Breast augmentation all started in the year 1964 when two young surgeons in Houston, Texas implanted a silicone breast prosthesis in the first patient. Since that time, millions of women have undergone the procedure to enhance the appearance of their breasts. The surgical aspects of the procedure have not changed that much since, and the implants themselves are quite similar to the original implants except for some minor modifications to the silicone material used in the manufacturing of the device.
National statistics continue to rank breast augmentation as the most popular cosmetic procedure performed by board certified plastic surgeons. American society places a high premium on the female breast and many women have elected to change the shape and volume of their breasts to improve their appearance and self-esteem (among many other benefits). A breast enhancement today is a very reliable and safe procedure that enjoys tremendous patient satisfaction.
Breast size and shape preference is somewhat regional in nature. Currently, in Austin, Texas, the demand is for moderation in size and “natural” in appearance. Implants that create balance and proportion that do not make one look overweight is in vogue. Active patients in this fit city prefer to avoid large implants that can impede their lifestyle. Women prefer a size that doesn’t scream, “look at me.”
Your Initial Consultation
The consultation process at Westlake Plastic Surgery is the most important time in your journey. This is when you and I get to know one another and when we focus on choosing the right implant for you. This means a lot of conversation and education. My nurses and I will spend the time necessary to try on the various implant sizers and determine what works best for you, your body and your personality. There is no pressure to decide then; we insist on a return visit at which time we will do it all over again to make sure that we get it right. My goal is to make sure that we don’t go to big or too small—we want it to be just the perfect fit. There are several patient imaging systems available today that are designed to offer simulated results of surgery. Although these systems are novel and fun to some degree, there is nothing better and more realistic than standing in front of the mirror with your breast implant sizer on to know, real time, what your result looks like. Read my blog on how to select the right implant size.
I recommend that you visit with several surgeons before you proceed with surgery. It really helps to learn firsthand the differences among surgeons and the quality of their practices. You want to put yourself in the best hands, always. Great results and great care come from great doctors. Please take a moment and read my article on how to get the most from your consultation.
Most plastic surgeons offer breast enhancement. It’s important to select a surgeon who has an excellent reputation and vast experience with all forms of breast procedures. Besides routine breast augmentation, I also enjoy a busy practice helping those who have had previous work done and are looking for corrections and modifications. If you have had previous breast work and you are looking for improvements, take a moment and visit my breast revision center. My vast selection of before-and-after “patient stories” speak volumes about my experience and the quality of my outcomes.
My best, honest advice to anyone seeking a breast enhancement is to do your homework, choose your surgeon wisely and avoid the “impulse buy.” As common as a breast augmentation is nowadays, it is still a major surgical procedure that requires serious considerations. Complications can and do happen and you want to be in the best hands. Never assume that a breast enhancement is a simple routine endeavor. When it comes to your breasts, you always want the best.
Proportional and natural are the buzz words when it comes to breast augmentation. Patients are very familiar with what they don’t want to happen — breasts that are too large, fake in appearance, balloon like, unnatural, hard, “stuck on” or not proportional. Cleavage is desirable, natural superior fullness is wonderful, and a size that is sustainable over the long haul is smart. Women prefer that that first thing someone sees when they walk into a room is not their breasts.
I also have patients who specifically seek out results that are not mainstream. Some prefer the “fake look” with larger rounded breasts.
Having performed thousands of breast augmentations, I can tell you that every patient is different in her goals and that I can work with almost all patients to safely and predictably reach her goals. There are many size choices between “go big or go home” and “I just want a little fullness.”
Implants and Body Proportion
The beauty of breast implants is that the benefits extend well beyond the breasts. Breast augmentation changes the appearance of your whole figure. For instance, if you are pear shaped, enhancing the size of your breasts creates a more balanced figure. Your abdomen will look smaller, and you will look like you have lost some weight. Women with “broad” or “strong” shoulders often benefit from larger breasts because their shoulders appear more balanced and less generous. Ample “bootie” is well balanced with some fullness on top. And curves are a great way to enhance those who are thin and narrow. Read my blog on how the benefits of a breast augmentation go beyond breasts.
