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Breast augmentation- overview updated 18 February 2020


The decision to have a breast augmentation is a major one with life-long consequences. Please be sure you understand this operation well and have all of your questions answered before proceeding. Once surgery is done, it can never be totally undone.


The only way to add meaningful volume or fullness to your breasts is to use breast implants. You cannot do exercises, take pills, use creams, or use “vacuum pumps” to accomplish this goal!! Some surgeons are using fat grafts to enlarge breasts. This procedure has not been widely adopted because there are still lingering questions about the long term effects of injecting one’s own fat into the breasts. The process usually requires more than one operation and rarely increases breast size more than ½ - 1 cup size. I do not feel confident enough in this procedure to offer it to my patients.


The following information is being provided to you in order to ensure that you are fully informed about breast augmentation. It is a comprehensive summary of this very popular plastic surgical procedure. Together with your consultation with me, the information contained herein should allow you to make an informed decision about whether or not this operation is for you. Please read carefully and initial each page after you have done so. The original will go in your chart and you may have a copy if you wish.


Our facility-

            The surgery is done in our office which includes a state-licensed ambulatory surgery center. We have all the necessary staffing, equipment, and resources to perform surgery with the safety our patients deserve, and to handle any emergencies. I recommend doing the surgery here because we can better preserve confidentiality, our staff are very familiar with operations we do, and our facility costs are significantly lower than at other ASC’s or hospital operating rooms. I have admitting privileges at Florida Hospital Waterman, Leesburg Regional Medical Center, and South Lake Hospital if you wish to go elsewhere for surgery, but the costs will be greater. In the event of a problem, we can transfer patients immediately across the street to Waterman Hospital. This has never been necessary following a breast augmentation. Because this is a state licensed ambulatory facility, we cannot keep patients overnight. In over 30 years, I have never seen a patient who was unable to go straight home after their breast augmentation.



            I perform breast augmentation under general anesthesia. Another option is using local anesthesia with heavy sedation. I do not believe sedation is any safer and it presents potential problems, such as patients feeling pain, becoming aware, or squirming while undergoing surgery, making the procedure more difficult to perform. Many practices that do office-based breast augmentation perform this surgery under local anesthesia with sedation only because they are not accredited to do general anesthesia. We do not have this limitation. I have never had a single patient experience any complication from anesthesia during, or after, a breast augmentation.



            Several incisions are used for breast augmentation. They are along the edge of the areola (the colored skin around the nipple), in the crease under the breast, the axilla (armpit), and the umbilicus (belly button). The last two are used by very few plastic surgeons because they are more difficult and offer only one advantage- a scar away from the breast. I have chosen not to offer these options. I do not like the incision on the margin of the areola. This is the visual focal point of the female breast and our eyes are drawn to this. This incision also carries a greater chance of causing loss of feeling to the nipple area and affecting future breast feeding. My go to incision is under the breast where it is well hidden. For saline implants, the incision is usually an inch and a half in length. For gel implants the incision will be 2-3 inches long. 


Implant position-

            Once an incision is made, a space must be created for the implant. This space is called a “pocket” and can be placed either under or over your pectoralis muscle, a large, flat triangular muscle which sits under the breasts. When I examine you, I have you contract this muscle to assess its position and degree of development. Most breast augmentations are done with the implant placed beneath this muscle. Advantages of this position are several. With more tissue over the implant, it less prone to be seen or felt through the skin. Under-the-muscle implants are less likely to experience tightening of the scar tissue that naturally forms around the implant. This is called capsular contracture and will be explained below. Under-the-muscle position makes it a little easier to obtain acceptable mammograms later. For some patients, such as those with very developed muscles or some breast sagging, it may be better to place the implant on top of the muscle. The pectoralis muscle must be partially released from it’s attachments to the ribs in under-the-muscle placement. This should result in no appreciable loss of upper body strength or arm motion. Breasts with sub-muscle implants may demonstrate some change in shape when the muscle is contracted. This is usually subtle and causes no problems. The vast majority of breast implants in the U.S. are placed under the muscle. My current approach involves a variation of the under the muscle, called a “dual plane”. The muscle release in this approach reduces the tendency to tug on the breast when it is contracted.



