Who's a good candidate for breast augmentation? Permanently changing your body is a big decision and one you, not someone else, should make. I encourage people to research the procedure thoroughly and find a board certified plastic surgeon they feel comfortable with and who will spend the time necessary to answer all their questions.

I see two different types of patients seeking breast augmentation, each with their own motivation. Many younger women wan their breasts enlarged because their breasts have always been small and they want breasts more proportionate to their body. I see an immediate increase in self-confidence in these patients because their appearance dramatically changes and they are able to wear the things they have always wanted to wear but didn't feel comfortable in because of their breast size. Many women after pregnancy lose breast volume and fullness in the upper portion of the breast. These are typically patients who have been satisfied with the size of their breasts but after having children their breasts begin to look deflated and they don't fill out their bra and look as good in clothes as they once did. They are not necessarily wishing to have their breasts larger, just fuller.

About the procedure:
Implant Position (on top or underneath muscle)
Implants can be placed either submuscular (below the pectoralis muscle) or subglandular (on top of the pectoralis muscle). I put man of my implants on top of the pectoralis muscle for one reason, they look more natural, particularly as patients age and their breasts begin to hang or sag. Implants under the pectoralis muscle can look very natural in patients with small perky breasts but after preganancy and with age the breasts begin to hang and becomes very flat at the top of the breast. Implants under the muscle in a patient like this develops a very unnatural “snoopy nose” appearance. The implant stays where it was placed under the muscle and as the breast begins to sag it begins to slide off the implant. This can make the breast appear to sag more than it actually does. Either a mastopexy (lift) is needed to move the breast back over the implant or the implant needs to be taken out and placed on top of the muscle. As the breast begins to hang with age the implant follows the breast, maintaining its natural shape. I prefer to move the implant above the muscle because the scars from a lift are often
unacceptable.

The only downside of implants above the muscle is that they usually are more palpable (the shell of the implant can be felt when lifting or pushing in on the breast). The degree of palpability is also determined by the thickness of a patients' tissue. Patients with thin skin and breast tissue feel their implants more than patients with thick tissue.

Although patients with implants under the muscle feel them less, all patients with saline implants can feel their implants to some degree. It's a trade off, if you want larger, fuller, prettier breasts you must deal with implant palpability as long as saline implants are used. Implant palpability does not seem to bother patients as much as I thought it would once they get used to the feel. And it doesn't seem to bother husbands and boyfriends. Men seem to be more concerned with size. Silicone gel implants will soon be available for primary augmentation so implant palpability won't be as much of a problem.

Other advantages of implants above the muscle are less postoperative pain and quicker healing. Patients with implants above the muscle see their final result in about 3-4 weeks when the swelling is gone, whereas patients with implants under the muscle need at least 2-3 months of healing before the pectoralis muscles relaxes, the implants drop and the breast softens up and looks natural. Patients with implants under the muscle have more pain and take longer to return to work, on average 7-10 days compared to 4-5 days above the muscle. In patients with small breasts which do not hang or sag (typically younger patients who have never been pregnant) implants can be placed either above or under the muscle with very natural results. However, in these patients I tend to put the implants under the muscle to lessen implant palpability.

Implant Type:
For primary augmentation, saline implants are the only type of implants approved for use by the FDA. Silicone gel implants have been approved for select patients needing a lift with implants or those patients already having saline implants that experience significant palpability or visible rippling. I use smooth or textured implants made by Mentor, one of only two companies approved by the FDA to sell saline implants. The texturing of the implants allows the breast to stay soft even when put above the muscle. In my practice the rate of scar tissue formation or “capsular contracture” is less than 1% with textured implants. Smooth implants are put under the muscle. They are less palpable than textured implants but have a slightly higher capsular contracture rate. I use round implants in most patients with the breasts looking very natural. However, I feel a tear-drop shaped or “anatomic” implant needs to be used in patients with very small breasts which have no shape. This prevents a very fake round look to the breast. I see no significant difference between round and teardrop shaped implants in patients with larger breasts that already have a natural hang to the breast. Mentor has a lifetime warranty on their implants and will replace any implant that leaks. If this occurs in the first ten years after augmentation, the patient will be reimbursed $1200 for surgery costs. I usually do not charge my patients to replace a leaking implant.

