• Length of Surgery: 45-60 minutes
• Anesthesia: General
• Outpatient vs Inpatient: Outpatient (Ambulatory)
• Recovery Time: 1-3 days

A breast augmentation is a safe, outpatient procedure that is performed to enhance the volume, size, and shape of the breasts. Breast augmentation can be achieved by using breast implants (silicone or saline), fat transfer, or by combining breast implants and fat transfer, which is also known as a composite breast augmentation .  In addition, Dr. Couto implements the “24-hour breast augmentation fast track recovery”, created by his mentor Dr. William P. Adams. This consists of advanced perioperative techniques that minimize breast tissue manipulation which help expedite post-operative recovery.

Dr. Couto is a Cleveland Clinic trained plastic surgeon, and one of the few plastic surgeons in Latin America to have completed an American Society of Aesthetic Plastic Surgeon (ASAPS) endorsed subspecialty training in Aesthetic Surgery and Medicine.  

During his training, Dr. Couto had the privilege to have mentors that are considered top leaders in the field of cosmetic breast surgery. This includes, Dr. William P. Adams, one of the describers of the dual-plane breast augmentation technique and the creator of the 24-hour breast augmentation fast track recovery and Dr. Louis L. Strock, a pillar in the field of transaxillary breast augmentation. 

Dr. Couto has also authored book chapters and publications in peer-reviewed journals related to breast implants, breast augmentation, and breast cosmetic surgery.  

The consultation is divided into five parts: 

1) Health and Medical History Evaluation

A comprehensive evaluation of the patient’s health and medical history is performed. During this part of the consultation, we focus on identifying any potential risk factors for the surgery. Fortunately, most of these can be easily modified with lifestyle changes. Although this procedure is short and relatively low risk, our patient’s health and safety will always be our main priority. We like to set the patient for success, not for failure; therefore, modifying any potential risks is essential. 

2) Discuss with the Patient About Surgical Goals

Dr. Couto has a deep discussion with the patient to learn about their concerns and goals. Here, we explore the patient’s desired breast cup sizes and appearance. Listening to our patient’s interest is crucial, since it is our priority to determine if we can meet their expectations. 

3) Breast Analysis & Surgical Recommendations

A comprehensive breast analysis is performed. In this part of the consultation, our objective is to determine whether the patient is a candidate for breast augmentation only or if the patient will benefit from a combined breast augmentation and lift. This question is answered using objective measurements of the breast and a 3D-imaging simulation system that enables us to show the patient how she could look with different types of breast implants.

We examine their size, shape, descent and identify any existing breast or chest asymmetries. We also evaluate the contour and proportion of the breasts in relation to the body. After this examination, Dr. Couto discusses with the patient his recommendation and explains in detail everything that is involved with the procedure and its recovery.

4) Breast Implant Selection

This is the most crucial part of the consultation, since the breast implant should fit as perfect as fitting a hand in a glove. Choosing the incorrect breast implant could result in a suboptimal aesthetic result or even lead to complications. Therefore, using the information obtained from the breast analysis and taking in consideration the patient’s desired size and aesthetic goal, we guide the patient to select the correct implant. Furthermore, we use 3D-imaging technology to select breast implants. This 3D simulation system enables us to determine the correct breast implant size/shape and show the patient how the breasts could look with the selected implants. 

5) Pricing and Scheduling Information

Once the evaluation has been completed, our team will provide an individualized quote that is tailored to the procedures discussed during the consultation and review the steps involved to book the procedure with us.

Nor all breasts are equal and not all implants are a “one size fits all.” Dr. Couto’s philosophy is not to impose a breast implant on a patient, but instead to guide them in selecting with him the implant that will be most beneficial to the patient’s  body. To do so, we take in consideration the patient’s breast dimensions, chest anatomy, and desired size and projection. Lastly, we utilize 3D-imaging simulation to show the patient how she could look with different types of breast implants.

Three-dimensional imaging is a simulation system that produces high resolution images of how the patient could look with different breast implant shapes and sizes. After performing a detailed breast analysis, Dr. Couto uses this technology to guide the patient in selecting the correct implant and help them visualize how they may look with specific implants.

Breast implants are divided into two major groups: silicone gel and saline water. It is important to know that both are made of an outer silicone shell. The main difference between them is the material that fills the shell, which can be silicone gel or saline water. Here we enlisted the advantages and disadvantages of each implant type:

Silicone:

• Advantages
  • Softer and feel more natural to the touch compared to saline
  • Less rippling or undulation of the implant in thin skin
  • In the extremely rare event of an implant rupture, there is no apparent change in breast size. This is due to the new cohesive material technology used, which prevents migration of the silicone, similar to a gummy bear candy. Furthermore, if silicone gel leakage from implant rupture occurs, numerous scientific studies have shown that silicone is safe to the body and it can be easily removed.

