10941 Raven Ridge Road, Suite 101, Raleigh, NC

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Michael Law MD Aesthetic Plastic Surgery

Breast Augmentation Surgery in Raleigh NC

Located in Raleigh, North Carolina serving patients in Raleigh, Cary and Durham NC.

The women who choose this practice for breast augmentation surgery want to feel more confident about their breast appearance, to look great in form-fitting clothing, to get rid of their padded bras and swimsuit tops, and to have more options when shopping for clothes or when looking through their closet for what to wear to an important event or just out to lunch with friends – but they do not want to look like their appearance is the result of a surgical procedure.



There are more breast implant options than ever before for breast augmentation patients in the United States. We now have four companies that have FDA approval to market and sell breast implants. Three of them offer cohesive silicone gel implants and conventional (single-chamber) saline implants: Allergan, Mentor and Sientra. Cohesive silicone gel implants are now available with varying degrees of ‘cohesiveness’, meaning that you can select exactly how soft or firm you would like your breast implants, and thus your augmented breasts, to be.

The newest company offers one specific implant product, which is a two-lumen ‘structured’ saline implant: the Ideal Implant. This implant represents an attempt to create a saline implant that feels more natural than conventional saline implants, but that does not require a radiologic test to monitor the status of the implant (like the MRI scan you will need if you want to know if one or both of your silicone gel implants have ruptured).

Round silicone gel implants are available with both smooth and textured surfaces, which have some differences with respect to implant performance. Saline implants all have a smooth shell, while shaped silicone gel implants all have a textured shell. In this practice we place only round breast implants (cohesive silicone gel, structured saline and conventional saline), as shaped implants have been shown to provide no observable improvement in augmented breast shape compared to round implants, and they have a risk of rotation which, when it occurs, requires another trip to the O.R.

This is the most important thing to know about this multitude of implant options: THERE IS NO PERFECT BREAST IMPLANT. There are instead lots of implant options, and there are pros and cons for each implant option that you might consider. Given the natural breast that you are starting with and your goals for the outcome of your breast augmentation surgery, there is quite likely an implant choice – that combination of implant fill material (silicone gel vs. saline), implant shell type (smooth vs. textured vs. structured smooth) and implant proportions (base diameter / projection / volume) that is perfect for YOU.

The most important step in the process is finding a surgeon who both understands your goal for the outcome of the surgery, and who has experience with all of these implant options. And who has a relationship, I should add, with all of these implant companies. This provides you with the best chance of finding your breast implant ‘perfect fit’, and the best chance of you being thrilled with your new breast appearance for many years to come.


A natural-appearing breast is noticeably fuller in the lower pole (below the nipple) than it is in the upper pole. In profile (viewing from the side), the upper pole slopes gradually from where the breast begins in the upper chest down to the nipple, and the lower pole is full and rounded. For any patient considering breast augmentation, there is an implant size above which the upper pole begins to look rounded, convex, and unnaturally full.

Mild upper pole fullness can look beautiful and youthful, but excessive upper pole fullness due to overly-large or overly-projecting implants looks decidedly fake, and like what most people think of as a ‘boob job’.

Implant selection is of course a critically important part of the process, but it is but one of many factors that lead to a lasting, natural-appearing breast augmentation result. Patient education and preoperative preparation, surgeon experience, operative technique, precise implant pocket dissection, protective implant insertion technique, implant-stabilizing incision closure technique and attentive post-operative patient management are all absolutely critical components of success in natural-appearing breast augmentation.

Natural-appearing breast augmentation can be achieved for all patients if the surgery is performed by an experienced surgeon who uses biodimensional planning techniques to assure the selection of an appropriate implant type, profile and size, who selects an appropriate approach to implant placement, who pays great attention to detail in the operating room and who provides patients with detailed instructions for and attentive care in the postoperative phase.

Hundreds of thousands of women have their breasts augmented each year in the United States, and those who have had great breast augmentation procedures don’t look artificial – they look beautiful and natural, with breasts that are full but in harmony with their figure. They look great, they wear what they want to and fill out their clothes nicely, and the fact that their breast appearance is a result of a breast augmentation surgery is their little secret.

