Breast augmentation is one of the most popular procedures in plastic surgery. This operation is completely elective and is used to enhance the size and appearance of a woman’s breasts or to rejuvenate the breasts to a more youthful state after time or pregnancy have taken their toll. While the desired results of the operation are fairly straightforward, there are many subtleties and decisions that must be made along the way to achieve those results. It is important that patients work closely with their surgeon to make sure that the operative plan and the anticipated results are clear, as to achieve the greatest satisfaction. Here we will explore some of the major decisions facing both the patient and surgeon when planning breast augmentation surgery.

The most obvious first issue is what type of implant to use. Today, in the US, there are three basic implant types. Saline implants, which have a silicone shell that is filled with salt water; round silicone implants, which also have a silicone shell but are filled with a cohesive silicone gel; and form stable implants, which have a silicone shell that is shaped like a natural breast and is filled with highly cohesive silicone gel. Historically, the debate has been between saline and silicone. Saline implants are generally regarded as safer by the public after silicone was banned for breast augmentation in the 1990’s. Few realize that silicone remained available and used for breast reconstruction (after cancer) throughout that period in the U.S. and was never banned in Europe. Today, extensive scientific research has debunked all links between silicone and autoimmune disease and both types of implants are considered safe. So the decision really comes down to patient preference.

Saline implants are slightly heavier which can burden a patient with thin skin and have a higher incidence or “rippling”, a phenomenon when you can see the scalloping edge of the implant through the skin. The major advantage of saline is a shorter scar, because the implant is inflated after insertion. Additionally, if the implant ruptures, your body naturally absorbs the liquid and you are aware of the rupture almost immediately. Silicone, on the other hand, has a more natural feel but has the disadvantage that ruptures are usually not detected by physical exam. Therefore, implant manufacturers currently recommend that patients selecting silicone undergo an MRI 3 years after implantation and then every 2 years after that to detect any leakage. Even in the face of rupture, the increased cohesiveness of the silicone gel used today often limits any infiltration of the gel outside of the natural scar pocket formed around the implant. One must always keep in mind that implants are not considered lifetime devices and a significant percentage of patients will elect or need to undergo revisionary or replacement surgery within 10-15 years.

Finally, form stable implants or gummy bear implants are breast shaped silicone implants that were released in the U.S. market at the beginning of 2014. These implants are slightly firmer than round silicone implants and are designed to give patients a more natural breast shape after augmentation. The added risk of these implants, although low, is that if they rotate in the pocket created for them, the appearance will be reflected in the breast and will likely require additional surgery to correct. Ultimately, while all three types can give great results, no implant is flawless. Implant selection is a decision between the patient and surgeon based on the patient’s anatomy, expectations, and tolerance of potential complications.

The next major issue is scar location. The three most popular locations are in the inframammary fold (under the breast), periareolar (around the nipple) and transaxillary (through the armpit). The inframammary is the most popular as the scar is well hidden beneath the breast and this approach gives the surgeon the most control over the development of the implant pocket and positioning. The periareolar approach often leaves an almost imperceptible scar at the junction of the nipple and normal skin. This approach has begun to fall out of favor over concerns that bacteria in the breast ducts that convene at the nipple may contaminate the implant. The transaxillary approach has the advantage of no scar on the breast but leaves the surgeon with limited control of dissection and can have a higher incidence of implant malposition. More radical approaches, such as transumbilical (through the belly button), have failed to gain widespread popularity as they further limit control of implant positioning in exchange for avoiding scars that patients usually find satisfactory.

Another anatomical consideration is whether to place the implant under the pectoralis muscle (subpectoral) or under the breast alone (subglandular). The advantage of placing the implant under the breast alone is a more natural appearance, no risk of animation (movement when the pec muscle is flexed), and less postoperative pain. The advantage of placing the implant under the pectoralis is that natural movement of the muscle is believed to help prevent a capsular contracture, a complication where the natural capsule that forms in the breast becomes hard around the implant. Subpectoral placement also has a decreased incidence of implant palpability (feeling the implant through the skin) and of visible upper pole rippling. While patient input is important in all aspects of operative planning for a breast augmentation, selection of implant placement is often a decision that requires the informed advice of your surgeon based on your tissues and expectations.

As with anatomical location of the implant, the need for an additional lift, or mastopexy, in addition to a breast augmentation is an issue frequently addressed at consultation. Again, this is an individualized decision that is based on the quality of a patient’s tissue, nipple location, and desired results and often requires the informed input of an experienced surgeon. It is true that a woman will get approximately 2 cm of nipple lift with implantation alone, but pushing the envelope much more than that by using larger implants can lead to lackluster results and further issues with skin stretching and implant sagging down the road. Many patients are unhappy about the additional scars associated with synchronous lift, but must understand that this may be a necessary component of the operation in pursuit of the best aesthetic outcome.

Recovery from augmentation surgery is also an individualized experience. Generally, women experience the greatest discomfort in the first 24 hours, which is associated with the stretching of the pectoralis muscle, from the creation of implant pocket. Significant improvement in pain is seen in the next 48 to 72 hours and most patients are back to all routine activities by day 5-7. We recommend that a patient avoids cardiovascular exercise for two weeks after surgery and heavy lifting and core exercises for a full 4-6 weeks. It is also important for patients to understand that after breast augmentation, it often takes 6 weeks for all of the swelling to resolve and for the implants to settle into their final location. The “high riding” appearance of the implants in the immediate post operative period can be alarming to patients and requires patience and a little faith. Natural asymmetries that existed prior to augmentation often persist postoperatively and should be appreciated by both the surgeon and patient as such when evaluating the final results of the procedure.

Breast augmentation is not only popular, but it is also one of the most satisfying operations in plastic surgery for both the patient and surgeon. A thorough understanding of the potential and limitations of this operation, as well as the anatomy and decision making surrounding it, allows for an informed patient to work with their surgeon to develop and individualized surgical approach and achieve the best possible results.

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