• Disadvantages
  • Although implant ruptures are rare, they are more difficult to identify clinically. Unlike saline breast implants, silicone gel implant rupture produces no apparent change in the size of a breast. This is due to the new gummy bear silicone gel technology, which prevents leakage and migration of the silicone material.  An easy way to confirm silicone breast implant rupture is with ultrasound imaging. 

Saline:  

• Advantages
  • Skin incision may be slightly smaller because these implants are filled once they have been inserted in the breast. 
  • In the unlikely event of a leakage due to implant rupture, saline water is easily absorbed  by the body.
  • A ruptured implant is easily identified, since the breast immediately deflates.
• Disadvantages
  • The implants can feel firmer to the touch than their silicone counterpart. However, Dr. Couto uses the structured saline implants (Ideal®), which offer a new technology that minimizes this firmness by mimicking the natural touch that silicone implants provide. 
  • Higher risk of rippling in thin skin and small breasts.
  • A ruptured implant causes the breast to deflate and lose volume.

Implant Position: Subglandular vs Submuscular vs Dual Plane

Historically, breast implants were either placed below the breast gland (subglandular) or below the chest muscles (submuscular). However, these approaches had their disadvantages. While subglandular breast augmentation had a higher risk of capsular contracture and implant palpability, placing the implant submuscularly exhibited greater movement of the implant with chest muscle contraction (breast hyper animation) and prevented a natural breast enhancement.  In order to capture the benefits of these two approaches, the dual-plane breast augmentation was created. This technique, which was perfected and popularized by one of Dr. Couto’s mentor, Dr. William P. Adams Jr, consists of placing the superior aspect of the implant below the chest muscle (submuscular) and the inferior portion of the implant below the breast gland (subglandular). Having the muscle cover the superior portion of the implants creates a natural transition between the chest and the breast, while reducing the risk of capsular contracture and implant palpability. The benefit of having the inferior part of the implant subglandular is that it provides adequate volume and projection of the breast.

Skin Incisions:
There are three types of skin incisions used in a breast augmentation:

• Inframammary Fold: A small incision is placed in the breast crease, which allows the scar to hide nicely in the breast fold after implant placement. This is Dr. Couto’s preferred approach, since it provides consistent results and has the lowest risk of capsular contracture and complications.   
• Periareolar: The incision is placed at the inferior border of the areola. The idea of using this approach is to conceal the scar in the areola. However, when compared to the inframammary fold incision technique, the periareolar technique has suboptimal scars, can distort the shape of the nipple-areola complex, and has a greater risk of nipple sensory changes. Most importantly, numerous scientific studies have shown that the periareolar approach has a higher risk of implant infection and capsular contracture, since the incision goes through the breast glands and ducts, which are non-sterile structures.    
• Transaxillary: The breast implant is inserted through an incision placed in the axilla. Since there is constant movement of the arms, the scar healing process can be affected and the results are most likely to be less favorable.

Composite Breast Augmentation (Breast Implant & Fat Transfer) 

If a composite breast augmentation (breast implant and fat transfer) is planned, we would proceed with the fat transfer after inserting the breast implant. In this part of the procedure, fat is harvested from the abdomen or thigh using liposuction techniques (hyperlink). After properly processing the fat, it is injected mainly in the upper pole of the breast. Using this technique we can further enhance the breast cleavage.  

  Patient with

• Small breasts
• Breast Asymmetry 
• Loss of Breast Volume
• Congenital Breast Deformities

Several weeks before the procedure, a preoperative appointment will be scheduled. During this appointment, we will discuss the surgical plan, review the 3-D simulation and confirmed the selected breast implants,  and clarify any questions involving the surgery. Furthermore, we thoroughly review with the patient the preoperative/postoperative instructions and the medication regimen and schedule your future post-operative appointments. 

We always emphasize to our patients that  medication (e.g. aspirin, ibuprofen), vitamins and herbal supplements (e.g. Fish oil, Omega-3, Garlic or Tumeric pills, Ginko Biloba) should be stopped at least 3 weeks before surgery, as this increases the risk of bleeding.  Nutrition is crucial for an effective healing and recovery process. Therefore, we recommend to our patients to optimize their protein intake and avoid foods high in salt/sodium  after any surgical procedure. This could be easily achieved with supplements available in our practice. 

We provide the patient with a detailed postoperative protocol to ensure a comfortable and quick recovery. Following surgery, it is common to feel soreness and sensitivity around the surgical site; however, this is easily manageable with our postoperative pain regimen medication. Furthermore, we start all our patients in a scar therapy to optimize the healing process and obtain the best scar results.   We recommend our patient to take 2 days of work (less if working from home) and avoid lifting anything heavier than 7-10 pounds for 4 weeks. Patients can resume their aerobic exercise (e.g. running, walking, spinning) 2 weeks after surgery. However, you will be able to restart your gym exercises and full activities 4 weeks after surgery.