Breast Augmentation

The female breast is a universal symbol of sexuality, motherhood and femininity today, dating back even to the time of ancient cave paintings. Modern breast augmentation with implants has become one of the most common aesthetic procedures.

In breast augmentation surgery there are many alternative techniques and materials. Different implant shapes with surface variability are available and access to the surgical pocket can be through several different routes. All have advantages and drawbacks, but accurate planning is always essential. Implant selection and preoperative planning should not be arbitrary, but based on a meticulous analysis of biological prerequisites and implant dimensions.

Good patient communication and meticulous planning minimizes the risk for re-operation and dissatisfaction and is the foundation for a longterm, stable result.

To achieve successful breast augmentation results,

It is crucial to understand patient desire and establish realistic patient expectations , not to select an arbitrary implant volume, measuring and analyzing dimensions and proportions of existing breast and thorax, selecting implant width in relation to current and desired breast width, using dimensional analysis during preoperative markings, calculating  and positioning implants, marking nipples in relation to base and projection, selecting sub-muscular or sub-glandular implant position depending on the amount of covering glandular tissue.

To optimize outcomes,

Your surgeon has to; create realistic patient expectations, avoid oversized implants, respect limits of existing thorax and breast, select adequate implant width, plan the surgery carefully, calculate ideal vertical implant position, calculate ideal amount of nipple inframammary fold skin, calculate the distance needed for the amount of glandular tissue, favour sub-mammary fold incision, use dual plane implant position in most cases , use sub-facial implantation in appropriate patients which is preferred over subglandular, engage in careful control of hemostasis and make sure that the patient is normotensive before the wounds are closed and encourage early mobilization with arm elevation above head directly after surgery and recommend long time surgical taping of scar (up to 6 months 3 M micropore tape).

Indications and contraindications are very important;

Developmental breast hypoplasia or asymmetry, involutional breast deformity as a result of weight loss or pregnancy and breast feding, patients with normal breast volume who desire a more youthful appearance are the most common indications that suggest this certain medical treatment is necessary.

Contraindications are which someone should not continue with this particular treatment because it is not recommended . These are patients with unrealistic expectations or abnormal desires, psychiatrically or psychologically unfitting patients.

Implant selection should be based on patient desires, width of existing glandular tissue and desired breast width, thorax shape, envelope characteristics, amount and shape of glandular tissue.

Mastopexy ( breast lifting) procedures are common to rejuvenate the female breast, but do have limitations in achieving the most youthful appearance in the upper pole. Breast implants can produce a more long-term and stable youthful upper pole.

Patient and implant selection;

The first step in implant selection is the understanding of the patients’ expectations and desires. Breast augmentation is a dimensional planning process, with the introduction of form-stable, high-cohesive silicone gel implants, dimensional planning has become crucial. To use sizers in a tight-fitting sports bra may give the patient a certain feeling for the expected volume. Silicone gel and saline have been used long term. All implants consist of a solid silicone envelope. The surface may be textured or smooth. The benefit of silicone as a filling material is its softer, more ‘natural’ consistency and form. Saline implants have a higher rupture-risk. Silicone gel is available in a form stable version; the round implant will retain its shape in standing position, as opposed to saline or standard responsive silicone gel implants, which become more position dependent. An anatomical high cohesive form-stable silicone implant will also maintain its anatomical shape in all positions. Form-stable silicone implants have a very low incidence of rupture.

Selections of implant dimensions;

A dimensional analysis should be undertaken. If high cohesive form-stable devices are used this is crucial, as these implants cannot be deformed. The most important dimension to define is the ideal implant-base width, which should be measured, existing glandular tissue width should also be measured. Measuring the ideal width of the desired new breast provides information on ideal implant width if the tissue-cover is subtracted. These measurements should then be added together and divided by two, as a pinch is a double-fold of tissue. Subtracting the tissue cover from the ideal breast width provides the ideal implant width. This is done by elevating the arms 45º above the horizontal plane, simulating the expected, ideal nipple position after a correctly performed augmentation. When selecting implant projection, this is highly related to the tissue characteristics and to the patient’s desires. The selected projection together with the base dimensions of the implant supplies the implant volume. Implants are thus selected as a result of the dimensions of the ideal new breast and implant. During the evaluation, it must be stressed that breast augmentation complexity varies greatly. Tuberous breasts, severe ptosis, secondary augmentation cases and pronounced asymmetries are more difficult to correct.