The Implants-

You have the choice of silicone gel or saline implants. Although saline implants have been my “go to” for most of my patients over the years, the new gel implants are excellent and I am happy to offer them. If I feel that one or the other is best for you, I will tell you and why. Saline and gel implants come in several styles. At the present time, I am offering only smooth, round implants for reasons given below.


I cannot offer gel implants to patients 22 years or younger at the time of their surgery.


How to choose an implant size-

The most important decision to be made, which will determine your results, and satisfaction, is the size of implant chosen for you. There are a wide variety of ways to determine the best implant size: complex formulas, computer programs, and such. None can guarantee you will get exactly the size implant you imagine for yourself. Your breasts will, to some degree, limit what I can put in. For nearly 30 years I have determined the implant size for each patient by using implant sizers in the breasts at the time of surgery. I can place these in the pocket and inflate them to any size I wish, to see how the breasts look with an implant actually in them. I encourage you to tell me what your goals are. Unless, you wish otherwise, I try to produce a result that will look natural, be well proportioned to your body, and feel as soft and normal as possible. Very few patients ever return seeking a different size implant. In my experience, patients who choose their own implants are often disappointed because of picking one that is too small. If you are unhappy with your implant size, I will recommend that you live with them for one year. Some patients simply take longer to adjust to their new appearance. If, at the end of that time, you still wish for a bigger, or smaller, implant, I will offer to exchange your implants for new ones at a discounted fee. This offer is good for six months from that one year anniversary of your surgery.


Bra cup size-

Please understand that there is no uniform standard that defines an A, B, C, or D cup bra. The style of bra, type of material, manufacturer, and personal patient preferences all influence the cup size someone wears. Victoria’s Secret, for example, makes their bras small so that their customers will have a larger cup size, usually by one or even two sizes, than when they purchase bras from other manufacturers. This is why using cup size to describe breasts is very imprecise and I have not found it very useful. While I will do my best to get you the cup size you wish, my primary goal is not a specific cup size but, rather, a happy patient. If you are happy with your results, then cup size is irrelevant. If you desire something more conservative, or “showy”, please let me know. As long as it is not medically inappropriate, or dangerous, I will do my utmost to help you achieve your goals.


Recovery and convalescence from surgery-

            Some postoperative discomfort is to be expected from all surgery and breast augmentation is no exception. I will inject a long acting anesthetic around your breasts. You will receive medications for pain and this will usually keep you fairly comfortable. Most patients are off of the prescription pain medications within a few days. Only a few will need a refill. You should remain physically quiet for the first 5-6 days. After I see you for your first postoperative visit, if you are doing well, I will no longer restrict your activities. This means that you can resume doing whatever you can do comfortably. Just use common sense and don’t overdo things like exercise, etc. for a week or two. You should be back up to 100% within 4 weeks. In three months you should see your final result. I will usually take my final photographs 6 months after surgery, at your final visit.  



            I will take photographs of your breasts before surgery and at your final visit. This is to help plan your surgery and assess the final results. They do not show your face and will never be shown to anyone without your express, written permission. You are welcome to have copies of your before and after pictures if you wish. I may ask you for your permission to use your photographs in our practice and this would be greatly appreciated, but you should feel no obligation to allow their use if this makes you uncomfortable.


Breast augmentation; the upside-

            Breast augmentation has a very high patient satisfaction rate, one of the highest for any cosmetic surgery. In studies of patients who have had breast implants for over ten years, the satisfaction level is consistently greater than 90%. It is very uncommon for women to be dissatisfied with the results of their surgery. Even those patients who have complications, or less than perfect results, tend to prefer their breasts with implants over how they were before surgery. My goal is that you will always be very happy with your decision to have this surgery.


Breast augmentation; the downside or risks/complications/limitations-

             Breast augmentation, like all surgical procedures, carries risks, and complications can occur. Every effort is made to prevent complications but no operation, and no surgeon, or patient, is perfect. Every procedure has limitations in what it can accomplish. Below is a listing of the more common risks and limitations.