Choosing your size by simply requesting an “A, B, C or D” won’t work for most patients because there is no standard measurement and you need to visualize what actual volume implant works best for your body type. This is a shot in the dark. Computer generated examples of size changes on your figure are just that—computer generated. If you want to know exactly what you will look like with an implant of a specific shape and volume, simply try them on and look in the mirror!
Silicone vs. Saline
Currently, there are three breast implant manufactures that sell FDA approved breast implants in the US market. They are Allergan, Mentor and Sientra. Both silicone and saline implants are widely popular. About 90 percent of breast implants sold in America are the silicone variety. As you can probably determine after visiting my website, the majority of implants chosen in my practice are silicone. This is a patient’s decision, which is only made after appropriate education regarding the pros and cons of the two implant types.
In November of 2006, the Food and Drug Administration approved the use of silicone breast implants after having removed them from the American market 14 years prior. Their reintroduction to the market was due to the lack of any scientific evidence that silicone is associated with disease conditions or adverse effects to your health (there was no evidence). The most convincing argument that favors silicone implants over saline comes from patients who have had experience with both. They almost unanimously recommend the silicone implants — they feel softer and more comfortable, as if a part of their breast rather than separate from their breast. The breast implant and the natural breast behave as one.
|Do they cause disease?||No||No|
|Is size adjustable?||No||Yes|
This is not only the critical part of your journey, it’s also the fun part. Most of the consultation time is spent choosing the size and implant shape that works with your figure and your personality. Read my blog about how to choose the right breast implant size. Every patient has a preconceived notion of what size and shape she thinks she wants. It must be understood that there are limits on implant choice based on the anatomy of your chest wall and your breasts. Engineering principles are involved in the decision. To provide you with an analogy, I can’t sit six people at a table for two. Large implants won’t work with a small chest. My primary goal is to make sure you make the best choice in implant size so that your results are long-lasting and pleasing.
Having a large and shapely breast is not common because of the negative impact that a larger (heavier) implant has on the shape of the natural breast tissue over time. The ideal breast enhancement result is achieved when the best size and shape are created using the smallest implant possible. During your consultation you will try on silicone sizers and observe, firsthand, what volume works best for you. The A, B, C, D cup size system of breast measurement is imprecise and varies by bra manufacturer. Be aware that breast augmentation complications are directly related to implant size — larger implants are associated with more problems than smaller ones of moderate size.
Whatever implant size you choose, I adjust the size up a bit because it will look smaller once it’s under your breast. I encourage my patients to be realistic when they choose the size. As you go through life, you will change the way you see yourself and your breasts, so it’s reasonable to assume that what works for you one day may be different the next. There is always worry about going too large or too small. How about getting it just right from the first try? That’s why I spend so much time determining the size: this is an important decision and it needs to be right on. Relying on your surgeon to choose your size without you trying on sizers often results in breasts that are too large (the logic being that larger breasts will make for a happier patient). Check out this blog post that goes more in depth on considerations when choosing implant size!
The inframammary incision is the gold standard of incisions, and is the location most frequently used by experienced surgeons. Not only does it provide the ultimate visualization and control for the surgeon, but it also involves the least soft-tissue trauma, the fewest potential nuisances and the lowest chance for post-operative complications. In the majority of patients, it’s the best incision. The reasons why this incision is so common and preferred are simply that it is efficient and the scars heal very well, often becoming almost invisible after a year or two. The saline incision is so small that it’s hard to justify any other incision. The silicone implant incision is larger, so this is often the best place to hide it.