Preoperative markings;

Accurate and detailed preoperative marking is essential. Two important questions should be addressed. The first is the vertical location of the implant on the chest wall. Secondly, the ideal amount of skin in the lower pole of the augmented breast should be calculated. The final step is to mark the location of the upper pole of the implant and measure tissue covered here.

Sub-muscular versus sub-glandular implant placement;

Indications for both sub-muscular and sub-glandular implant positions exist and the decision should mainly be based on the tissue cover. A pinch and measurement of the tissue with a calliper provides information for implant positioning. Benefits of sub-muscular implant position are that the implant edges are better covered, resulting in less implant edge visibility. It is also less likely that the tissues will become atrophied due to the pressure of the implant. It appears that sub-muscular placement has better long-term aging compared to sub-glandular implants, especially in smaller breasts. Advantages of sub-glandular placements are that the breasts will have no movement during pectoralis muscle activity and a more natural appearance is produced in the ptotic breast. In the tuberous, contracted breast the risk for double bubble deformity in the lower pole is minimized. This implant position is more common than sub-glandular/sub-facial.

Incisional approach;

The length of the incision depends on the type and size of implant used. Form-stable silicone implants necessitate a 4.5–6 cm incision.

The new sub-mammary fold incision;

According to the preoperative markings described above, sub-mammary fold incision has several advantages. These are less risk for sensory disturbances that may be pronounced in the periareolar and the axillary approach; less contamination of the implant through the submammary fold incisions; and easy inspection and palpation of the implant pocket. It is easy to control the exact position of the implant through the sub-mammary fold. Dual plane dissection and the division of the pectoralis origin of the pectoralis muscle is also easier to divide than through the axillary and the periareolar incision. Emphasizing the fold by suturing of Scarpas fascia to thoracic wall is important.

Dual Plane II,

More commonly used is the dual plane II, where the sub-glandular pocket is created up to the areola plane. The muscle is then divided distally from its lateral border, cutting it horizontally towards the sternum. The muscle is elevated with a cutting cautery. The muscle is divided obliquely, parallel to the chest wall, to minimize the risk of entering between the ribs and intercostal muscles. In sub-muscular placement, dividing inferior-medial origin of pectoralis major muscle is planned carefully always well below nipple plane. Blunt finger dissection with possible exception of lateral in the direction of the axillary.

Implant insertion;

After careful control of the haemostasis, the implant can be inserted. Bleeding is usually minimal and no discharge is seen in the drains. Checking implant’s position on thoracic wall, palpate around edges, avoid creases and buckles are performed. A ‘no touch technique’ is recommended, where the surgeon changes the gloves and is the only one to touch the implant during insertion.

Incision closure;

The new sub-mammary fold incision can be utilized to mark the new sub-mammary fold, resulting in a less conspicuous scar and a better shaped lower pole. Absorbable monofilament sutures are favoured in all layers. To use deep dermal ridge suturing in two layers to maximize final scar appearance is needed.

Complications and side effects;

Oversized breast augmentation adds to the frequency of complications. Surgical complications with bleeding, pneumothorax and nerve damage could be minimized with careful planning and a meticulous surgical technique.

Early and late postoperative complications;


This is an uncommon complication if a meticulous technique is used, but occurs in approximately 0.5–2% of cases. Hematomas should be evacuated, as even small hematomas may contribute to capsular contraction and wound dehiscence.


