By: Bruce Dubin M.D., F.A.C.S
Breast Augmentation is conceptually a very simple procedure. The objective is to place an implant beneath the breast. In performing the
operation, several decisions must be made. Some of these choices are made by the patient and some are made by the surgeon. Each of these
details should be thoroughly discussed before surgery.
The patient ultimately picks the size. Implants come from the manufacturer in a wide range of sizes with relatively small incremental
volume changes proceeding from the smallest to the largest implants. There is not just one size that will be “perfect” for a given
patient, but rather a range of sizes all of which will look nice. The goal should be to pick the implant size that most closely matches
a given patient’s desire and expectation. I have found that the most accurate way for a patient to communicate her goal to the surgeon
is by a photograph. As the ultimate outcome is essentially visual, a picture best convey all the aesthetic nuances. I have patients do
“homework” and bring me examples of what they like and also what they don’t like. These pictures can then be used in the operating room
to fine-tune the sizing process to give the patient what she wants.
The patient must also decide whether to use saline or a silicone gel implant. The “perfect” implant does not exist and the patient must
decide what compromise she wishes to make. Visually, one cannot distinguish between saline and silicone. Without a basis for comparison,
both types of implants will feel acceptably soft to the patient. However, if one does has a basis for comparison or is experienced in
feeling breasts, a silicone gel implant will feel more natural than a saline implant. Why would a woman ever select a saline implant?
The answer has to do with the consequences if the product ever leaks. In the even that a saline implant leaks, the body will absorb the
saline just as if an I.V infusion had been given. The failed device will need to be replaced but there is no residual material to deal
with other than the collapsed implant shell. On the other hand, if a silicone implant leaks, the gel will not absorb but remains in the
pocket that contained the implant. In this event, the gel remains well localized and relatively easy to clean out, most of the time.
However, in some cases the gel can leak out of the pocket and enter the breast where it can cause inflammatory lumps referred to as
“silicone granulomas” and even more rarely, the gel can migrate with the body. While these complications are statistically very uncommon,
they are impossible with the saline product. Therefore, in terms of absolute medical safety, the saline device is inherently biologically
safer than silicone. Thus, each prospective patient must prioritize her choice between inherent medical safety (saline) and aesthetic
The surgeon must decide where to place the implant, specifically above or below the pectorals major muscle. The majority of board
certified plastic surgeon prefers the submuscular pocket. There are a number of published studies that clearly demonstrate the advantages
of the submuscular plane. These include a significant reduction in rates of encapsulation (scar tissue forms around the implant which
makes the implant feel hard), less palpable edge effects such as “rippling”, and less potentially interference with mammograms.
The surgeon will usually pick the route of insertion. My own personal preference is for an incision at the bottom third or half of the
areolar border. A scar placed in this natural transition zone usually heals with an imperceptible scar and this position also affords
excellent surgical exposure for proper implant placement and control of any operative bleeding. The surgeon will generally decide whether
to use a textured or smooth implant. I always select a smooth implant and dislike the textured devices. I will generally select a
moderate or high profile device. Other surgeons do feel differently.
Patients usually are concerned about recovery issues. Most women are able to return to normal activities of daily living and sedentary
work activities within a week or less. If work requires forceful upper body activities such as lifting, a longer recovery period will
be required. Patients can resume controlled gym activities at 2 weeks. Post-op recovery regiments can vary from surgeon to surgeon.
My routine is very simple. Patients wear a sports bra for the first two weeks except when showering which they may do on the second
post-op day. Patients are advised to avoid wearing an underwire bra for the first month and to avoid extreme heat or sun exposure for
the same period. I personally do not believe in post-operative massaging or other manipulations.
In this brief article, I have attempted to highlight the major issues in the breast augmentation. For a more detailed discussion or for
answers to specific questions, I can be reached on my website.