            Capsular contracture- All breasts will form a layer of scar tissue around the implant. This scar is called a capsule. If the capsule shrinks (contracts), and/or thickens, it can begin to squeeze the implant and this can make the breast feel unnaturally firm. Severe contracture can distort the breast shape or even be painful. No one knows exactly why a few patients do this. Some researchers feel that it may be due to bacteria from your skin colonizing the surface of the implant. I take measures in surgery to try to prevent this but it is not possible to do this perfectly. Contracture to some degree occurs in between 5 and 15 % of patients, depending on the study, and it is not possible to predict who these will be. I may ask you to do several things after your surgery to prevent contractures. These include taking vitamin E orally, massaging your breasts, wearing a compression bra or strap and/or taking one or more medications for this purpose. Not all surgeons do all these things.  It is very important to follow my instructions carefully, but even diligent adherence to this program does not guarantee that a contracture cannot occur. If a contracture occurs severe enough to produce an unacceptable outcome, correction will require revision surgery. There will be an additional cost for this revision which will mainly cover the expenses of surgery. If you experience capsular contracture after such a revision, I do not usually recommend more surgery to try to fix this as I feel the chance of success at that point is very low. If a revision does not resolve the problem, I will offer to remove your implants at no additional cost to you. Over my career, very few patients have done this.


            Capsule stretching- Less common than contracture, in some patients, the implant pocket may gradually stretch. This can result in too much visible movement of the implants. When you lay down, the implants may shift too far to the side. When you sit up, the implant may sit too low on the chest, making the nipple look too high on the breast. This problem is difficult to correct and requires surgery to tighten the implant pocket with stitches. Correction sometimes requires the use of expensive materials to reinforce the suturing of the pocket. The fee for this type of corrective surgery may exceed that of the original surgerye.  Successful correction of this condition cannot be guaranteed.


            Stretch marks- Young patients, patients who have never been pregnant, and those with small breasts and tight skin are at risk of stretch marks from having implants inserted. Some people are simply genetically predisposed to stretch marks. There is no way to predict who will get them. They are not common but when they do occur, they are permanent as there is no way to eliminate stretch marks.


           Leakage- Saline implants have a risk of leaking of between 5 and 9% in the first 10 years. After that, the failure rate increases by 1% per year. Your implants carry a lifetime replacement warranty. If they leak or fail for any reason, you will be given 2 new implants by the manufacturer. For the first 10 years after surgery, the manufacturer will provide a stipend for the cost of replacing one implant ($1200). You can obtain $2400 of coverage, for replacement of 2 implants by paying the maker $200 within 45 days after your surgery (I strongly recommend this). You will receive a brochure explaining this. Leakage of a saline implant is harmless, as noted above. Some leaks occur overnight. Others may take weeks to become obvious. All leaks eventually become obvious. The presence of capsular contracture increases the risk of implant failure. If you experience deflation of your saline implant, do not delay getting in to see me. The longer you wait the more difficult it is to replace the implant as the pocket shrinks around the deflated implant.


Gel implants have a leak rate of between 0.5-2.7% over 3-4 years. Precise numbers are difficult to come by since gel leaks can go undetected for years. The latest recommendation from FDA and implant manufacturers is for women with gel implants to obtain an ultrasound of their breasts five years after implantation and every three years after that. This is a recommendation, not a requirement. This underscores the importance of returning to see a plastic surgeon periodically for a check up. 


            Visible rippling and wrinkling- Implants cannot perfectly mimic the breast tissue that you do not have naturally. Saline implants, as they settle, may produce ripples and winkles that can be seen on the surface of the breasts or can be felt through the skin. This is more likely with large saline implants but can occur with any implant. Rippling is less common with gel implants and least with the form stable implants. Contracture of the pocket makes rippling and wrinkling more prominent. Remember that breast augmentation is an unnatural process that tries to produce a natural result. A few patients may get that near perfect result which looks and feels entirely natural. Most patients get a very nice result, but one that is not 100% “natural”. Rippling and wrinkling only rarely cause significant dissatisfaction with the procedure.


