INTRODUCTION Breast augmentation is the insertion of implants to increase the size of the breasts. Most women desiring implants find that their breasts are proportionally smaller than the rest of their bodies. Breast augmentation can help restore a woman’s sense of proportion and in many women can improve self-esteem and confidence. Currently women undergoing breast augmentation for the first time are able to choose between silicone and saline implants. Breast augmentation is the second most common cosmetic operation in the U.S., second only to liposuction. Patient satisfaction tends to be very high. One study showed an overall satisfaction rate of 97%.

BEFORE AUGMENTATION AFTER AUGMENTATION CLICK ANY IMAGE TO ENLARGE AND FOR ADDITIONAL PATIENT EXAMPLES

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AM I A GOOD CANDIDATE FOR BREAST AUGMENTATION?
Any healthy woman who feels that her self-esteem or body image would be improved with larger breasts is a candidate for breast augmentation. The most common types of patients who undergo breast augmentation are women who have lost breast volume after childbearing, and women who have always had disproportionately small breasts.

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HOW BREAST AUGMENTATION IS PERFORMED
The surgery is almost always done under general anesthesia at the hospital. There are several reasons for this. Firstly, monitoring by an anesthesiologist during surgery provides an extra element of safety so the surgeon can focus exclusively on your surgery and aesthetic outcome. Secondly, anesthesia guarantees that the surgery will be absolutely pain free. Sometimes it is difficult to get a patient 100% comfortable if local anesthesia is used, and that is not pleasant for either patient or surgeon. Although having an anesthesiologist does cost extra money, we believe strongly that the extra safety and comfort it provides is worth every penny.

Once the patient is asleep, an incision (approximately 1 inch long) is made and a pocket is created for the implant. The pocket can be either above or below the pectoralis major muscle. (More on this later.) Next a temporary implant (called a sizer) is placed into the pocket, and the patient (while asleep) is placed into a sitting position. The size, shape, and symmetry are then adjusted to best suit the patient’s preoperative wishes. Next the real implant is chosen and placed into the pocket and filled to the desired volume. Once the incision is sutured back together an ACE bandage is wrapped around the breasts, and the patient is awakened from anesthesia and taken to the recovery room. The procedure all in all takes usually about 2-3 hours.

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IMPORTANT THINGS TO KNOW BEFORE GETTING BREAST IMPLANTS
Most patients who have breast augmentation surgery are very pleased with the results. However, being an informed patient is critical to achieving long term happiness with surgery. The following facts are important information that all patients should know before having breast implant surgery.

Implant lifespan: Breast implants, like any other medical device, can not be guaranteed to last an entire lifetime. Any woman who has implants should know that at some point in her life, the implants will most likely need to be replaced. This would require further surgery.

Need for further surgery: Most women with implants will most likely need to have further surgery at some point during their lives. This could occur for many reasons--implant rupture, capsular contracture (hardening of the implant), or change in breast shape or volume from aging or pregnancy.

Mammography: Women with implants need to have their mammograms done at centers where the staff is accustomed to working with patients with implants. The mammography technician uses special displacement techniques to visualize the breast tissue in women with implants. This may require more views and possible more radiation exposure. Mammography may not be as sensitive in women with implants, although women with implants do not have increased chances of getting breast cancer. Also recent studies show that implants have not been shown to delay the diagnosis of breast cancer. MRI is the study of choice for women with implants and a history of cancer.

Breast feeding: Breast implants may reduce the ability to breast feed, although very little data exists on this subject. Using the nipple approach may decrease the ability to breast feed more that other incisions such as the inframammary.

Insurance: Health insurance premiums may increase in women with breast implants, and complications arising from implants may not be covered. It is wise to check with your insurance company regarding its policies prior to any surgery.

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WHICH IS THE BEST LOCATION FOR THE INCISION?
There are basically 4 different options regarding incision location. The best location can vary according to individual patient differences. Here we will review the pro’s and con’s of each type of incision.

Inframammary: This is located in the fold beneath the breast and therefore is inconspicuous when looking from the front.

Pro’s: This is usually the best overall location. This incision avoids cutting through any breast tissue and therefore has the least theoretical interference with future breast-feeding. Also, if you ever need further surgery (which almost everyone will at some point in her lifetime) this incision is the easiest to reuse and minimizes potential breast defects if the implants are ever removed. Also, when viewing the breasts from above or the front, the scar is not visible.