The axillary, or “armpit” incision is a breast augmentation where the implant is placed through an incision in the arpit. It is generally well hidden and there is no scar on the breast. . There is a higher incidence of implant malposition with this technique. Additionally, if you require an adjustment of your implant, it’s not uncommon to need a second incision in a different location to correct the problem. Only the smallest silicone implants can be placed using the axillary incision. The potential for post-operative issues is also greater with the axillary approach, and operative and anesthesia times are also longer. This incision is used in my practice only when a patient demands that her incision be in that location. Asian patients also benefit from this approach because of their tendency to scar poorly. Better to have an incision concealed in their armpit than on the breast. Read my blog about Asian breast augmentation in Austin.
The periareolar incision (incision around the of your areola) is not as common as it should be. It’s a wonderful approach if you have a large enough areola to accommodate the implant. There is no evidence that this incision, closer to the nipple, affects breast sensitivity compared to other incisions. Since there is a greater amount of dissection through the breast with this approach, it can, at times, lead to excessive scarring and a visible contour irregularity. This incision may also be associated with a greater inability to breast feed, by some reports, although I have not seen this in my experience. For the right patient, this is a great incision as it hides so well.
The umbilicus or “belly button” is an option for the placement of saline implants. This is called the TUBA procedure (Trans-Umbilical Breast Augmentation). Click here to learn why I don’t recommend this approach.
Patients who have excellent outcomes, without complications or reoperations, rarely complain about any incisions. A skilled surgeon usually delivers excellent scar results.
Implant Location: Above or Below the Muscle
Choice of implant pocket location determines soft-tissue coverage for the patient’s lifetime and is the single most important technical decision. I place the vast majority of implants below the muscle. Implants are heavy, and the muscle helps support the weight of the implant (a 350cc implant weighs about 1.2 pounds!) Implants “behave” better below the muscle, and they are less likely to form a contracture. The more tissue covering your implant, the less likely you will experience implant irregularities. Implants placed below the muscle tend to feel more natural and have a more natural “take off,” or gradual transition (slope) between the chest wall and breast, which most women prefer.
Some surgeons have had a very nice experience with subglandular implants. They don’t move as much as when placed below the muscle, there is less pain associated with the procedure and if you prefer the “fake” look it’s created by using saline implants on top of the muscle and inflating the implant to the maximal recommended fill. My biggest concern is the potential for implant contracture and palpable implant irregularities in thin patients with small breasts.
The bottom line is that either location in the right patient will work quite well. It’s my job to help you choose the best location for your breast and skin type so you enjoy all the benefits of your enhancement long into the future.
A “shaped implant” refers to an implant that looks like a “tear drop.” They have less fullness at the top and more at the bottom of the breast — this resembles a natural breast more so than a round implant of the same size. These implants are typically referred to as “gummy bear” or “anatomic” implants as they are the firmest implants. They have to be firm so they don’t lose their shape unlike a round implant. They are designed to be placed in a tight pocket beneath the breast and NOT to move.
These implants were introduced to the general market in 2012 and there was a lot of anticipation that they would one day be very popular. This hasn’t quite turned out that way and in 2017 these implants command a small segment of the market. The biggest issues with these implants are that they can rotate after placement, they don’t move and can be a bit unnatural, and there are studies that show neither the patient nor surgeon can’t tell which implants were used. For these reasons and others, these implants are not popular at all and the current “thinking” amongst reputable plastic surgeons is that they simply don’t have a role in cosmetic breast enhancement. If your surgeon is comfortable using these implants and feels that he/she is getting superb results that can’t be achieved with standard round implants, you might want to consider them. I would recommend that you consider round breast implants before the anatomic variety. What we thought would be a good thing simply didn’t prove itself in the marketplace.
Textured vs. Smooth Implants
“Textured” means that the outer shell of the implant is rough, and it feels like very coarse sandpaper. These implants were originally designed to reduce the rate of capsular contracture, but have not really produced the theoretical benefits. All shaped breast implants are textured. Round implants may be smooth or textured. It’s interesting that in the US most implants are smooth walled and in Europe most are textured. Obviously, the benefits, if any, of these implants when used for cosmetic breast augmentation is not obvious or we would all choose the same breast implant type.
