Breast augmentation involves placing a breast implant behind the breast to “augment” (enhance) the volume of breast tissue you were born with, to create a more balanced appearance to your body if you have relatively small breasts, or to replace breast volume you may have lost after having children, following significant weight loss or with age. Breast augmentation can help to improve a woman’s sense of body image, and in many instances can enhance self-esteem and self-confidence! As women Plastic Surgeons, we intimately understand how a woman’s feelings about her breasts can influence her self-image and feelings of femininity.Most women seeking breast implants find that their breasts are comparatively smaller when compared to the rest of their body proportions, or that their breasts have become deflated after having children. Other women are seeking better symmetry of their breasts if one is a significantly different size or shape than the other. All women who undergo breast augmentation simply wish to feel more “balanced” in their body shape and be more Proportional to their natural curves. Breast implants can also used to help correct abnormal shapes of the breast and to reconstruct the breast following breast cancer.

As opposed to many images of Plastic Surgery and some bad “boob jobs” out there, most women seeking breast augmentation in our practice want to avoid an obvious and unnatural “fake” look! Our goal is always to create a beautiful, Natural breast augmentation result that looks in most cases like you were just born that way!

Good candidates for breast augmentation include women who are healthy, in good physical shape, at their ideal body weight (or a stable weight following major weight loss), women with relatively small breasts relative to their frame, and women who wish to have fuller or perkier breasts.Women seeking breast augmentation often express they wish to have the effect of wearing a padded (or push-up) bra. If already a Mom, they may wish to be as full as they were while nursing, or for their breasts to be similar to they were before they had children.Sometimes a breast augmentation is combined with a breast lift (mastopexy) if there is also significant breast droop. Your Plastic Surgeon will examine you and determine whether a combined mastopexy-augmentation (breast lift with implants) procedure is appropriate.

Read Dr. Horton’s blog post about the newest 7th generation breast implants that are now available and that are providing women with the softest, safest augmentations and reconstructions.

Women considering breast implant surgery in the United States have the option of choosing either saline-filled or silicone gel-filled breast implants. All breast implants have a Silicone Shell. Silicone is a natural element and an inert solid which is biochemically most similar to carbon (the element that makes us “organic”) that is used safely in countless implantable medical devices.

The Fill Material of breast implants can be either Saline (sterile salt water) or Silicone Gel. Both can create equally beautiful breast augmentations, and all have been approved by the FDA (United States Food and Drug Administration) as safe and effective options for women undergoing breast augmentation, breast reconstruction or implant revision surgery.

Breast implant volume sizes range from as small as 50 cc up to 800 cc, and implants may be smooth-walled or textured, round or shaped. The most appropriate implant for your unique situation depends on many factors including your age, your breast volume and density, your skin tone, your weight and your aesthetic goals. When you meet with your surgeon, she will go over all the options for you and help to determine which implant is most appropriate for you.

For most women seeking breast augmentation, we usually recommend silicone gel implants over saline. Gel-filled implants tend to have a more natural look, feel more like breast tissue, and have less chance of “rippling” (seeing waves of the implant through the skin if you are thin and have little tissue padding).Saline-filled implants have a slightly increased incidence of rippling and “palpability” (the ability to feel the implant). The overall rate of complications when comparing saline to silicone gel implants is equivalent.Silicone gel implants are also often the preferred implant of choice for the final stage of breast reconstruction after cancer, for the reasons listed above. Please see our section on breast implant reconstruction for more information about breast reconstruction using implants.

Breast augmentation is a personal decision for a woman, and one that should not be taken lightly. We encourage all our patients to educate themselves about the safety and science of breast implants before considering any surgical procedure. Most women who come to see us in consultation for breast augmentation have one major question: “Is silicone safe?” We spend a great deal of time and effort educating women about their options for surgery, and when discussing breast augmentation, we emphasize that all implants, both saline- and silicone-filled, are SAFE!