            Abnormal movement of the implants- because implants are not the same as your natural breast tissue, the way they move in your breasts will not exactly mimic breast tissue. You may see the implants shift as you change position. This is more likely in patients with very thin breast tissue and skin. If your implants are under the muscle, when you forcefully contract the muscle, the inner, lower area of the breasts will probably flatten and the implant will visibly move. This is only rarely objectionable. I use a technique for placing implants under the muscle which has nearly eliminated this problem. Unless you are an elite, competitive athlete, you should not notice any change in your athletic abilities after breast augmentation. For elite athletes, or those with highly developed muscles, I may recommend putting the implants above the muscle and using gel implants.


            Loss of nipple/areola sensitivity- 90% of women will not lose any of the natural sensitivity of the breast, especially the nipple/areola area. Most patients will have some numbness in the breast skin, most often in the lower half of the breast. This usually resolves in a couple of months. Hypersensitivity of the nipples can occur and this usually resolves in a few weeks. In a few patients, loss of some degree of normal sensitivity may be permanent, and in a rare patient, the nipples may be quite numb. So far, no patient of mine has ever expressed regret over having the surgery because of loss of feeling. Loss of sensitivity can take as long as 1-2 years to fully resolve.  Beyond this, it is permanent.


           Calcifications in the breast tissue- over years, calcium deposits may form in the tissue around your implants or in the scar tissue around the implants and this can appear on a mammogram. This is a natural response to the presence of implants in some women. The calcium deposits are harmless but can make interpretation of mammograms difficult. Extensive calcium deposits can make the implants feel hard and uneven. This will usually mandate a revision procedure. Rarely, clarifying the nature of calcium deposits may require a biopsy of the breast. Any surgery on your breasts carries the risk of harming the implants in some way.


            Breast implants and cancer- At this time, it is almost universally accepted that women with breast implants do not have an increased chance of developing breast cancer. Numerous studies over the past 30 years, of tens of thousands of women, have failed to demonstrate any link between breast implant surgery and increased risk of breast cancer. In 2011, FDA reported a possible connection between breast implants and an extremely rare form of lymphoma of the breast. As of August 2018, about 800 cases have been reported worldwide, out of an estimated 10 million women with implants. This is an incidence of 0.008%. The actual risk is not clear but is estimated to be between 1 in a 1000-30,000 women with implants. By comparison, your natural lifetime risk of breast cancer is about 1 in 10, without implants. So far the problem appears to be exclusively connected to textured implants; no case of lymphoma has been reported in a woman who has only had smooth implants. In 90% of cases where the textured implant has been identified, it has been from a single manufacturer, Allergan. I used Allergan textured implants only briefly in my practice, years ago. At the present, I am not offering textured implants until this issue is better understood. The FDA is aware of this concern and the problem is being intensively monitored and studied. So far, the FDA has not felt this problem justifies any change in the status of breast implants as an approved medical device. In 2019, Allergan voluntarily took their Biocell textured implants off the market. 


            Breast implants and illness- There has been a small and very vocal group of women on various internet sites and on social media who developed a wide variety of medical symptoms after getting implants. In some cases, these occurred right away; in others, it took decades. The list of symptoms is almost endless. These women claim they have “breast implant illness” (BII), a diagnosis that has not been formally established. Some sources claim that implants are toxic devices and that no one should have them, a radical position that few agree with. While the numbers of women who claim to be sick from implants is impressive, it amounts to less than 1% of the over 5 million women who have breast implants. This issue is being taken seriously and the American Society of Plastic Surgeons recently formed a task force to study this. Breast implants are already the most studied medical device in history. Removing the implants and the scar around them has not consistently resolved these issues. Available studies have not shown that women with implants are at higher risk of auto-immune disorders or other illness, but some claim that the studies are flawed or of too short a duration. In 30 years of practice I have seen less than a dozen women with symptoms such as are being ascribed to implants. I do believe that there might be a small population of women who are unusually susceptible to the presence of silicone and may react in undesirable ways. It is important to realize that we do not know everything there is to know about breast implants. We know more about implants now than we did 40 years ago and will know more in the future than we know now. Women desiring implants must understand and accept that there are some aspects of implant surgery that we do not have answers to. If you cannot accept this, perhaps you should consider not having the surgery.