An “implant profile” refers to how narrow or wide the implant is. Low profile implants are flat and high profile implants are narrow. The difference can be very significant in the final appearance of the breast. Currently, my patients overwhelmingly prefer the higher profile implants as they look perkier, more youthful and less matronly.
I often calculate appropriate implant profile depending on your anatomy and the size of the implant that we are considering. Smaller implants often necessitate lower or moderate profile implants while larger implants benefit from the high profile shape. With higher profile implants, there is less side cleavage and less underarm fullness. During your consultation, I will often change the profile so you can see in the mirror how things look differently depending on implant profile.
Breast Augmentation using Fat
Wouldn’t it be wonderful to be able to take fat where it isn’t wanted and transferring it to the area’s where we do! Fat has proven quite effective in correcting small irregularities of the breast in both the cosmetic and reconstructive areas, but it has not been as successful in making a smaller natural breast significantly larger. Currently, a small breast can be augmented with fat but the size gain, in the best of hands, is modest. This technique also requires the use of the Brava suction device to pre expand the breast prior to fat filling. This is cumbersome and time consuming and uncomfortable. For these reasons (little gain for a lot of work), this has not achieved a high level of popularity. It is an alternative for the right patient who doesn’t want a breast implant, who prefers only a modest increase in size and has the time and money to spend on the process. It’s entirely possible that in the future there will be enhancements in fat transplantation science that will allow us to move it around at will, but we are not there yet.
Breast Augmentation Recovery
The typical patient needs about two or three days to recover from a breast augmentation. After this time, you will be off narcotics and you can take anti-inflammatories such as Motrin or Tylenol. There will be discomfort for several weeks afterwards that gets better every day. You should avoid any major exercise for the first week and then gradually work back to a full schedule. Avoid heavy lifting (kids, weights) for about two weeks after surgery.
Adding a lift or reduction to your procedure does not add much to your recovery. Most of the discomfort associated with the procedure is related to the placement of the implants below the muscle, which stretches the muscle and feels tight. The smaller the implant used the less stretching of the muscle and therefore less discomfort.
Forty percent of my patients elect to use a post-operative pain pump for maximal pain relief. This system automatically and continuously delivers a local anesthetic to the breast through a tiny catheter paced into each breast. It lasts about two days, requires no care and is removed at home.
All breasts will require time to “settle” after an augmentation. The breast implants sit up high relative to the breast with the nipple-areola complex on the low side. After a few weeks, the muscle and tissues relax and stretch, allowing the breast implant to drop, soften, and a more natural appearance with a teardrop shape. It is actually quite exciting to see this occur! A breast band may be recommended in patients who need some help lowering their implants and reducing excess upper breast fullness. Read my blog on recovering after breast augmentation.
The process of a breast augmentation does not end simply after your implant is inserted. After many years of practice and thousands of breast enhancements, I have clearly seen the benefit of breast molding or shaping during the post-operative period. I am actually able to use the breast implant to help mold or shape the new breast. This is how I can create cleavage when breasts are widely separated and how I can improve the appearance of narrow or poorly shaped asymmetrical breasts.
It requires effort and some muscle so if there is someone who can help you during this time all the better. Molding should start about two weeks after surgery and is typically finished by six weeks. It should be done 2 or 3 times a day for 20 to 30 minutes. Read my blog about the most important factor that determines the appearance of the breast after a breast augmentation.
In those rare patients who have perfectly symmetrical breasts on an even rib framework, not much work needs to be done. For the vast majority of patients, however, moving the implant in one direction or another will expand the tissues of the chest and breast and help to create a great shape. Cleavage is typically not made during surgery; it’s made after surgery by moving the implants towards the midline and expanding the tissues in the middle of the chest. Trying to make two differently shaped breasts look even is a combination of art work by your surgeon and a lot of hard work by the patient afterwards. It should be noted that patients who elect for the placement “gummy bear” or “anatomic” implants should NOT move their implants to shape the breast.
