Starting with the premise that the submuscular augment approach is the best technique to insure reliable long term results I would like to discuss the different incisions, the implants and recovery.

The original incision used for a subcutaneous augment was an infra-mammary incision. This incision was either made along the natural crease below the breast or in many instances just above that crease. The incision was generally about four centimeters in length and this incision allowed easy access for dissection of the pocket above the muscle and the implant, whether saline or silicone, could be easily inserted through this incision. Complications could include the normal problems such as infection, poor scarring and numbness of the breast and/or the nipple. Later it was noted this scar often had worse cosmetic results if used repeatedly for additional procedures such as treatment of capsular contraction. More specifically, this scar if used many times on some women became contracted and looked like a wire had pulled the scar into the breast tissue leaving an obvious scar and deformity that was difficult to correct.

As the submuscular augmentation became more common the use of a peri-areolar incision was used. This incision made creation of the submuscular pocket easier with greater visualization of the areas to be dissected and in time was noted to be better than the infra-mammary incision for a number of reasons. The normal complications such as infection, poor scarring and numbness of the breast and/or nipple were still possible but it seemed the scarring was less noticeable and the serious long term numbness of the breast and/or nipple was decreased. In addition, although the need for repeated surgical procedures was dramatically reduced with the submuscular approach and the less common occurrence of a capsular contraction, when additional procedures were necessary the scar was no worse than the first time in most instances. For these reasons the peri-areolar incision grew in popularity with the exception of the woman with very small areola that prevented a four centimeter incision from being practical and the implantation of silicone implants virtually impossible.

The axillary incision under the woman’s arm was a third incision that was used for a submuscualr approach. This incision was in an area away from the site of the operation and in most instances easy to conceal. This approach did beg for the use of endoscopic instruments and many found it a harder procedure to perform the augment and the incidence of capsular contraction was greater due to lack of good visualization by many of the pocket and a greater problem with bleeding in the pocket which almost always increases the risk of capsular contraction.

Finally, some very creative minds decided the augment could be done through an incision in the umbilicus through a tunnel into the area of the breast. This incision was obviously away from the site of the procedure and could also in most instances be easily disguised but the complications of asymmetry and capsular contraction as well as the voiding of the warranty of the implants make this incision one to comment about but not one to consider in my opinion.

Finally, let me talk about saline versus silicone implants. Both implants have been around and used since the beginning. In general, it was felt that the silicone implant offered a more natural feel, was more difficult to discern under the skin of a woman’s breast and easier to use at the time of the operation because they came pre-filled from the factory.

Saline implants come from the factory sterile and empty. They have always been less expensive than the silicone implants. As implied by their name, this is a silicone shell bag with a valve that allows one to first remove all the air out of the silicone bag and then fill the bag to an amount of saline. This allows the surgeon to use the same implant for a number of different sizes just depending upon how much saline was placed in the implant at the time of the operation. There are limitations of course. An under-filled implant has wrinkles that one can feel and possibly see and an over filled the implant is too firm. In addition, an under-filled saline implant can suffer from stress fractures where the silicone shell bends over and over in time and will leak. The other source of leaking is the valve. Overall, saline implants are reported to leak 5% over time. When they do leak, the saline is absorbed through the capsule and the implant will seemingly vanish in a very short period of time.

Silicone implants come from the factory pre-filled and of a specific size and shape. The sizes usually are 25 to 50 milliliters in difference until the implants get very big and then they may be 100 milliliters between sizes. The shape of the implants are generally round and lozenge shaped but they may have different profiles for the same size implant. A high profile will have less diameter and thus be taller and produce more projection as compared to the moderate profile or the low profile which although the same size will have smaller diameters and less projection. The problems of under-filling or over-filling is not a part of the silicone implant. There are no stress fractures and no valves that would leak. The incidence of rupture and leakage of the silicone implants is less understood because the silicone cannot be absorbed by the body through the capsule so the silicone stays in the pocket without any change in size even if the outer shell has ruptured.

There have been in the past and less common now an anatomically shaped implant which resembles a tear drop shape that more closely resembles the natural shape of the breast in some people’s opinion. The anatomical implants must come with a textured shell to keep them properly oriented in the woman’s body.

At one time all implants had a smooth outer silicone shell and today most of them still do. These implants are mobile and free moving within the pocket giving them a more natural and softer feel. Textured implants, originally designed to decrease the incidence of capsular contractions, are non-mobile and will not move within the pocket and I feel are not as soft or as natural in feel.