Silicone is one of the most widely-used soft implantable materials in medicine. Different types of silicone have been used for decades in medical devices such as intravenous (I.V.) tubing, “tubes in the ears” in children, in pacemakers and artificial joints. In fact, silicone breast implants are the most extensively studied implantable medical device in the history of medical devices! All breast implants have a silicone shell; the fill material is what differs.

The United States FDA approved silicone gel-filled breast implants for cosmetic breast augmentation only after reviewing a vast amount of scientific data, peer-reviewed published studies and clinical research supporting the safety of silicone breast implants. Silicone gel implants have always been available to breast cancer patients for post-mastectomy breast reconstruction.

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Learn About “Breast Implant Illness”
Learn About the FDA’s Labeling Requirement for Breast Implants

Natrelle: Please click here to find safety information regarding the quality of Natrelle implants, surgery considerations, and common and uncommon complications.

Sientra: Please click here to read Sientra’s commitment to providing transparent, evidence-based information about their implants to help physicians and patients make an informed decision.

Breast implants can be inserted through different incisions:The Inframammary Fold (IMF) Incision (in the natural fold beneath the breast) is used in most instances of breast augmentation, for a number of reasons:

Which Incisions are Used For Breast Augmentation?

Breast implants can be inserted through different incisions:

The Inframammary Fold (IMF) Incision (in the natural fold beneath the breast) is used in most instances of breast augmentation, for a number of reasons:

Inframammary fold (IMF) incisions best preserve the two major functions of the breast:
(1) Breastfeeding and (2) Pleasure! When an incision is made in the fold under the breast, the scar lies in a natural crease and does not tend to stretch or become raised, as can happen in other areas. All vital anatomic structures of the breast that lead to the nipple and areola (milk ducts, nerves and blood vessels) remain intact, preserving breast function. No breast tissue is transected during surgery. Therefore this incision also has the least theoretical interference with future breast feeding and/or mammogram readings.

Furthermore, once an implant is inserted into the breast, there is the potential that another surgery may be required at some point during your lifetime. The inframammary incision is most commonly used for future breast surgeries such as implant exchange, breast revision or breast lift. The IMF incision is the easiest to reuse and minimizes potential breast deformity without creating any additional incisions if the implants are ever removed.

Inframammary scars are hidden when viewing the breasts from above or from the front, are concealed in bras and even triangle-top string bikinis, and are generally only visible on careful inspection up close when the breasts are lifted. Most other incisions used for breast augmentation are a “one-time option” only, with an IMF incision required in the future.

Peri-areolar incisions are made around the bottom of the “areola”, the pigmented circle that surrounds the nipple. Bacteria live in this region together with milk ducts, blood vessels and nerves leading to the nipple. By definition, some of these structures must be divided (cut) during surgery when using this incision, resulting in a higher potential risk of complications (infection, numbness, breast feeding difficulties). In addition, if a raised or “hypertrophic” scar were to form, it could be visible through clothing in this area. For these reasons, the peri-areolar incision is used less commonly for breast augmentation.

Trans-areolar incisions (going through the areola and the nipple) also potentially sever breast tissue and/or ducts, blood vessels and nerves to the nipple. Nipple retraction (permanently inverted nipples) can result from scar tissue that normally forms after surgery in this area. The risk of infection from bacteria living here is slightly higher using this approach. Incisions through the areola may interfere with the ability to breast feed, and if this incision is used multiple times, a permanent indentation may occur if the implants are removed. For all these reasons, the trans-areolar incision is used rarely.

Trans-axillary breast augmentation makes an incision in the armpit, known as the axillary area. This is also a “one-time incision” (it cannot be reused for future breast implant procedures) that creates a scar in the area where most women shave, and is also a site of normal bacterial growth (hence antiperspirant and deodorant use here!). The incidence of infection can potentially be higher when using this approach, and if a complication should develop, a separate incision is often required – usually under the breast in the IMF.

