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.