Con’s: If the patient does not have a well-defined inframmary fold, this incision will be more visible.

Periareolar or Transareolar: This incision is placed either around the bottom of the areola or through the areola. Transareolar is the least visible incision of all.

Pro’s: This tends to heal well with a low incidence of problem scarring. Sometimes, however, the scar can be visible as a thin white line (periareolar).

Con’s: This incision may interfere with the ability to breast-feed in the future. Also, if this incision is used multiple times, a permanent indentation may occur if the implants are removed. We generally do not recommend this approach for women who have a higher chance of problem scarring, because the scar may be more visible due to its anterior location.

Transaxillary: This is located in the armpit.

Pro’s: With this approach, there is no visible scar on the breast.

Con’s: We believe that there are too many disadvantages to this approach to recommend it on a routine basis. Firstly, if a problem scar occurs, which is unpredictable, it will be visible in sleeveless clothes. Secondly, if a revision is ever needed (which is highly likely over a woman’s lifetime), it is very difficult to re-use this approach, and another incision will be necessary anyway. Thirdly, this incision can interfere with the lymphatic drainage of the breast, which could affect cancer treatment if the woman ever develops breast cancer. Finally, implants put in with this technique often tend to ride too high and don’t look as natural.

Umbilical: (belly button incision)

Pro’s: With this approach, there is no visible scar on the breast.

Con’s: We believe that there are too many disadvantages to this approach to recommend it. Firstly, if a revision is ever needed (which is highly likely over a woman’s lifetime), it is impossible to re-use this approach, and another incision will be necessary anyway. Secondly, the surgeon has little control over the pocket and is more likely to end up with bleeding or uneven breasts. Finally, the belly button has a high bacteria count and theoretically this approach could increase the risk of infection.

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ABOVE OR BELOW THE MUSCLE
This is a controversial topic, even among plastic surgeons. The answer to this question will vary according to the individual patient. This discussion is intended to tell you the advantages and disadvantages of each option so you will better informed about which option may be best for you.

Historically, the first breast implants were placed above the muscle. However, these implants (which were silicone) often ended up developing capsular contracture. Then in the 1980’s, surgeons learned that by putting the silicone implants below the pectoral muscle, the incidence of capsular contracture was reduced. It is still not understood why this occurred. Because of this finding, however, many surgeons began routinely placing implants below the muscle. Then, in 1992, the FDA removed silicone implants from the market, and saline implants became the implant of choice for breast augmentation. Although many surgeons still routinely placed their implants below the muscle, it was not known whether this reduced the incidence of capsular contracture with saline implants. Since that time we have learned that saline implants perform differently than silicone implants. Studies to date show no discernible differences in capsular contracture rates in saline implants whether they are above or below the muscle.

The primary difference between subglandular (above the muscle) and subpectoral (below the muscle) implants is not so much appearance but feel. In a still photograph, it is usually not possible to tell the difference between the two. The difference becomes apparent in the dynamic sense. For instance, when a woman with subpectoral implants flexes her pectoral muscles, the implants will move down and out. Some surgeons have called this the "dancing breast syndrome." This may be apparent at the gym, for instance. Also, as part of the muscle is detached from the bone, subpectoral implants can sometimes affect muscle strength and function. For women who are very athletic, subpectoral implants may be less desirable than subglandular implants, which do not affect muscle function.

Advantages of Subpectoral Implants: Theoretically, mammography is a little more sensitive if implants are subpectoral. We recommend subpectoral implants in women who have had breast cancer in the opposite breast, and in women with a strong history of breast cancer.

In very thin women, subpectoral positioning may reduce the appearance of implant rippling in the upper part of the breast. However, rippling may still occur, whether the implant is above or below the muscle. Furthermore, if the implant is going to be palpable, it is usually in the lower part of the breast, where the muscle does not cover the implant anyway.

SUBMUSCULAR AUGMENTATION, MUSCLE AT REST	SUBMUSCULAR AUGMENTATION, MUSCLE FLEXED
IMPLANT MOVED TO SUBGLANDULAR POSITION, MUSCLE FLEXED
CLICK ANY IMAGE TO ENLARGE

Disadvantages of Subpectoral Implants:
Subpectoral implants will move whenever the muscle is used. This can occasionally be uncomfortable and can look unnatural. Also, sometimes these implants tend to ride too high, and do not look good in women with slightly droopy breasts (i.e. after childbearing.) Muscle function can be slightly affected as well. The operation is also more painful initially.

