With so many women discussing their breasts, it is no surprise that breast augmentation has become the most performed plastic surgery procedure in the United States. But even though it seems like everybody is considering trading up, the reality is that getting breast implants is still a serious surgery and cannot be taken lightly. Navigating and researching the decisions that need to be made can be overwhelming.

The best breast augmentation is one that looks completely natural and does not raise eyebrows. Whether you want to add volume after pregnancy, give a little lift to combat gravity, or because you feel like you have never had enough, here are the four key decisions you need to make about breast implants: Where to insert them? Where to make the incision site? Should you use silicone or saline implants? How big should they be? Here’s what I tell my patients.

Placement Plane: Deciding where to place your implants

Breast implants can be placed above or below the chest (pectoralis) muscle. There are excellent reasons to choose each option. The implant is often placed above the muscle and under the breast gland when the patient has ptosis, or sagging of the breast. Because the pectoralis muscle does not need to be stretched when you place the implant above it, it is the less painful option. But if you do not have a substantial amount of natural breast tissue, you may be able to feel the outline of the implant and the transition from your chest to your breast may look less natural.

A submuscular approach has the advantage of a lower rate of capsular contracture—that’s when the capsule which your body naturally forms around the implant hardens, becomes painful, or distorts the breast shape. It also leads to a more natural transition from the chest to the breast and you are less likely to see rippling from the implant. On the flip side, if you have a sagging breast, unless your breast is surgically lifted at the same time, you may see a “double-bubble” which means that the implant and the natural breast form two separate mounds. Placing implants underneath your muscle is also more painful and requires more time to recover.  I inject a medication called Exparel during the surgery to help with post-operative pain.  Exparel is a slow releasing local anesthetic which medication in the first three days after surgery.

My favorite technique is using a dual-plane where the top aspect of the implant is underneath the pectoralis muscle and the bottom is under the gland. This allows the surgeon to take advantage of both techniques leaving the implant less palpable, giving the patient a more natural breast shape, and reducing capsular contracture rates.

IMPLANT POSITION

Breast implants can be placed above or below the chest (pectoralis) muscle. The first image shows your natural anatomy before the implant is inserted. The second image shows the placement of the implant above the muscle. The advantage to this procedure is that it is shorter, less painful, and may be beneficial for patients who have sagging or ptotic breasts. The third image shows the implant placed underneath the pectoralis muscle. This placement allows for a smooth transition from the chest wall to the breast, avoiding palpation of the implant. Submuscular placement also dramatically decreases your risk of forming a capsular contracture and rippling.

X Marks The Spot: The Incision

The incisions for breast augmentation are strategically located to conceal any evidence of surgery. There are four incision choices: underneath the breast (inframammary), a hemi-circle at the bottom of the areola (periareolar), under your arm or through the axilla (transaxillary), and through the umbilicus or belly button (transumbilical).

An incision under the breast is used in 90% of cases in the United States as it heals well, is well hidden, and provides the surgeon with excellent visualization during surgery. Although the periareolar incisions (an incision at the bottom of the areola) are also very popular, studies have shown that they can lead to higher rates of capsular contracture and desensitization of the nipple. The transaxillary approach (or under your arm) is the third most popular choice.  I do not recommend this incision as a scar will be visible when wearing a sleeveless top. Transumbilical incisions limit the surgeon to using only saline implants and are not a popular option.

IMPLANT INCISION

Implant Options: Saline versus silicone

Preference for implant material has dramatically changed over the years. When the implant is placed underneath the pectoralis muscle, it matters less which implant you choose because it is deep within your body. Several years ago, most of my patients opted for saline implants, but today my practice now has overwhelmingly transitioned to silicone.

The FDA banned silicone implants in 1992 because they were suspected to increase the risk of systemic illnesses. After further research, silicone implants were shown to be safe and returned to the market in 2006. Since then, silicone implants have gained in popularity because they have less visual irregularities than saline implants, like rippling or wrinkling, as well as a lower rate of deflation over time. On the other hand, silicone implants have a higher rate of capsular contracture than saline implants because there is often a slow leakage of silicone into the capsule surrounding the implant. One misconception is that if the silicone implant leaks, it will leak silicone into your entire body. But what really happens is that the silicone remains contained within the capsule or scar tissue that surrounds the implant and there is often no loss of volume.

The newest silicone implants have a thicker shell and a more cohesive or viscous gel, so they are much less likely to rupture or leak than silicone implants that were manufactured just five years ago. In fact, if you cut the new Sientra implant in half and hold it upside down, no silicone will leak from the shell. Because it is unclear if a silicone implant has leaked, the FDA suggests that women have an MRI every two years to check if the implant is still intact. New research suggests that ultrasound technology may replace the need for MRI testing, but MRIs remain the gold standard for detecting a leak. But before you get your heart set on silicone implants, know that you have to be over 22 years old to have them, according to the FDA.

Saline implants have advantages as well. For starters, the size is adjustable down to a cc of saline—that’s about one fifth of a teaspoon. Whereas silicone implants come in standard sizes, the amount of saline injected into a saline implant can be adjusted in the operating room to fine tune asymmetries. Additionally, because a saline implant is deflated when it is inserted into your body, the incision can be smaller than one created for a silicone implant. One downside though is that that rippling is more significant, so a thin woman with little breast tissue may have more visual irregularities. When a saline implant leaks, the saline or salt water is absorbed by your body and your breast becomes flat.

Many patients tell me that they find the silicone implants feel more real. They often state that the saline implants felt colder.

Calculating Size: How Big Will You Go?

Deciding how large you want your implants to be can be a stressful decision. Much of the decision is based on the width of your ribcage. Narrower patients will need smaller implants as larger implants would extend under their arms. To make the final decision, you should come into the office and try on implant sizers. It’s best to bring two different types of shirts—a fitted T-shirt and a looser button down or sweater—to get the best idea of what the additional volume will look like when wearing clothes.  Beyond taking into consideration your own ideals or visions, you also have to consider the goals you are trying to achieve, your lifestyle, and your age.

The Location

Breast augmentation is performed as an outpatient procedure in a surgical suite. Due to the nature of the procedure, general anesthesia is necessary.

The Recovery

Patients are allowed to perform light activity on day one and return to work in a week. For the first few days, you will experience swelling and discomfort. Most patients will take pain medication for the first three to four days.

Exercise

You can begin light exercise on day one but it is best not to over exert yourself as it will lead to increased swelling. You can resume strenuous activity in six weeks.

Longevity

The newest generation of breast implants do not have an expiration date. If they are not bothering you, there is no reason to replace them.

Pregnancy and Breastfeeding

To learn more about how pregnancy and breastfeeding impact breast implants, visit: How Pregnancy And Breastfeeding Impact Breast Implants.

THREE MONTHS POST SURGERY

A Picture is Worth a Million Words

A picture may be worth a million words but in the age of the internet, online photos can be viewed by billions of eyes. In respect of patient privacy, a before and after section was not created on our website. Several patients have agreed to allow their photos to be viewed by prospective patients in the office. You may request to view photos during your consultation. Some patients have also agreed to speak with prospective patients if you would like to learn more about the procedure from a patient’s perspective

What is the first step?

If you have been thinking about considering breast implants or a breast augmentation, please call our office at (212) 600.4109 to arrange for a consultation.  Our New York City practice accommodates out of town and international patients who need to travel in for surgery as well as those who are local to Manhattan.