A breast lift is considered when the breast is saggy and the nipple-areola complex is low on the face of the breast and if the skin of the breast is quite lax. Experience is needed to know when to lift and when not to. Some patients will realize a beautiful result with an implant alone, while others may need an implant and a lift at the same time. It’s always possible to lift the breast as a secondary procedure if you think it is needed. An experienced surgeon can really help here as he/she knows what will work best for you. Read my blog “How do I know if I need a breast lift?”
Although a breast implant alone can provide some “lift” to a breast and take up some of the lax skin, I have seen many patients whose surgeons tried to place an enormous implant for the lift but the result was overly large breasts that sit low and are not attractive. Another common error is to perform a breast augmentation and a lift only around the areola at the same time (Benelli procedure). This often results in funky looking breasts with really big (stretched) areolas and poor scars.
Women have concerns about a lift because it means breast scars. I can honestly tell you that a breast that looks great with a scar is a lot better than one that does not without the scar. This has been proven to me time and time again. Women are concerned about how their partner will react to the scars but I can tell you that this issue is overblown. But, men do not have a problem with a scar on the breast if the breast is shaped beautifully. They tend to see the “big picture” and not the details: a deflated breast with nipples pointing down is not ideal, while a breast that is full with nipples pointing to the sky reveals youth, vitality and beauty.
The term “failure” and “rupture” sounds a bit spooky when you are talking about something that you are putting in your body. However, in terms of breast implants the consequences of either of these events happening is simply an inconvenience and not something that is causing you harm.
We are now performing breast augmentations using fifth generation implants, and like most manufactured goods, they are better than those from previous generation. However, you must understand that ALL IMPLANTS WILL FAIL OVER TIME. It’s not a matter of if, but when. The failure rate is measured by the percentage of implants per year that fail, as reported to the manufacturers. This rate is about 1-5% per year and is cumulative, meaning that the longer the implant has been in place, the higher the likelihood of failure.
A saline implant is a water-filled bag. If it leaks or ruptures, it simply gets smaller or deflates. The water is absorbed by the body and is harmless. A silicone implant is different in that the silicone material inside the implant does not leak into the body—it stays within the implant capsule that develops around all implants. You may not actually know that the implant is ruptured because it still works just like it did before. The best analogy would be run flat tires — they work even if there is a disruption of the implant.
I have heard from many patients that their breast implants need to be changed after ten years. This is not usually the case. In the real world, patients with saline implants will seek a revision if they wake up one morning with a smaller breast, and those with silicone implants may not seek a revision until they have developed a breast implant contracture or noticed a change in their breast (pain or discomfort). Most women with breast implants will not seek to revise their breasts if they are not having any problems no matter how long they have had their implants. They are simply not going to fix something that they don’t think is broke.
Keeping Your New Breasts Looking Their Best & the Proper Bra
Age, health status, gravity, weight loss and gain, hormones and pregnancies will have a profound affect on the breast. (see before and after photos of a patient who had a child after her breast augmentation).
The female breast undergoes the most changes during a lifetime than any other organ in the human body. Your genetic makeup can profoundly influence the longevity of your breasts. This explains why some women who are older and have had children still have relatively youthful-looking breasts. How can you ensure that your breasts will have their best shape and appearance over your lifetime? It is important to maintain a healthy lifestyle by eating well and not smoking or abusing your body. As discussed before, your initial choice of implant size and position above or below the muscle is extremely important because these decisions have the most impact on the future of your enhancement.
Posture is very important when it comes to the appearance of your breasts. Breasts always look more youthful and lifted when your shoulders are back. Hunching your shoulders forward and down makes your breasts appear droopy. Good posture is an easy way to make your breasts look their best.
Wearing a bra is the single most important factor in keeping your breasts their very best. There is no such thing as not wearing a bra after a breast enhancement. A bra will keep your breast implants in the ideal position, will minimize sagging related to the effects of gravity, and will keep you comfortable and supported during rest and activities. Wearing a bra at night that is supportive and comfortable will keep your breasts from falling to the side. Read my blog about wearing a push up bra after breast augmentation.
