Tulsa Surgical Arts • Board Certified by the American Board of Cosmetic Surgery • 7322 E 91st Street • Tulsa, OKlahoma 74133

Angelo Cuzalina, MD

Breast Augmentation

Breast augmentation in Tulsa, OK is a cosmetic surgery procedure designed to enhance the body contour of a woman unhappy with her breast size. In addition to being a reconstructive technique following another breast surgery procedure, it may also be used to correct volume loss after pregnancy or to help balance breast size asymmetries.

While breast augmentation will enlarge the breasts, it will not alter basic defects in breast shape or form. Major asymmetries may be improved, but will not be completely corrected. A slight difference in the size or shape of the two breasts is considered normal and should not be a cause for concern. If breast size or nipple position asymmetries are severe, then additional procedures to further improve symmetry may be necessary. Long experience with this operation has demonstrated it to have highly satisfactory results for the majority of patients who are considered suitable candidates for the surgery.

Recent findings have linked a rare form of cancer to textured breast implants. Dr. Cuzalina uses only smooth-surface breast implants on his patients and offers complimentary follow-up appointments for any breast augmentation patients who may have questions or concerns about their implants.

Breast Augmentation Incisions

At Tulsa Surgical Arts, all breast augmentation operations are carried out in our AAAHC-approved Cosmetic Surgical Center under general anesthesia on an outpatient basis. A breast implant is placed through a small incision and then under the breast tissue or under the muscle. The incision can be made in locations such as:

  • Under the breast
  • In the armpit
  • Around the nipple
  • In the belly button

It generally takes one to two hours to complete the entire procedure. A breast implant is composed of an outer silicone shell filled with saline or silicone gel. The outer surface may be smooth or textured, and implants come in various shapes to meet the specific needs of individual women.

Silicone Breast Implants

Silicone implants were first popularized in the 1960’s. Controversy
in the early 1990’s led to widespread fear about the possibility of silicone
breast implants causing autoimmune diseases in women. Extensive studies since
then have showed no evidence that silicone breast implants have any
relationship to breast cancer, autoimmune disease or any other systemic
illnesses in patients. Specifically, patients with breast implants have no
higher incidence of diseases such as rheumatoid arthritis, scleroderma or
lupus, in comparison with the general population.

The Food & Drug Administration approved the use of the third
generation silicone gel implants in November of 2006 for women 22 years of age
and older. These implants are not filled with liquid silicone, but rather a
cohesive silicone gel. Dr. Cuzalina was a part of the study of these implants
that led to their approval for cosmetic use. 

The increased safety of the cohesive gel implants led to the FDA’s
approval of these implants for cosmetic use. Saline implants are FDA approved
for breast augmentation in women 18 years of age and older. The FDA set the
age of approved use higher for silicone gel implants to ensure that a woman is
emotionally mature enough and fully understands the risks of these

There is no perfect breast implant and both the saline and silicone gel
implants have advantages and disadvantages. The silicone gel implants feel
softer and more natural, have less chance of rippling, but are more expensive
and have a higher chance of developing tightening of the scar tissue around
the implant known as capsule contracture. 

The manufacturers of silicone gel implants (Mentor and Allergan)
recommend that you get an MRI after 3 years and then every 2 years thereafter
to ensure that your implants are not leaking. Insurance will likely not cover
the cost for an MRI. The manufacturers also warn that your insurance carrier
may increase your health premiums or decline coverage if you have silicone gel

Saline Breast Implants

Saline implants are very safe and if they become damaged or deflate,
your body will absorb the water. Saline implants are more prone to rippling
and feel less natural than silicone. We will review the implants with you at
your consultation and help you to decide which implant is best suited for

Our experience suggests to us that there is approximately an annual 1%
risk of leakage from saline implants. The FDA clinical trials for silicone gel
implants suggest a leakage rate of 8-15% over the course of 10 years.
Replacement is generally a relatively simple operation. Additional cost is
involved, but most implant companies offer warranties that help offset a small
portion of the fees for up to 5 to 10 years.

Living With Breast Implants

Following breast augmentation in Tulsa, OK, routine examination for
breast changes remains very important. Some studies have suggested that it may
be more difficult to detect early breast cancer on routine mammography,
although this has not been proven and other authorities feel that with proper
technique, mammography can be as successful in augmented patients as in the
normal population. 

According to the most current information present, special techniques should allow patients to detect cancer without significant increased risk as long as the implants remain soft.