            Interfering with mammograms- implants do block x-rays and produce a shadow on mammograms. To get around this, mammogram techniques are modified for women with implants. A displacement technique (Eklund technique) is used to push the implants out of the way, and additional views are taken. Most, but not all, of the breast tissue can be seen. It is theoretically possible that a small lump might be missed, and if this lump were cancerous, this could result in a delay in diagnosis and treatment. Studies have compared breast cancer patients who had breast implant surgery with those who never had implants. No statistical difference has been found in the results of the cancer treatment between the two groups. Capsular contracture, by making the breasts difficult or impossible to compress, can compromise mammography. Breasts that stay soft can be examined by mammography more effectively. This is why I feel compliance with the postoperative instructions to prevent contracture is so important early on after surgery. Follow your primary care provider’s recommendations for obtaining screening mammograms.


            Breast implants and breast feeding- For young women, the possibility of one or more future pregnancies must be factored in. Pregnancy will create unpredictable changes to your breasts, with or without implants. You may gain or lose breast tissue, your skin may stretch, the nipples and areolae may darken and enlarge, and you may get stretch marks. You can safely breast feed with implants. It is not possible to predict how your breasts will look or feel after a pregnancy.


            Complications common to all surgery- Breast augmentation also has many complications in common with other surgeries. These include, but are not limited to, such things as infection, bleeding, poor quality scars, delayed healing, injury to structures in or around the area of surgery, complications related to anesthesia, and complications which can be serious, or even life threatening, such as blood clots in the legs or lungs, heart attack, stroke, pneumonia, and more. The likelihood of any of these happening to you is less than 1%. There are many more potential complications of surgery, enough to fill a book, but these are so uncommon that they should not be of concern. 


            Summary of complications- While complications from breast augmentation are rare, they can and do occur. The only way to completely eliminate the potential for complications is to avoid having breast implant surgery.



Future surgery-

I do not feel that it is realistic to expect a breast implant to be in your body for decades without some degradation of the implant, potential for leakage, or some other problem at some time in the distant future. It is not true that breast implants have to be replaced on some regular schedule, such as every ten or fifteen years. It is highly likely, however, that at some time in the future you will need, or simply desire, another operation on your breasts as a result of past implant surgery. The most common reasons would be to replace a leaking implant, remove them altogether at some time, exchange them (for something larger, smaller, or, perhaps, a newer, better implant than is available today), correct a late occurring contracture (this is less common than early contracture but can happen), perform a breast lift for sagging, or some other procedure. Because breast augmentation is a cosmetic procedure, any surgery related to this will probably be regarded as cosmetic by most insurance companies and, therefore, not covered by insurance.


What will your breasts look like years from now?-

Many things will affect the look of your breasts over the years. Pregnancy and breast feeding (if applicable to you), weight loss or gain, health issues, habits (exercise, sleep, diet, smoking, drinking, etc.), and genetic makeup all affect how your breasts will change with time. It is therefore impossible to predict how your breasts will look years from now. After implant surgery, your breasts will be heavier and gravity will affect them more. I recommend that you not go braless routinely. Beyond your skin and some fine ligaments, both of which will stretch with time, a bra is the only support your breasts have. Hopefully, your breasts will look nice for many years.


Smoking and breast augmentation-

            Besides being one of the worst things for your health, smoking can have very significant adverse effects on the results of breast augmentation. It has been my experience that patients exposed to cigarette smoke during the critical period before and after surgery are much more prone to developing capsular contracture, which I discussed above. This holds for those who smoke themselves, and those who inhale much second hand smoke. If you smoke around the critical period around your surgery, it may affect your result.  Smoking should be stopped for 6 weeks before surgery and full 3 months afterwards. Ideally, you should stop altogether! If you smoke and develop a tight, hard breast, I will not offer a revision attempt unless you stop smoking.



There are innumerable variables and intangible factors that can affect the outcome of any operation. Many of these are out of my control, and yours. You must understand, and accept, this small degree of uncertainty if you wish to undergo a breast augmentation. If you decide to move forward with the surgery I guarantee that when I do the surgery, I will bring to bear all of my skill and experience on that day to provide you with the best result that I can. Beyond this no surgeon can promise more. I hope that you will be able to say that you are happy with the result of this surgery and will enjoy these for many years. My goal is for nothing less than for every patient to be able to do this.



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