A Primer on Breast Augmentation

Nina S. Naidu, MD, FACS
Article by
New York Plastic Surgeon

According to the American Society of Plastic Surgeons (ASPS), breast augmentation was the most popular surgical cosmetic procedure in 2007, with a 64% increase from 2000 in the number of procedures performed. Among Asian-Americans, it was the second most popular cosmetic surgical procedure after rhinoplasty. All breasts are made up of fatty tissue, glands, ducts, and a layer of skin. However, the size and shape of the breasts reflects an individual woman’s body type. When considering breast augmentation, it is important to educate yourself about your options, evaluate your personal motivations, and have realistic expectations about the results from your surgery.

Types of breast implants
There are currently two types of breast implants approved by the Food and Drug Administration (FDA) for use in the United States. Saline implants consist of a silicone shell filled with salt water. Silicone implants also have a silicone shell but are filled with a cohesive silicone gel. Both have advantages and disadvantages.

Silicone implants generally feel much more natural than saline implants, and are less likely to form ripples which may be visible beneath the skin. Saline implant ruptures are easier to detect than silicone implant ruptures. For this reason, the FDA recommends that women with silicone implants undergo an MRI examination three years post-implantation and every two years thereafter to screen for rupture.

Implant location
Breast implants can be placed either partially under the pectoralis major muscle on the chest (submuscular) or over the muscle and under the breast glands (subglandular). While placing the implant over the muscle results in less postoperative pain, placing it under the muscle decreases interference of the implant with mammograms, is less likely to show the edges of the implant, and possibly decreases capsular contracture which can distort the breast. The decision for location of the implant also depends upon the thickness of the breast tissue, and is ultimately determined at the time of consultation between the patient and surgeon.

Incision sites
There are four potential incision sites for breast augmentation, which include under the breast (inframammary), around the nipple (peri-areolar), through the armpit (transaxillary), and through the belly button (transumbilical).

The inframammary and peri-areolar incisions allow the best visualization of the implant pocket, which means that the implant is more likely to be positioned correctly. While the transaxillary incision has a relatively hidden scar, it is difficult to place larger silicone implants through this location and implant positioning is more challenging. Transumbilical placement can only be performed with saline implants, and it is extremely challenging to place the implants correctly from such a distant site. For this reason, many surgeons do not perform transumbilical breast augmentation.

Size and shape
While patient preference is the primary determinant of the final breast size, implant size is sometimes limited by the patient’s tissues. Tissue characteristics that are examined during the consultation include the amount of existing breast tissue, the stretch of the skin, and the width of the chest. Because most Asian-American women have smaller frames, their range of possible implant sizes may be smaller. Keep in mind that placing an implant that is too large for your tissue can result in stretching of the skin which may require future corrective surgery. In addition, excessively large implants can be visible beneath the skin.

While every surgeon has his or her preferred method of determining the optimal size for a given patient, most use sizers in the office which are tried on by the patient underneath her clothing. This allows the patient to visualize what breast size she would like to have after surgery. The shape of the breasts after augmentation is partially dependent upon the starting shape, but also upon the particular implants used. For example, high-profile implants have a narrow base but produce significant projection, while low-profile implants have a wider base with less projection.

Surgical setting and anesthesia
Breast augmentation surgery is usually performed in an outpatient center or hospital. The surgery lasts 1-2 hours and you are able to return home the same day. General anesthesia, during which you are completely asleep, is most commonly used, but some surgeons will perform the surgery under sedation. Patients are advised to avoid any strenuous physical activity, including sex, for two weeks after surgery to avoid the risk of bleeding. Most patients are able to return to work within 4-5 days following their surgery.

Risks of breast augmentation surgery
Every surgery comes with its own set of risks and benefits. Some of the most common risks of breast augmentation surgery include bleeding, which may occur up to two weeks after surgery, and infection, which may require implant removal in severe cases.

Contrary to popular belief in the 1990’s, breast implants do not cause breast cancer. Several large and well-controlled studies have confirmed that there is no increased risk of developing breast cancer following breast augmentation.

Another risk of breast augmentation surgery is implant rupture. The risk of implant rupture is directly correlated to implant age, with rupture occurring in about 10% of patients at 7 years following surgery.

Approximately 15% of patients develop a capsular contracture, a tightening of the tissue capsule surrounding an implant. This can occasionally distort the appearance of the breast if it is severe. Your ability to breastfeed may be diminished following breast augmentation, and sensation to the nipple may also change following surgery.

Breast implants do interfere with mammographic screening examinations, particularly when placed under the breast tissue. Although most technologists are skilled in moving the implant to improve visualization of the breast tissue, complete visualization of the breast tissue is not possible. Finally, it is important to remember that breast implants are not lifetime devices and therefore you will most likely need additional surgery on the breasts for removal with or without replacement in the future.

Getting started
Many patients who have undergone breast augmentation report an increase in their self-esteem and confidence. When seeking more information about breast augmentation, you are urged to choose a surgeon who is board-certified by the American Board of Plastic Surgery (ABPS). While many states allow a physician with no plastic surgery training at all to label him -- or herself as a plastic surgeon, only the ABPS requires that the physician complete an accredited training program in plastic surgery and pass a series of rigorous examinations for certification. Ask to see before and after photos of other patients who have undergone breast augmentation to get an idea of the surgeon’s outcomes.

Finally, while prices vary for surgery, do not choose your surgeon based on price alone. There are many resources for additional information, including the American Society of Plastic Surgeons (www.plasticsurgery.org), Breast Implant Safety.org (www.breastimplantsafety.org ), and Natrelle (www.natrelle.com).