Risks of Breast Augmentation Surgery in Tulsa, OK

As is the case in all surgery, there are certain risks that are
inherent with this operation. Although the scars are usually well hidden,
irregularity or thickening of scars can occur which might require

Rarely, hemorrhage may require removal of prosthesis to control the
bleeding. Infection is probably the most serious risk of breast augmentation.
If an infection occurs, antibiotics alone will rarely clear up the infection
unless the implant is removed. It may be necessary to leave the implant out
for a period of about three months before it is safe to attempt

The risk of infection during the first year, as reported by the
manufacturer, is between 0.5 and 1%. Our own experience is currently lower
than this. Infection is usually confined to the first few weeks after surgery,
however infection from certain bacteria can show up later. Fortunately the
prosthesis can usually be successfully replaced at a later time after the
infection has completely resolved.

Another potentially serious complication is implant rejection. Silicone
is the least reactive material used for implant construction. Most patients
tolerate the material without difficulty. Nevertheless, a very small
percentage will react to the material, making successful augmentation an

This is a very uncommon problem and is more often a problem related to
an implant that is too large for the soft tissue that is available or delayed
wound healing. Delayed wound healing that could predispose one to implant
exposure may occur in persons with diabetes, history of radiation, autoimmune
disease, or smokers. Implant exposure is more common in patients who smoke
since this can compromise the incision or quality of tissue covering an

Will I lose sensation in my breasts after having breast implants?

Sensory changes can occur resulting in numbness or discomfort, and
while these symptoms are usually not long-standing or severe, they can be in
some cases. Temporary sensory changes are common and usually last 2 to 6
months. Risk of permanent sensory loss increases with increased implant size
since larger implants stretch the sensory nerves further. Implants could
possibly interfere with nursing although many patients nurse after the
operation without difficulty.

What is capsular contracture?

One problem that can occur with breast implants is related to the
natural tissue capsule that forms around the implant within the body.
Sometimes this capsule thickens or contracts causing an unnatural firmness or
shape to the breast. This condition is called “capsular

In severe cases, calcium deposits can develop and the patient can also
experience discomfort or pain. In mild cases, breast compression exercises may
allow the capsule to stretch and soften. Although in more advanced cases,
further surgery and possible replacement of the implant is

For years, many surgeons believed that by applying a textured surface to
the silicone implant, it would decrease the risk of firmness (capsular
contracture). This belief was based on experience years ago with polyurethane
covered implants. These implants were found to remain soft in the vast
majority of patient. Recent reports by implant manufacturers suggest that this
may not always be the case and that in many circumstances smooth implants may
have the same rates of capsular contracture.

Our experience suggests approximately a 1% annual risk of developing
capsular contracture severe enough to indicate surgical revision following
saline breast implant placement. Patients should be aware that the studies
presented to the FDA indicate that the overall risk of requiring further
surgery is significantly higher and could be as high as 15 to 20% within the
first three years following surgery. Massage of the breast after implants may
help prevent contracture, but its efficacy is debatable.

In the past, surgeons often recommended extremely firm compression
(enough to tear internal scar tissue) to treat capsular contracture by a
procedure known as a closed capsulotomy. Because of the risk of breaking the
outer membrane of the implant, this technique is no longer recommended in most

Correcting Capsular Contracture

Currently, we use a laser or modified cautery endoscopically to
release the scar tissue through a small incision. This endoscopic capsulotomy
is a simple procedure that works well for mild capsular contracture, but may
be inadequate for more severe scar thickening. For more severe capsular
contracture a complete capsulectomy (removal of all scar tissue) and
replacement of the implant may be required. Unfortunately, there is no
certainty that the scar tissue will not reform.

Rippling, or surface irregularities over the implant that can be seen or
felt, is a potential problem with any type of breast implant. It occurs more
frequently with saline-filled implants because the water in the implant is
less viscous than silicone gel. The added risk of rippling is the trade-off
for the increased safety of the saline filled device. 

Because of the potential problem, placement of the saline filled implant
under the muscle may be indicated to help decrease the risk of rippling. This
is because it gives more soft tissue coverage over the implant. This may be
particularly true for patients who have very little breast tissue.

Since the pectoralis muscle only covers the upper portion of the implant,
rippling can still occur where there is not muscle coverage. The bulk and size
of the pectoralis muscle varies from individual to individual, and so there is
no set rule as to how much of the implant will be protected. A major factor
influencing the possibility of rippling is implant size. 

