Breast augmentation is surgery to increase breast size by placing breast implants.

There are a few decisions you must make with your doctor when planning your breast augmentation.
The key decisions are:
   • Size
   • Shape and Texture
   • Type of Implant Filler
   • Scar Location
   • Implant Location – Subpectoral vs. Submammary

You and your doctor must also discuss the risks inherent in breast augmentation surgery.

SIZE
This is, for the most part, a personal decision. There are a couple of important points to remember when choosing an implant size. First of all, as the implant gets to be a larger volume, it also gets wider, so if you go to a size wider than your chest you'll get the unnatural "breasts sticking out the sides" look. One way around this if you want to go large is to try high-profile implants, which give you more outward projection at a larger volume, with a smaller implant width. Overall, big implants do bad things to your breasts over time, so if you are thinking of going with a size more than 500cc, think carefully about what your stretched-out breast skin will look like when you are 50, 60, or 70 years old. Also, a very large implant is mostly not subpectoral (under the pectoralis, or chest muscle), and it loses the advantages of being placed in this anatomic location.

I've seen patients try many creative techniques to find the right size implant. Trying the implants on in your bra can give you a rough idea. Or, even better, measure the right amount of Jell-O or rice into a Ziploc bag at home and wear it in your bra. The most reliable method is to find someone who has implants you like, and who has a body type similar to yours. You can find hundreds of examples at implantforum.com.



SHAPE AND TEXTURE
There are different shapes of implants. The two most common are discussed below.

Anatomical implants are fuller on the bottom, where a breast is naturally fuller, and are therefore supposed to look more natural. Occasionally, these rotate and shift and then look extremely unnatural. In addition, having full breasts up top is often a desirable look, perhaps why anatomical implants are used so much less frequently by all plastic surgeons compared to round.

Round implants are equally full on the top and bottom of the breast. They have a flat back side that goes against the chest wall (or pectoralis muscle, if the implant is placed in the sub-mammary position).

The wall of the every implant is made of a silicone polymer. It can be smooth or textured. A textured implant is more likely to stay where the surgeon puts it and is less likely to be malpositioned, but it sticks to the capsule that surrounds it and therefore is more likely to have problems with rippling. Rippling refers to a implant under the skin which causes a visible deformity that looks like waves of fluid. Because of the increased risk of rippling with textured implants, I recommend smooth implants for most patients.



TYPE OF IMPLANT FILLER
There are two types of implant fillers: saline and silicone. Both are contained within silicone sheeting. Saline implants are filled with salt water that is completely safe to the body. Because they are filled with water, many feel they are more "water balloon" like in feel and appearance. If you have a decent amount of breast tissue, the implant will be well covered and appear very natural, especially for smaller implants less than 350cc. Silicone implants feel much more like real breast tissue. The current consensus in the medical community is that silicone is nonreactive and does not cause autoimmune disease or cancer, although ruptured implants, especially older ruptured implants, can cause contracture, calcification of the capsule, and leakage of silicone outside of the immediate area. The good news is that a new "cohesive" silicone implant has been approved soon by the FDA. With a cohesive silicone implant, even if the implant ruptures, the silicone doesn't leave the implant area.



SCAR LOCATION
An incision must be made in order for the implant to be inserted. And anytime there is a skin incision, there will be some scarring. There are four places where an incision can be made in order to put in an implant:

1. just above the crease at the bottom of the breast (inframammary)
   
2. at the edge of where the areola meets normal skin (infra-areolar)
   
3. in the armpit (transaxillary)
   
4. in the belly button (transumbilical breast augmentation, or TUBA)
   

The inframammary is easy for the surgeon, and if placed correctly, will not show when you are wearing a bikini top. There will be a scar on your breast that is usually 3cm to 4cm long, depending on if you choose saline or silicone implants.

The periareolar scar is located on the breast, but is masked because it is located at a natural line. The scar is usually just around the lower half of the areola or less, right where the pigmented areolar skin meets the normal breast skin. If you have small areolae or a lot of breast tissue, this is a tougher operation for the surgeon and a longer procedure for you. It can result in altered nipple sensation. Very small areolae cannot be used for silicone breast implants.

