An Interview with Dr. McKee about Breast Augmentation Surgery
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If you are one of the increasing number of women who are considering getting breast implants, then you probably have many questions about the procedure. Am I a good candidate for the procedure? Will it look natural? What are the risks of complications? In Part 1 of this 3-part series, Dr. McKee speaks openly about implants, incisions, the problem of “going too big”.
David E. McKee:The first decision you have to make about breast augmentation is where are you going to put the incision? Where am I going to have permanent scars? It’s not a question of whether or not you’re going to have scars, it’s a question of where you’re going to have scars. There’s the belly button, very few people in the country are doing that operation. Nobody in Nashville as far as I’m aware is doing a belly button. So, if you eliminate the belly button, then you’re left with 3 basic places for a scar: the crease under the breast, around the areola on the front of the breast, or scars in the armpits. The armpit scar is a very nice scar, it’s off the breast, so it’s not very noticeable, but it requires you to do the operation as a blind surgeon, you can’t really see what you’re doing. So I reject that approach. I either use the incision under the breast or the incision around the areola, but the incision around the areola, to me, is just in a more noticeable place than the incision in the crease under the breast.
Will there always be a scar?
DEM: There’s always a scar. You cannot do any surgical procedure without a scar.
What kind of scar could I expect to have?
DEM: My standard approach, I use a 4-5 cm-long incision in the crease under the breast, which ends up about a centimeter or a centimeter and a half up on the bottom of the breast after the implants have settled just a little. 5 centimeters is 2 inches, so it’s just under 2 inches long. It heals as a thin white line scar. It can heal as a wider scar- if it does, we can always do a little revision in the office and see if we can’t get a thinner scar. I’ve never had a keloid scar on the breast, but I have had a few scars that I’ve revised in the office under local anesthesia.
After deciding where to make the incision, the next decision is where’s the implant going to be? Is it going to be under the breast or under the muscle and there are specific indications in my mind and advantages and disadvantages to each of those locations.
The third decision is what kind of implant are we going to use? Not only do we have to decide between gel and saline, but we also have to decide between textured and smooth, round and shaped, or tear-drop implant, so it’s a very complex choice. I will use pretty much any implant that a patient wants, but I have my own prejudices based on 30 years of doing augmentations. My standard implant is a gel, round, smooth implant. That’s the implant I think will give the most consistently good result. But there are complications associated with all the implants.
What’s the difference between silicone and saline implants?
DEM: A saline implant is empty when you get it and you just fill it up with IV saline, which is just salt water. You have some flexibilty in terms of adjusting the volume on the operating table. The gel comes pre-filled, you cannot adjust the volume, but there are plenty of sizes of gel to accommodate different needs. The biggest difference for me, and the reason I prefer gel, is because it’s more natural to the hand. The gel is made with a consistency that is very much like natural breast. The saline is much firmer.
How long do implants last?
DEM: The average lifespan on the new generation of gel implants, I think, is going to be greater than 15 years. It’s probably going to be closer to 20 years. Probably on the latest generation of saline implants, it’s going to remain about 15 years. But there are no guarantees. I certainly have patients with 30-year old implants in, but I also have patients where I’ve put implants in who have had implant failure within the first year. So these numbers are averages of length of survival of implant, so for an individual all bets are off. But the average lifespan, I think, is going to be over 15 years for both types.
How do I decide what size is best for me?
DEM: There is no right or wrong answer about size, but I always tell people, ‘The harder you push, the bigger you go, particularly the smaller you are to start with, the higher the complication rate. Of all complications: implant displacement, getting the implants uneven in terms of their position on the chest, capsular contraction, infection, bleeding, nerve injury- injury to the nerve that goes to the nipple and gives you permanent feeling in your nipple. All of those complications go up the harder you push,the bigger the implant you try to put in. So I try to encourage pts to be realistic about their size, particularly the young women who have never been pregnant, who have A or AA breasts. We can certainly go to a C, C+ a little bit, but beyond that I think you are risking complications and I try to discourage that. Ultimately, it’s up to the patient, but if a patient asked for me to do something I wasn’t comfortable doing, I’d just suggest that they probably ought to go see somebody else.
We size patients in the office with a bra and different implants that are placed in the bra just to give an idea, a starting place. The office manager helps them work through that process. It’s not perfect, but it gives us a range, it gives them some idea.
David McKee, M.D. 