For your bra to work its best, it must be properly fitted to the size and shape of your breasts. Click here to see the features of an ideal breast augmentation bra. The main function of your bra is to minimize the influence of gravity by transferring the load of the implant from your skin and muscle to the bra. Experts say that about 8 in 10 women wear the incorrect bra size. Most women wear a band size that is too large. A more snug band size—going from, say, a 34 to a 32—increases the size of the cup. You can wear a bra with an underwire if you have implants. A working bra does not necessarily mean it has to have a wire for support—there are many bras that work very well without the need for a built in wire. Just as with implants, each and every bra is different and you will have to try on many to find the few that work right for you. It’s important that you become your own bra expert so that over your lifetime you will know exactly what your bra is supposed to do and how it’s supposed to feel.
The reason why breast augmentation is the most common procedure performed is because the risks are low and the reward is very high. Serious complications from a breast augmentation are rare. Breast implants are not associated with cancer and do not cause disease or health problems. The procedure is not perfect however, and there are problems associated with breast implants with which everyone considering an enhancement should familiarize themselves. A very thorough review of the complications can be obtained from the three major manufacturers of breast implants.
After the insertion of thousands of breast implants and insight obtained over 25 years of practice, there are two categories of complications. The first occurs early after surgery. During this time it’s possible to develop a breast hematoma or infection. A hematoma is an accumulation of blood around an implant. If this occurs, it is usually necessary to return to surgery to remove the blood, because it can cause an infection or implant contracture. An infection is rare in quality hands. If it does occur, it is necessary to remove the implants and wait for a year or so to replace them. It is definitely a big disappointment, but not life threatening.
The second type of complication occurs after the initial surgery, say six months afterwards. The two big issues that can arise during this phase are breast contracture and implant/breast shape irregularities. Although a breast contracture can happen any time, it generally occurs many years after an augmentation. It’s a sign that you can be a “hard healer” or than your implants are ruptured. In my experience, subglandular breast implants contract more than those that are submuscular.
A breast implant or shape issue is a big category that includes the common reasons for a breast revision. This could mean implant displacement that results in an unsatisfactory shape of the breast — lateral breasts, low breasts, ptosis, high riding implants, uni-boob and other conditions.
ALCL is a new condition that we are trying to get a better understanding of. Called Anaplastic Large Cell Lymphoma, this is rare problem that may be associated with breast implants, particularly textured implants. It usually manifests as welling of the breast years after implant placement. It is typically a local type of cancer that is cured after removing the breast implant and implant capsule. There have been over 100 cases reported worldwide. As of this writing, we are learning more about it and it’s possible relationship to breast implants. Again, it is very rare but something we are keeping an eye on. Visit this link at the FDA website to learn more.
You can review in detail many of the possible post-operative complications that require breast revision by learning from my extensive experience with breast revision.
Breast Implants and Breast Feeding
A breast augmentation alone is not likely to interfere with a woman’s ability to breast feed. It’s important to remember that fifteen percent of all women are not able to breast feed in general, regardless of whether or not they had a breast enhancement. It is hard to find good scientific data to implicate breast feeding problems with breast implants. Professionally, I have never come across a patient who has told me that she couldn’t breast feed after an augmentation.
Breast augmentation today is a routine procedure that has low risks and high patient satisfaction. The results are transformative to patients in more ways than I can count. It is a game changer — far more than simply having “bigger breasts.”
Although it is a procedure offered by many surgeons, my best advice is to seek out those who have clearly demonstrated vast experience and impressive results. Try to avoid choosing your surgeon based on price as you may regret the decision, and the cost to make them right can be significant. Avoid making an “impulse buy” when you are young, as many of these patients have regrets later. Most of the time spent with your surgeon should be on getting the implant size and shape right before surgery. Breast augmentation and bra use go hand in hand. Choose your surgeon wisely and enjoy your investment!