The transaxillary approach places the scar behind the fold in your armpit crease. Although theoretically this scar is visible when you lift up your arms, it is usually very difficult to find. It also has the advantage of having no visible scar on the breasts. Because the implant is placed from the top, the implant will tend to ride up and sit high. Your doctor may want you to wear a snug wrap or bandeau above your breasts to keep the implants in place for the first few weeks post-operatively.

TUBA places the incision in the top part of your belly button. The whole operation is done through a long tube passed from the belly button to the breast. After the pectoralis muscle is bluntly pulled from the chest wall, the implant is then placed under the wall, relying on the pressure of the filled up implant to stop any bleeding, as the surgeon cannot directly see the area being dissected. The placement of the implant under the muscle is unreliable, and for that reason I do not offer TUBA.



IMPLANT LOCATION – SUBPECTORAL VS. SUBMAMMARY
Breast implants can be placed in two different layers: under the pectoralis (the chest muscle), called subpectoral; or over the pectoralis muscle, called submammary. In my view, the only advantage of the submammary approach is that it gives the breast more lift if, let's say, you want to augment a saggy breast. In all other ways, however, this method is inferior. With subpectoral implants:
   • the breast implant tends to stay in its position in the long term
   • mammograms are more accurate
   • visible rippling is less likely
   • the breast appears to be more natural, especially in those with thin skin
   • the risk of capsular contracture is lower



RISKS
There are always risks with every surgery. I have included the six that are most common in breast augmentation.

1. Rippling
   This is caused by visible fluid waves under the silicone shell of the implant. It is most likely to occur in women with submammary implants and thin skin. It can be minimized by using smooth, rather than textured, implants, and with something called "overfill" if saline implants are used. Overfill means that the surgeon fills the implant to a total volume greater than the usual amount recommended to "pop" out the wrinkles. In general, this takes only an extra 20 or 30cc's.
   
   
2. Implant Malposition
   Implants can migrate too high, too low, too far toward the middle of the chest, or off to the side. They should be right under your nipples.
   
   If they are too high - a common problem - your breasts will look as though they are hanging off the implant, especially if you have some breast droop (which could be fixed with a mastopexy).
   
   If they are too close together, you will look "wall-eyed," in other words your nipples point outward. Your implants may even touch each other midline, called "bread loafing."
   
   Implants that are too far toward the side (called lateral implants) can rotate fully out into the armpit, leaving the nipples pointing inward.
   
   Finally, low breasts will have upward pointing nipples with a "bottomed-out" appearance. These problems can be prevented during the augmentation procedure by careful dissection of the implant pocket. Implants that are too low usually need to be fixed surgically. Don't worry if your breasts look too high immediately after your surgery, especially if you have subpectoral implants - this is normal and can be partially due to swelling of the pectoralis muscle on top of the implant.
   
   
3. Capsular Contraction
   This risk is high, occurring in up to 25% of all implants. Normally, your body tries to section off the implant from the rest of you by forming a fibrous capsule around the implant. With time, your body may have an abnormally heightened response to the implant, and form a very thick, or contracted, and very tough capsule around the implant. As the capsule contracts, the breast gets tight and firm, and starts to look less like a breast and more like a half-melon or even a round ball. Capsular contraction can be repaired surgically. Its risk can be minimized during the augmentation procedure by placing the implant under the pectoralis muscle and by not using too large an implant.
   
   
4. Rupture
   Unfortunately, there is a risk that your breast implant may spontaneously rupture, which in saline implants, results in the immediate deflation of your breast. This occurs at a rate of 1% per year. The two American companies that supply breast implants, Mentor and Inamed (Allergan), have different warranties that cover replacing ruptured implants, and even the payment of your surgical fees.
   
   
5. Infection
   Any surgery has a small risk of infection. When infection occurs with breast implant surgery, it may necessitate the removal of your implant and its replacement at a later date. Aside from the employing the "no-touch" technique (in which the surgeon doesn't handle the implant at all except when absolutely necessary, and of course always in a sterile fashion), and taking preventative antibiotics, there is little you can do to prevent this, but it is, thankfully, very rare.
   
   
6. Hematoma
   Any surgery may cause a pocket of bleeding, called a hematoma. If one of your breasts is more painful and a larger size than the other, call your doctor immediately. If a hematoma is not evacuated, it may cause you to have problems in the future, such as slow recovery, infection, and capsular contracture.