgeon who is certified by the ABPS, a patient can be assured that the doctor has graduated from an accredited medical school and completed at least five years of additional residency - usually three years of general surgery (or its equivalent) and two years of plastic surgery. To be certified by the ABPS, a doctor must also practice surgery for two years and pass comprehensive written and oral exams.

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Dr. Freedland will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding vitamins, iron tablets and certain medications. If you develop a cold or an infection of any kind, especially a skin infection, Dr. Freedland may have to postpone your surgery.

If you smoke, plan to quit at least two weeks before your surgery and not to resume for at least two weeks after your surgery. Avoid overexposure to the sun before surgery and do not go on a stringent diet, as both can inhibit your ability to heal. Though it is rarely necessary, Dr. Freedland may recommend that you have blood drawn ahead of time in case it is needed during surgery.

Whether your surgery is done on an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery, and to help you out for a day or two after you leave the hospital, if needed.

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While some surgeons may prefer to perform the operation in an office facility. Dr. Freedland feels a hospital provides the safest environment for your surgery and therefore performs almost all of his procedures at a JCAHO accredited hospital. The surgery is usually done on an outpatient basis; rarely does it require an inpatient stay.

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Some surgeons may use a local anesthesia, combined with a sedative to make you drowsy, so you'll be relaxed but awake, and may feel some discomfort. Most patients prefer to have this procedure performed with a general anesthesia, so you'll sleep through the entire operation.

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The method of inserting and positioning your implant will depend on your anatomy and Dr. Freedland's recommendation. The incision can be made either in the crease where the breast meets the chest, around the areola (the dark skin surrounding the nipple), or in the armpit. The FDA has recently condemned the "belly button" approach as an operation with an unacceptable complication rate. Every effort will be made to assure that the incision is placed so resulting scars will be as inconspicuous as possible.

Working through the incision, the surgeon will lift your breast tissue and skin to create a pocket, either directly behind the breast tissue or underneath your chest wall muscle (the pectoral muscle). The implants are then centered beneath your nipples.

Most surgeons believe that putting the implants behind your chest muscle may reduce the potential for capsular contracture. This placement is also felt to interfere less with breast examination by mammogram than if the implant is placed directly behind the breast tissue. Placement behind the muscle however, may be more painful for a few days after surgery than placement directly under the breast tissue.

There is a recently developed technique, however, that helps accurately place the implant under the muscle and therefore allows for the placement of the state-of-the-art "tear-drop" shaped implant without distortion. This technique reduces bleeding and therefore reduces the risk of contracture. Most impressive, though, this technique reduces pain so that most patients take little or no pain medications and are performing their normal activities within a few days after the procedure. Ask Dr. Freedland specifically about this technique.

You'll want to discuss the pros and cons of these alternatives with Dr. Freedland before surgery to make sure you fully understand the implications of the procedure he recommends for you.

The surgery usually takes less than one hour to complete. Stitches are used to close the incisions, which may also be taped for greater support. A gauze bandage may be applied over your breasts to help with healing.

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You're likely to feel tired and sore for a few days following your surgery, but you'll be up and around in 24 to 48 hours. Most of your discomfort can be controlled by medication prescribed by Dr. Freedland.

Within several days, the gauze dressings, if you have them, will be removed, and you may be given a surgical bra. You should wear it as directed by Dr. Freedland. You may also experience a burning sensation in your nipples for about two weeks, but this will subside as bruising fades.

Your stitches usually dissolve on their own, but the swelling in your breasts may take three to five weeks to disappear.

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You should be able to return to work within a few days, depending on the level of activity required for your job.

Follow Dr. Freedland's advice on when to begin exercises and normal activities. Your breasts will probably be sensitive to direct stimulation for two to three weeks, so you should avoid much physical contact. After that, breast contact is fine once your breasts are no longer sore, usually three to four weeks after surgery.

Your scars will be firm and pink for at least six weeks. Then they may remain the same size for several months, or even appear to widen. After several months, your scars will begin to fade, although they will never disappear completely. Dr. Freedland can instruct you on skin care products that can help make your scars less visible.

Routine mammograms should be continued after breast augmentation for women who are in the appropriate age group, although the mammographic technician should use a special technique to assure that you get a reliable reading, as discussed earlier. (See all surgery carries some uncertainty and risk.)

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For many women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance.

Regular examination by your plastic surgeon and routine mammograms for those in the appropriate age groups at prescribed intervals will help assure that any complications, if they occur, can be detected early and treated.

Your decision to have breast augmentation is a highly personal one that not everyone will understand. The important thing is how you feel about it. If you've met your goals, then your surgery is a success.

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