Advantages of Subglandular Implants:
Subglandular (above the muscle) positioning of the implant is more natural anatomically and therefore the implant will move more naturally with the body. Also, the surgery is less painful initially. Muscle function is unaffected.

Disadvantages of Subglandular Implants: This position may decrease the sensitivity of mammography. Some surgeons think that subglandular positioning increases the rate of capsular contracture, although there is little data to support this with saline implants.

Our recommendations: In general, our patients usually prefer the subglandular approach, as this tends to produce a natural look and feel. Satisfaction has been very high, and our rate of capsular contracture has been very low. Also, many of our patients are athletic and they appreciate the fact that the implant is unaffected by muscle movement and that function is unaffected.

Split Muscle Technique: We recommend subpectoral positioning for women with a history of breast cancer on the other side, for women with a strong family history of breast cancer, and for women who have capsular contracture with subglandular implants. For those women who wish to have muscle coverage without  unnatural motion, Dr. Eskenazi pioneered a split muscle technique. This is ideal for women with low body fat and need coverage of the upper part of the implant.  Ask her more about this.

SUBGLANDULAR IMPLANTS Advantages More natural anatomically More natural when moving Less invasive surgery Less painful surgery  Less bleeding during surgery MRI as accurate as under muscle Disadvantages Mammography a little less sensitive

SUBPECTORAL IMPLANTS Advantages Mammography slightly better Possibly less upper pole rippling in very thin women Recommended in breast cancer patients Possibly less upper pole rippling in very thin women Split muscle technique covers implant and prevents unnatural motion. Disadvantages More painful surgery Less natural with movement May be uncomfortable in athletic women

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SHAPES AND TEXTURES
Implants come in round and "anatomic" shapes and in smooth and textured surfaces. In our experience, the smooth round implant seems to give the most natural looking and feeling result. Textured implants adhere to the surrounding tissues and are thicker to the touch. They often do not move with the body and have a higher incidence of visible rippling. Studies do not show significant differences in the capsular contracture rates between smooth and textured saline implants.

There are several varieties of "anatomic" implants, some of which are not really anatomically correct. The main disadvantage of these shaped implants is that they need to be textured to prevent rotation. This, of course, increases the chance of visible rippling, and the implant will not feel or move as naturally. Furthermore, a recent study has shown that in the body, the round implant behaves like a shaped one anyway.

Our Recommendation: In general we have found that the smooth round implants are as natural as shaped implants. They do not rotate and move to the side naturally when you lie down. Occasionally textured implants are used in women with a history of capsular contracture.

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CAPSULAR CONTRACTURE
Capsular contracture is when the normal scar tissue that the body forms around the implant thickens and contracts. This can make the implant feel hard and can distort its shape, and sometimes can be painful. This can be very frustrating to patient and doctor when it occurs. Unfortunately, the cause of capsular contracture is unknown, although we do know that bleeding and infection can contribute to it. In saline implants, capsular contracture can occur from 3-5% of the time, although it generally does not tend to be as severe as in silicone implants. Some contractures are so mild that patients don’t notice them or object to them. In more severe cases, however, the implant can look rounder, feel too firm, and can change in shape. Occasionally, further surgery is required to release or remove the contracted scar tissue. At this moment in time, there is no absolute way to prevent capsular contracture. It seems that massaging the implants regularly can help prevent it, but this is only recommended with smooth implants. We have several unique techniques of massage and postoperative treatment for preventing capsular contracture including oral medication, the Soft-EZ clamp and lasers which make our capsular contracture rate extremely low.

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SILICONE VS. SALINE
The FDA removed silicone implants from the market in 1992 for further evaluation. Recent studies have shown no link between silicone implants and connective tissue diseases, and recently the Institute of Medicine released a statement that silicone implants are not associated with any systemic illnesses. 

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RECENT NEWS ON IMPLANTS
Both silicone and saline implants made by Mentor Corporation and Allergan Corporation have been approved for breast augmentation in women over 18 years of age and for breast reconstruction. Implants by PIP America have not yet been approved.

The FDA has stated that breast implants are not approved in the following circumstances:

• the patient has an active infection anywhere in the body
• the patient is pregnant or nursing
• the patient has cancer or pre-cancer that has not been adequately treated.

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