Choices That Need To Be Made While Undergoing Breast Implant Surgery
By Daniel Golshani

For a woman, undergoing a breast augmentation can be very exciting and life changing. Although the choice to have the operation may seem simple, there are many factors to be considered and choices to be made from incision site and placement to precise details regarding the implants. During the consultation with a board certified plastic surgeon, specific decisions are made during the course of the history and physical examination. Initially, the focus is addressing the psychological and emotional issues which the patient might have with respect to her breast followed by the physical findings, all which help create a path in choosing the best type of implant as well as type of procedure for the patient. Aspects considered include the type of implant, the texture of the implant, placement of the implant, incision site, and the dimensions of the implant.

Currently, the types of implants available are saline and the new cohesive silicone gel implants. Silicone gel implants have now been available for almost 4 years to the general public. After undergoing a series of prospective randomized studies, the FDA has approved silicone gel implants for the use of breast implants. The new silicone gel implants are cohesive, meaning they are designed in such fashion that even with a rupture of the implant shell, very minimal amounts of silicone may leak from the implant due to the nature of the silicone gel. Both types of implants are safe. The decision to have silicone or saline is generally based on preference of the patient as well as recommendations by the plastic surgeon.

Breast implants are available either smooth or textured. Generally speaking, smooth implants are most often used because they are able to move freely in the pocket, have thinner shells, longer implant life, and less risk of rippling. Textured implants, on the contrary, adhere to the skin in the pocket and prevent the implants from moving. Textured implants were originally designed to reduce the risk of capsular contracture, though it has not been conclusively proven in medical studies. Anatomical implants are solely available with a textured surface to prevent the implants from turning in the pocket. On the downside, textured implants have a higher rate of leakage and rippling in the breast post operative compared to smooth implants.

The decision to place the implant beneath or over the pectoralis major muscle are often times affected by the patients features such as the presence of very large pectoralis major muscles in an athletic patient, the presence or absence of breast tissue, and body contour and form. In general, it is accepted that placement of implants beneath the pectoralis major muscle yields a better contour and natural shape over longer periods of time as compared to implantation on top of the muscle. Also, patients are generally happier with the implant placed in a subpectoral position. On the contrary, in a patient who is a body builder or very athletic and where elevation of the pectoralis major muscle might result in potential functional issues for the patient as well as increase the chances that the implant may be displaced as a result of pectoralis major muscle over time, the implant would be placed in a subglandular location over the muscle.

The location of the incision varies depending on which type of implant is selected and what the patients breast shape is like. For example, a patient who has a very well formed areolar margin and has very minimal contour present beneath her breast, a peri-areolar incision might be the best location for the scar and usually yields almost invisible scars over a long period of time. Patients who present with a very well formed inframammary fold or crease beneath their breasts see great results with an incision in the inframammary fold and silicone gel implants because the scar can be hidden within the crease almost always yielding a scarless breast after surgery. The transaxillary or armpit approach is useful for patients undergoing saline augmentation mammoplasty as the passage of a silicone gel implant through the axillary incision could potentially jeopardize the integrity of the implant and nullify any warranties which may be included with the implant. When an implant is placed through the armpit, it is important for the surgeon to utilize a surgical scope to perform the procedure endoscopically, ensuring excellent placement and outcome. This also applies to the transumbilical approach where obviously silicone gel implant placement would be impossible. The integrity of a saline implant might also be questionable depending on the technique of placement. The decision for the incision location will be made with the plastic surgeon in order to achieve the desired outcome of the patient.

Finally, the type of dimensions, namely high profile vs moderate plus vs moderate profile, is selected in relation to the patients desired outcome as well as their anatomical features. High profile breast implants are more narrow in width and have more height as compared to moderate profile which is wider and less height. Moderate plus profile implants are in between high profile and moderate profile. During consultation, patients will have the option to try on different implants, including implants with different dimensions, in order to make a well informed decision.

Breast augmentation surgery is a complex procedure that involves a lot of decision making and choices to ensure excellent outcome for the patient. Consulting with a board certified plastic surgeon and having a clear idea of your desired outcome as well as realistic expectations can almost always guarantee great results.

Daniel Golshani, M.D., F.A.C.S., is a double board certified Plastic and Reconstructive surgeon, a diplomat of both the American Board of Plastic Surgery and the American Board of Surgery. Learn about breast augmentation and implant surgery today.

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