Complications:
• Hematoma - Bleeding around the implant post-operatively which can occur immediately following surgery or up to two weeks. Occurs less than 2% of cases. Can cause one breast to swell more than the other breast. Usually resolves without surgery. Ice packs for 24 hours and limited activity with your arms for the first 3-4 days is very important to prevent hematoma formation. I recommend wearing a sports bra and shirts that fasten in the front for the first few days after surgery.

• Infection – Very unusual. Occurs less than 1% of cases. I give one dose of preoperative IV antibiotics and use antibiotic foam around the implant. I do not routinely put patients on antibiotics after surgery. A wound infection can be treated successfully with antibiotics. A deeper infection around an implant usually requires temporary implant removal.

• Changes in Nipple Sensation – Patients usually develop a temporary change in nipple sensation following augmentation. This can range from a decrease in sensation to complete loss of sensation. Some patients may even experience hypersensitivity or too much sensation of the nipples. The change in sensation typically lasts several weeks before returning to normal. However, some patients may take several months to a year to regain normal sensation. Permanent loss of nipple sensation is very unusual.

• Asymmetry – Most patients have differences between their breasts. Size differences can be improved intraoperatively by adding more saline to one side but differences in shape may not be able to be corrected. Small differences in shape or symmetry between the breasts which may not be noticeable preoperatively often are magnified when the breasts are enlarged making these differences more noticeable. No one has mirror image breasts.

• Capsular Contracture – Every patient forms a thin layer of scar tissue around their implant (capsule). A patient may develop a thickening of this normal thin layer of scar tissue (capsular contracture), which may lead to a firmness of the breast. This could cause the patient discomfort or affect the appearance of the breast. Fortunately, with the use of textured implants the capsular contracture rate is less than 5%. Most of my patients that develop a capsular contracture have only a slight amount of firmness and surgical treatment is usually not necessary. (See Implant Type)

• Implant Palpability – Because saline is a liquid and not a gel, the implant has folds or wrinkles which can be felt or palpated when pushing in on the breast. Patients say this feels like a “bubble”. Even implants which are filled to their maximum recommended volume are palpable. How much a patient feels their implants depends on how thick the skin and breast tissue is and whether the implants are placed above or under the pectoralis muscle. Patients with very thin tissue not only can feel their implants quite a bit but may also be able to see the shell of the implant through the tissue which produces a “rippled” appearance. All saline breast implant patients feel their implants to some degree, and until gel implants are approved for use by the FDA, for primary augmentation palpability will be something patients have to live with. (See Implant Position)

• Implant Deflation – Occurs in up to 10% of patients every year. Deflation can occur several weeks to several years following augmentation. It is usually caused by folds or wrinkles in the implant rubbing together, creating a tiny hold where saline leaks out over time. It usually takes several days before an implant completely deflates, a patient may wake up one morning and notice one breast is not as full as the other. Implant deflation from trauma to the breast is very unusual. Implants should not be thought of as lasting a patients entire lifetime.

• Inability to Breast Feed – Augmentation has been known to interfere with breast feeding in some patients.

• Implants and Mammograms – Saline implants, particularly above the muscle, make mammograms less accurate. However, mammograms are still extremely important and patients should get regular mammograms when they reach the age of 35 or 40. Patients with implants need three mammographic views instead of the normal two because implants hide some of the breast tissue from the x-rays. Even with these three views radiologists can only visualize up to 80% of the breast tissue. Self breast examination and examination by your gynecologist is still very important. It will take some time to learn to distinguish what is breast tissue and what is implant when you examine your breast.

For more information about Breast Augmentation, before and after pictures, and to view a Breast Augmentation procedure in 3D, visit the American Society of Plastic Surgeons website by clicking here.