Blunt dissection adds to the risk of seroma formation. With sharp dissection and by leaving the loose connective tissue on the ribs this problem can generally be avoided. Seromas may also occur late and be related to a sub-clinical infection. These should be drained and cultures taken before antibiotics are administered.

Infections and septic shocks,

Patients receiving implantations should receive prophylactic antibiotics, ideally by IV, 20 minutes preoperatively. This regime almost entirely eliminates the risk for infections. Infections should normally be treated with implant removal and a longer healing period before new implants are inserted.

Asymmetries and implant malposition,

Meticulous planning and surgical technique minimizes risk, but capsular contraction or poor tissue adhesion of anatomical textured implants may result in malposition or rotation. To minimize this risk, the pore size of the textured surface should be larger than 300 μm20,21 .

Implant visibility, rippling, synmastia, perforation and implant extrusion,

These are uncommon, but if implants are placed in the wrong position in relation to the covering muscle, with too poor tissue cover and/or are excessively large, they may be seen.

Double bubble deformity,

This type of deformity of the lower pole of the breast may occur if the implant has to be placed significantly lower than the inframammary fold and the glandular tissue is contracted or tuberous. Higher projecting and form-stable implants (e.g. also minimize the risk of double bubble deformity.

Deformations during pectoralis muscle contraction,

For a natural-looking lower pole of the breast it is important to divide the origin of the pectoralis muscle. By dual plane dissection II–IV, deformations of the breast during muscle contractions are minimized.

Capsular contraction,

This is the most common late complication. Most studies confirm that submuscular positioning minimizes capsular contractions, as do textured surfaces, especially in the sub-glandular plane. With modern techniques the frequency of capsular contraction is approximately 5–10%.

Implant rupture,

All implants may rupture, but it appears that form-stable implants with high cohesive silicone gel have a very low rupture frequency. Extravasation of silicone gel is uncommon and highly related to closed capsulotomy.

Postoperative care;


These are not needed in common postoperatively if signs of infections are not present.


With meticulous technique and sharp dissection with a cutting cautery drains can be avoided without negative effects in most cases. If drains are inserted they are taken out through the axilla and vacuum is applied. Most patients do not need drains after 24 hours, as drainage is normally less than 50 ml per 24 hours.


Surgical tape, Micropore® or Steristrip®, is placed directly on the wound and no other dressing is usually needed.

A sport bra:

It may be useful to minimize implant movement, especially if form-stable implants are used.

For patients with large natural breasts, a bra should be used after the initial 3 weeks of healing, whereas patients with small natural breasts do not need a supportive bra after 3 weeks.

Physical activity and exercise:

Arm elevation is recommended directly after the procedure. Stretching the pectoralis muscle once every hour during the first 24 hours after the procedure minimizes postoperative pain in sub-muscular implantation. Pain is normally minimal. With mild analgesic medication patients should be able to go home within 4–6 hours.

Sports and vigorous physical activity should be avoided for approximately 3 weeks. Following this initial healing phase the patient can resume sports, but all sports that exert tension on the scar, or to much implant movement, such as serving in tennis or trampoline bouncing, should be avoided for 3 months. Vigorous stretching perpendicular to the scar may widen it during this period.


To improve the final scar appearance, scars should be taped with paper tape (Micropore®) for up to 6 months. This helps the scar to mature and reminds the patient not to exert excessive tension.

Shower and bath:

With surgical tape on the wound patients are allowed to shower the first postoperative day, but baths should be avoided for 1 week.

Long-term follow-up;

Self-examination on a weekly basis is recommended. This can be done with circular movements of the hand around the breast during showers. If patients experience changes and alterations in the firmness or appearance or notice nodules and irregularities, a follow-up visit is recommended. Otherwise, patients are recommended to call in for a check up 10 years after surgery.

MRI investigations of the breasts may be indicated after long-term implantation. No absolute recommendation of when implants should be exchanged can be given, but all patients should be informed that it is likely at some point. Modern implants will probably stay intact for 10 or even 20 or more years.