Trans-umbilical breast augmentation (TUBA) is actually more of a gimmick than a routine approach for most breast augmentations. In this technique, a long, rigid tube with a camera must be tunneled superficially beneath the skin of the belly button all the way to the area of the breast. There is no direct visualization of the structures of the breast, and if there are any complications during surgery such as bleeding or the wrong space is entered, a second incision must be made in the IMF. Only a tightly rolled up saline-filled breast implant can be used (silicone implants cannot be inserted using this method). This is also a single-use incision. A long band of scar tissue beneath the skin is often visible after surgery, creating a permanent deformity.

Breast implants can be placed either behind the breast tissue (known as the Subglandular Position) or behind the breast tissue and the pectoralis major muscle (the Submuscular Position). In the medical literature, sometimes a partial submuscular position is described (the “subpectoral” or “dual plane”). There are proponents for each technique, based on opinion, surgical training and professional experience.The Subglandular Position is recommended in most instances for breast augmentation in our practice. The reason for this is multifactorial, and is based on the belief that a breast augmentation should never interfere with muscle motion or function, and should create a natural result that remains constant in the long term and with changes in age and breast shape over time.

The subglandular breast implant moves as expected with changes in body position, without the “motion deformity” of submuscular implants (described below) and creates a more natural breast shape that is consistent over time. Subglandular implant surgery is associated with less pain when compared to submuscular implants, and long-term pectoralis muscle function is unchanged.

Breast implants placed beneath the breast tissue but above the muscle tend to maintain their natural appearance. With age, the subglandular position avoids drooping of breast tissue off the implant with age, known as the “snoopy deformity” (see below).

Subglandular (above the muscle) implant positioning is more natural anatomically. For women who are seeking to rejuvenate deflated or naturally small breasts, it makes the most sense to add volume to the breast where it is missing: in the breast space, rather than under a muscle!The pectoralis major (“pec”) muscle is a flat muscle that is activated and engaged in nearly all activities of the upper body and the “core” (the trunk). It has a straight vector of pull upwards and outwards, and it certainly was not designed to be stretched out over a breast implant!

Submuscular Implant (Before Surgery)

The “submuscular, “subpectoral” and “dual plane” procedures all involve placing the implant beneath the pectoralis muscle to some extent. Contraction of this muscle causes displacement of the implants upwards and outwards, along the vector of muscle flexion. This deformity is known as the Motion Deformity of submuscular procedures, and is avoided by placing the implant above the muscle.

For some women, chronic contraction of the pec muscle around the implant can create strain, tension or physical discomfort in the neck, upper back or shoulder area. In addition, because part of the pectoralis muscle is permanently detached from the sternum and ribs in submuscular procedures, implants in this location can sometimes negatively affect muscle strength and function. Implants placed beneath the breast tissue only do not flex or become distorted with pectoralis major motion.

Subglandular Implant (After Surgery)

With age, time and gravity (known as the “fourth dimension”), breast tissue and skin slowly lose elasticity and the breast can assume some droop. As a result, some women may be interested in a breast lift later in life. When breast implants are placed under the muscle, the breast tissue may sag and “fall off” the implant, creating what Plastic Surgeons refer to as the “Snoopy Deformity”. The submuscular implant stays in a position that is too high and the breast does not look natural or aesthetically pleasing. Please see the Breast Revision section of our Before and After Photo Gallery for an example of submuscular implants and their related deformities.

For all these reasons, Subglandular Implants are usually requested in women who are athletic, well-informed and fully educated about their options for breast augmentation and advantages and disadvantages of each technique, and who wish to maintain full function of their pectoralis muscles while avoiding any deformity! As women surgeons, we only recommend to our patients what we would do to our own bodies and what makes most sense functionally, aesthetically and when using common sense.

Subglandular implants look and feel natural, they preserve the anatomy of chest wall muscles, but most importantly, there is zero animation deformity with pectoralis major muscle flexion!