Larger breast implants tend to stretch and thin out the overlying tissue,
resulting in less natural coverage over the implant. For that reason, rippling
is more common in patients who select very large implants. This is a factor to
be taken into consideration selecting implants size. Implant texturing may
also increase the chance and severity of rippling. Smooth surface implants
seem to have less of a chance for rippling than textured surface

Our experience has shown that while a significant percentage of patients
are aware of some rippling, relatively few find it of sufficient magnitude to
be objectionable. If it is a problem, a possible treatment consists of over
filling of the implant. This is a surgical procedure in which additional
saline is placed inside the implant. By overfilling, the ripples are smoothed
out to a certain degree by the added pressure of the fluid placed within the
implant. The result of the operation is a much firmer implant, but, hopefully,
with decreased rippling. Another option for patients who suffer from implant
rippling is exchange of the saline implants for silicone gel filled

In selecting the size of the implant, the general choice should be
jointly made by the patient and the surgeon prior to surgery. While
ultimately, the choice of size is made by the patient, she should recognize
that there are advantages to a conservative selection. 

Capsular contracture and rippling are more common with larger implants.
Postoperative numbness and long term sagging are also more common with the selection of a larger
size. However, despite the increased problems with larger implants,
it is rare that our patients complain of being too large following breast
augmentation in Tulsa, OK. In general, our patients say they are extremely
pleased with their new size, with 3-5% saying they might have gone slightly
bigger if they had to choose over again. 

Choosing the Size and Shape of Your Breast Implants

The shape of your augmented breasts depends on the implant size and
shape along with how your breast appeared prior to surgery. The same size and
shaped implant on one patient can look completely different on someone else.
Therefore, one should avoid picking a size or shape solely on what ‘looks
good’ on someone else.

Implants may be round or teardrop-shaped (anatomical). While teardrop
(anatomical implants) may seem like a good idea they have some drawbacks.
Teardrop implants widths are different than their length and any rotation may
produce an unwanted asymmetry. Round breast implants are the same diameter all
around but not ball shaped. They come in a variety of widths and varying
amounts of projection to suit various patient preferences.

Many patients desire fuller cleavage. Although larger implants will give
more cleavage, the patient’s nipple position, chest shape, and breast shape
largely determine the amount of cleavage that can be achieved. During your
consultation and pre-operative visits, our surgeons and nurses will help
you determine the implant size by placing actual filled implants of various
sizes in special surgical bras to help estimate the size you desire. You may
want to bring different shirts to see how your new look appears in different

Some women find it effective to pad a bra by using baggies filled with
birdseed or rice to estimate the approximate additional volume they desire.
The final decision is yours, and you will need to decide on an implant size at
your preoperative appointment the week before surgery.

Surgical Placement of Breast Implants

The breast normally covers a muscle on the chest wall called the
pectoralis muscle. Breast implants can be placed above or below this muscle.
When implants are placed below the muscle, it is called a submuscular
placement or a subpectoral placement. When the breast implant is placed above
the muscle, it is called a subglandular or submammary placement, meaning that
it’s below the mammary gland.

Submuscular Placement

We generally prefer to place breast implants below the pectoral
muscle. A possible advantage of submuscular placement is that it may allow
better mammography and, thus, less chance of missing a breast lesion. Another
advantage of submuscular placement is that the implant is entirely beneath the
breast tissue, decreasing the possibility of interference with breast
function. Research indicates that implants placed below the muscle are less
likely to develop firmness (capsular contracture). This may be the result of
pressure or internal massage of the implant by muscle movement.

Disadvantages of submuscular implant placement include a slightly more
painful and prolonged recovery compared to subglandular placement. The most
severe pain lasts for one week on average. We tell our patients to avoid
lifting anything more than five pounds the first week and ten pounds the second

Patients should also avoid raising their elbows above shoulder level the
first ten days. Overuse of the arms and pectoralis muscles can cause the
submuscular implant to ‘ride up’ initially. Implants placed below the muscle also
require more time to settle than submammary implants. Slight flattening
beneath the breast should be expected initially. This requires one to two
months on average for the breast tissue to stretch and soften in order for the
breast to ‘round out’ in the lower half.

Patients who have moderate sagging of the breast may be at risk for a
problem known as the ‘double bubble’ deformity. This deformity can occur when
implants are placed below the muscle in women with some drop to their breasts.
The deformity presents as a ridge in the lower pole of the breast where the
previous inframammary fold was located.