Although they still costs more than saline implants, I feel the silicone implant is the best choice for almost all breast augmentations. The one major reason to use a saline implant would be a very small areola and the desire to have as small of a scar as possible and only a saline implant could possibly be placed in the pocket and then filled. I feel the silicone implant is more natural in its feel, softer, less noticeable through the thin skin on the lateral aspect of the chest and more permanent in that they do not leak and disappear. I also feel the silicone implant is not considered one that would ever need replacement regardless of its time in the woman unless the woman had a problem and wished the implant to be removed.

Breast Augment Information Blog In the last several months there seems to be a resurgence of interest in the breast augmentation and in particular a renewed interest in saline versus silicone implants. I wish to take the time now to discuss the particulars of this operation which I feel all interested in this operation need to know and understand before they consent to this operation. The breast augment operation has been around for many decades now as has the saline and silicone implants. Initially the operation was performed above the muscle (pectoralis major muscle), through an infra-mammary crease (the fold beneath the breast) incision, under local or general anesthesia and either saline or silicone implants were utilized. Normal complications associated with surgery such as bleeding and infection and poor scarring were understood and sometimes seen but the complication that caused the most concern and the greatest misunderstanding was the phenomena of the implanted breast getting firm, deformed and many times painful which was called a capsular contraction. All patients which have any foreign body placed within their bodies with few exceptions create a capsule around the foreign body to protect the body. Women with successful, natural, soft and normal looking breast after an augmentation all have a capsule form around the implant, whether it be saline or silicone, and this is to be expected. It is the unexpected formation of a capsule that actually contracts that causes the problem and caused the many complaints by these patients who are reasonably unhappy with the results of their augmentation surgery after a capsular contraction. The causes of capsular contraction were studied and changes were made for many decades to try and reduce the incidence of this problem. And, it was a strange problem. The capsular contraction problem could occur soon after surgery. So soon in fact that many breast augment patients mistakenly thought that a firm breast was just part of a breast augment operation. In others this problem would occur years and even decades after the original operation and after many years of having a soft and natural breast. In some women the capsular contraction would occur in only one breast leaving one breast firm and unnatural and the other soft and very natural. This seemed strange to many, of course, since a different result was occurring in the same individual having had the same operation with the same surgeon and the same implant used on both sides. This strange occurrence of it happening on only one side seemed to remove questions raised as to whether this was an allergic or rejection phenomena by the woman. In addition to research being performed at medical schools and research institutes the plastic surgeons themselves tried many different approaches to try and reduce the incidence of capsular contraction. Included in these efforts was a change in the implants and the technique of the operation. Changes in the implants included the use of saline or silicone implants. In addition implants with two lumens, one on the inside filled with silicone and the outside filled with saline (the double lumen implants) were created and used. The makeup of the outside shell of the implants was modified and smooth shells, foam shells and textured shells were produced and used in many instances. Different shapes and sizes and profiles were also used over time. In the end, it did not seem to matter a great deal what the content of the implant was made of (saline, silicone or double lumen) nor did the makeup of the shell or the shape or profile of the implant make any considerable measurable difference. Changes in the techniques used in the operating room at the time of the breast augmentation also did not seem to change the fate of the capsular contraction incidence either. Antibiotic use, steroid use, antibiotic and steroid foam use and many thoughtful combinations of medicines were added to the pockets the implants were placed in during the procedure. At times these same medications were actually placed into the saline of the implants themselves when applicable. None of these changes in the procedure seemed to make any notable difference. Of course any conversation about capsular contraction and its prevention would not be complete without a discussion of breast massage. Breast massage after surgery was in fact widely encouraged, carefully taught and often evaluated in post operative visits. Unfortunately, massage did not change the incidence of capsular contraction either. The technique change that did most certainly modify the incidence of capsular contraction was the change of placement of the implants under the muscle instead of above the muscle. This change which came about in the early to the mid eighties consistently showed a decrease in the incidence of capsular contraction. With special attention to standard technique, in particular leaving the operative pocket site free of even minor bleeding and handling of the implants with more caution against contamination, the incidence of capsular contraction dramatically decreased. Capsular contraction and a firm deformed breast can still occur today even with an augmentation under the muscle and I still discuss this complication at length with each and every breast augment patient, but the incidence is now near zero in my practice and has been that way since the mid 1980s. Next I will discuss anesthesia, incision selection and implant selection in detail.