Breast augmentation surgery (or augmentation mammoplasty) is designed to increase the size of naturally small breasts, to replace volume lost as a result of weight loss or pregnancy, to improve natural asymmetry, or to help achieve symmetry following breast reconstruction.
The choices are: Peri-areolar (around a portion of the areola, the darkly pigmented area around the nipple), Inframammary (near the breast fold), Trans-axillary (under the arm) or Peri-umbilical (around the belly button). The peri-umbilical approach is not approved by implant manufacturers and I do not offer it as an option.
At the time of your consultation, a thorough discussion of the advantages and disadvantages of each option, as well as consideration of your history, lifestyle, future plans (e.g. breastfeeding), and potential need for other procedures (e.g. breast lift) will help you to choose the approach that is right for you.
The two traditional locations for placement of a breast implant are subglandular (between the breast tissue and the pectoralis major muscle) and subpectoral (between the pectoralis major muscle and the underlying ribs). A third option is referred to as a “dual plane” or split-muscle position, where the upper portion of the implant is behind the pectoralis muscle and the lower portion is behind the breast gland.
The advantages of subglandular placement include that the muscle is not disturbed in any way, the implants can potentially be placed closer together and the implants can more easily fill out extra skin present as a result of weight loss or pregnancy. The advantages of subpectoral placement include camouflage of the implant – the muscle helps to hide the edge of the implant, potentially making the augmentation look more natural and helping to prevent visible rippling; there is potentially better visualization of breast tissue by mammogram, and a possibly decreased risk of capsular contracture.
The advantages of the “dual plane” position are that the implants can potentially be placed closer together than with the traditional subpectoral placement; the implants can more easily fill out extra skin present as a result of weight loss or pregnancy; camouflage of the implant; and decreased resistance to “settling” of the implants compared to traditional subpectoral placement, which results in most patients seeing their final contour in three – four weeks. Placing the implants in this position also eliminates the need for a breast lift in many patients who would require one if the implants were placed in the subpectoral position.
The two main categories of implants are saline and silicone. Both types have a solid silicone (rubber) shell; the difference is in the filling. All silicone implants used in the United States have a "cohesive" silicone gel filling (though there are different levels of cohesiveness available). Implants also come in different shapes (round or contoured), profiles (projection) and surfaces (smooth and textured).
The advantage of saline implants are that it is easier to detect implant rupture, and rupture may be easier to treat than a ruptured silicone implant. The advantages of silicone implants are that they tend to feel more natural (softer) than saline implants. Many factors, however, contribute to the “feel” of an augmented breast, including the amount of tissue covering the implant.
In 2017, Allergan introduced the Natrelle Inspira cohesive implants, which are round devices that maintain upper pole fullness, providing patients with an option that creates increased upper pole fullness with a smaller implant volume.
Choosing the right implant is crucial to obtaining the post-operative appearance you desire.
The procedure is performed in an outpatient hospital setting under general anesthesia and takes approximately one hour.
In general, this is a very safe procedure but certain complications can occur. In addition to complications inherent in any surgical procedure (anesthetic risk, bleeding, infection, scarring, wound healing problems), there are risks that are specific to breast implants. They include capsular contracture (thickening and/or shrinking of the scar capsule around the implant, resulting in the implant feeling hard, and in the worst cases cold and painful), infection, pain, nerve injury (increased or decreased in nipple/areola and breast sensation), deflation/rupture of the implant, implant displacement and calcium deposits in the scar capsule. Some breast tissue will not be visualized on a mammogram following an augmentation; how much varies significantly, and is influenced by many factors, including implant location, size, and surface. At the time of your consultation, you will be provided a booklet published by the implant manufacturer, listing all known and some proposed potential complications and how often they occur.
The ability to breast feed varies naturally from woman to woman, and is not necessarily related to pre-pregnancy breast size. If breast feeding is important to you, having the implant placed through an incision under the arm or in the fold under the breast will maximize your chances to breast feed post-operatively; in other words, avoid the peri-areolar approach which would be more likely to cut ducts within the breast. If the ability to breast feed is very important to you, you should avoid any elective breast surgery until after you have had your children.
It is recommended that a woman who has undergone breast augmentation still obtain all mammograms that would normally be recommended. It is very important that you advise the mammographer (before the exam) that you have implants, as there are special views that are obtained.
You will be placed into a sports bra in the operating room. Most patients wear it continuously for the first two weeks; however it is not required unless you are moving around a lot. You will be asked to avoid heavy lifting, pulling or pushing for the first two weeks. Activity can be gradually increased after two weeks, however “working out” should be avoided for the first month.
Most patients who do not perform strenuous physical tasks at work may return after a few days.
Immediately after surgery your breasts will be a little swollen, and appear a little high on the chest. The swelling will decrease and the breasts will “settle” usually over the first three – four weeks. Swelling will completely resolve and final contour should be achieved within three months. The scars will soften and fade over the first year (up to two years in some patients). The scars must be protected from sun or ultraviolet radiation until they have completely matured.
I will ask for your desired post-operative size and shape and work toward that goal; however some limitations do exist. In order to achieve a good long-term outcome, the size of the implant used must be appropriate to the size of the chest wall, and appropriate implant selection must take into account the quantity and distribution of breast tissue present naturally, as well as the width of the chest wall and the amount and quality of skin present. As bra sizes vary by manufacturer, a post-operative bra size is never guaranteed. To obtain a general concept regarding post-operative breast size (not shape or projection) you may, at the time of your initial consultation, or at a subsequent visit, place different sizers into a bra which is not padded or push-up. While this does not demonstrate exactly what your appearance will be after surgery, it may help to provide you with an overall sense of size and projection.
Fluctuations in your weight as well as pregnancy will still affect the remaining breast tissue, so that increases (or decreases) in size proportional to overall changes in body weight are certainly possible. Spontaneous growth of breast tissue after surgery is also possible, particularly in younger patients.
The information provided here was prepared as a reference, covering many frequently asked questions about breast augmentation surgery. While I hope you find it informative, it is by no means complete. Please make a list of any additional questions you may have; you are encouraged to ask them during your consultation.
Copyright 2019. Craig S Rock, MD, PA. All Rights Reserved.