If we notice significant droop of your breasts we will “/breast-lift”>recommend a breast lift or placement of the breast implants
above the muscle to avoid this problem. Realize though that placing an implant
above the muscle in breasts with droop will ultimately result in larger
droopier breasts with time. 

Even in ideal situations, submuscular implants will likely have a
‘flexion deformity’ noticeable when a patient flexes their pectoralis muscle
causing a temporary crease along the edge of the muscle over the lower
implant. While noticeable briefly it is of no major concern and the breast
should appear normal at all other times. 

A thorough consultation and pre operative screening with your surgeon is
critical to determine your options and ideal treatment plan. We offer the
choice of implant placement, either above or below the muscle to our patients.
Currently, most of our patients elect to have their implants placed beneath
the muscle.

Techniques for breast augmentation incisions

There are several ways in which the breast implant can be inserted.
An incision can be made under the breast (inframammary), in the armpit
(transaxillary), around the bottom of the areola (periareolar), or through the
belly button (TUBA-transumbilical breast augmentation). 

Tulsa cosmetic surgeons Dr. Cuzalina
offers all of these incision choices, but he prefers using the transaxillary
incision in most cases. The incision under the breast (inframammary) is the
most common, but is our least favorite for a number of reasons. First, it is
the area that most people relate to breast enlargement surgery. Also, it may
not always end up in the new inframammary fold where it would be hidden the

More importantly, this approach places the scar very close to the
implant. If the incision should get infected, it may be more likely that the
infection could reach the implant. 

Finally, although inframammary scars usually heal well, we have seen
some instances of scar thickening that were very difficult to improve.
However, the incision has been used for decades and remains a viable option
that usually has no major problems.

The periareolar incision is made in a semicircular fashion around the
lower half of the areola approximately 4-5 centimeters in length. It offers
the advantage of keeping the incision far away from the implant and allowing
good surgical exposure of the entire pocket. The incision may have a slightly
higher risk for loss of nipple sensation as compared to the transaxillary
incision, but remains an excellent incision option.

The transumbilical breast augmentation (TUBA) is a method of augmenting
the breasts through a small incision in the belly button. This approach is
reasonable when the implants are being placed above the pectoralis muscle.
Although this approach can be used for placement of implants below the muscle,
it is much more involved than using any of the other incisions. The advantage
of this approach is the small hidden incision. The disadvantage is that the
abdomen can remain swollen for a longer period of time and only saline
implants can be placed with this method.

Endoscopic Transaxillary Placement of Implants

Cosmetic surgeon Dr. Cuzalina prefers the transaxillary incision
because it offers several advantages. The incision is approximately 4
centimeters in length placed high in the armpit. The incision usually heals
very well, leaving no visible scar on the breast itself. Because of its
distance from the breast, an endoscope can be used for direct vision
dissection and much better visualization of all muscle, nerves and

Since blood around the implant can organize and eventually lead to
thickened scar tissue, it is important to perform the surgery in as bloodless
a field as possible. The use of endoscopic surgery has allowed us to carry out
breast augmentation with more precision and less bleeding. 

Special instruments designed for this purpose allow us to work through
very small incisions, monitoring the operation on a video screen. The
dissection is performed under close observation using an endoscopic telescope
with a built-in video camera to project the inside of the pocket on a large
operating room screen. The pocket then is tailored under direct vision rather
than the traditional blind dissection. The improvement is obvious since it is
always better to see clearly what one is cutting.

Recovering from Breast Augmentation in Tulsa, OK

Anesthesia is provided by a registered nurse anesthetist or by an
anesthesiologist. A layer of elastic tape will be used for one week to help
support the breast along with a light compression bra. Patients usually return
to light activity within two to three days after surgery. Full activity is
resumed within two or three weeks, but no vigorous bouncing type activities
(jogging or horseback riding) are recommended for six weeks. Although the breasts
usually look good almost immediately after surgery, there is an improvement in
the shape over the following several months.

Breast enlargement has been performed for decades and continues to increase in popularity. It is easy to understand why this operation has remained such a popular cosmetic operation for women. Breast augmentation in Tulsa, OK is a safe procedure that has produced pleasing and satisfying results for many women. With the improvements in technique and implant technology, many of the problems of the past seem to have been largely minimized. Certainly those patients who are psychologically stable and have realistic expectations benefit the most. A preliminary consultation can help you determine whether breast augmentation is right for you. Call Tulsa Surgical Arts or send us an email to schedule your breast augmentation consultation.