The breast can play a significant role in how a woman perceives of herself. If a patient is unhappy with her breast size, either because she was born with small breasts, wants to restore volume following pregnancy/breastfeeding, or is interested in further enhancing her cleavage and fullness, a breast augmentation may be the solution.
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:
Saline:
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:
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
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.
Our practice offers 24-hour fast track recovery breast augmentation, which is a protocol that consists of surgical techniques that minimizes breast tissue manipulation and reduces postoperative pain, swelling, and bruising. It also involves a postoperative pain regimen that does not include narcotic medications and ensures that the patient has a comfortable and quick recovery. We constantly hear our patients say that they don’t feel pain, and that they only feel some pressure in the chest that quickly goes away as the body gets used to the new breast implants. This protocol enables most of the patients to return to their activities of daily living in 24-48 hours. We also establish a scar therapy regime to optimize the healing process and obtain the best scar results.
When an implant is inserted in the body, scar tissue automatically forms around it; we call this a “capsule.” This is a normal healing response, as it attempts to isolate the implant inside the body by creating a barrier of tissue. This occurs not only in breast implants, but in every single prosthesis inserted in the body, whether orthopedic, neurological, facial, buttock, cardiac, etc. In terms of breast surgery, this capsule is typically a good thing, since it becomes the home of the implant and maintains it in place. However, in certain patients, this capsule becomes unusually hard and can alter the postoperative appearance of the breast. When this occurs, it is called capsular contracture. It is important to note that this is not harmful to the body.
Although the exact cause of capsular contracture is not entirely determined, studies suggest that this condition is mainly caused by implant contamination, presence of blood around the implant, and/or genetic predisposition.
So, how do we reduce the risk of capsular contracture? Dr. Couto follows the 14-point plan, which was developed by Dr. Couto’s mentor, Dr. William P. Adams Jr. This protocol consists of 14 steps that have scientifically shown to minimize the risk of capsular contracture and other complications. Additionally, Dr. Couto uses povidone iodine-triple antibiotic irrigation that has been scientifically studied to reduce bacterial contamination of the breast pocket. Lastly, Dr. Couto utilizes the Keller Funnel ®, a device designed to insert the breast implant without the need of touching or handling it. Thus, further reducing risk of implant contamination, and capsular contracture.
This is a particular area of interest for Dr. Couto. Together with Dr. William P. Adams Jr, Dr. Couto has received a scientific research grant from the Aesthetic Research and Education Research Foundation (ASERF) to study the role of bacteria contamination in the breast capsule and analyze the effectiveness of povidone iodine-triple antibiotic irrigation in decreasing the bacterial load of capsular tissue.
A breast augmentation of any kind will not affect your ability to breastfeed. During this procedure we are not compromising any of your mammary glands and ducts. In fact, one of the main objectives of this procedure is to minimize the contact between the breast implant and the lactating breast structures to reduce risk of capsular contracture.