When the goal of this operation is a natural-appearing breast enhancement, the results can be absolutely beautiful. However, if the goal is to create an excessively full breast profile which is out of proportion to the shoulders, waist and hips, then the results – by definition – never appear natural. These patients not infrequently end up having a series of operations to address problems related to the excessive implant volume.

Make sure you choose a surgeon who understands your goals, who takes time to show you why a certain implant is a great choice for you, and who clearly explains all aspects of the procedure to you. A surgeon whose ‘before and after’ gallery clearly demonstrates to you that they are capable of creating the kind of breast augmentation result that is consistent with your own personal aesthetic ideal.

You should also know this: the process of having breast augmentation surgery can and should be a pleasant experience for the patient, with a quick recovery and return to non-strenuous activity, if measures are taken to minimize postoperative discomfort. It is our pleasure and privilege to provide natural-appearing breast augmentation results and a rapid-recovery breast augmentation experience for our patients from North Carolina, from around the United States and from around the world.


Why are there textured and smooth breast implants?

The answer to that question depends on a number of factors, including your preop breast appearance, what your lifestyle is like, what breast volume you would like to have and what is pleasing to you aesthetically. Sientra, Mentor and Allergan all have silicone gel breast implant product lines for cosmetic breast augmentation that include the traditional round implants in both smooth and textured surfaces, and shaped / form-stable implants all of which have textured surfaces. For a number of reasons this practice offers only round implants for breast augmentation; our decision to stop placing shaped implants as of 2016 is discussed in another section.

Traditional, single-chamber saline implants are also available from Sientra, Mentor and Allergan. All available saline implants have a smooth shell, as saline-filled implants with a textured surface shell have a higher failure rate and are therefore no longer produced. Textured surface silicone gel implants, on the other hand, do not have a higher failure rate than smooth surface silicone gel implants. The newest implant to market is the structured Ideal Implant; this saline-filled implant has a smooth shell and is designed with two separate saline-filled chambers with internal ‘baffles’ (sheet of smooth silicone elastomer shell material) between the chambers.

So if you go with traditional or structured saline implants, your implants will by default have a smooth shell. If you go with a shaped silicone gel implant, your implants will by default have a textured shell. If you prefer round silicone gel implants, which is the most commonly placed implant around the world today, you and your surgeon will need to decide between smooth surface and textured surface implants.

Textured surface implants were originally developed with the hope in mind of reducing the rate of capsular contracture (CC). The general consensus in the plastic surgery literature for many years has been that there does not seem to be a significant difference in the contracture rate between smooth and textured surface implants, but some recent data from the implant companies shows that some textured surface implants do have a slightly lower rate of capsular contracture. The difference in the CC rate is small, however, and one needs a large study with many patients enrolled to observe a difference.

So for a single patient any potential small difference in CC rates in smooth vs textured implants, in my opinion, is not that relevant. There are a number of steps that a surgeon can take to reduce the risk of capsular contracture that are much more significant than the type of implant shell that is selected. Read more about the things we do to prevent capsular contracture at The Plastic Surgery Center here: What can be done to prevent capsular contracture?

Up until recently, most U.S. plastic surgeons have preferred to use smooth / round silicone gel implants. This bias comes from years of using primarily smooth / round saline implants, during the fourteen year (1992-2006) FDA-mandated moratorium on silicone gel breast implants, until the FDA gave approval to the new generation of cohesive silicone gel implants in 2006. Saline implants were previously available in smooth and textured versions, however the textured shell saline implants had a higher deflation rate and fell out of favor.

So the primary implant used in the United States for almost a decade and a half was a smooth-surface saline implant, and when the FDA lifted the moratorium in 2006 most American surgeons transitioned to using smooth-surface silicone gel implants. Again, it is important to understand that the ‘smooth vs. textured’ decision only applies to silicone gel implants; if you seek a saline implant breast augmentation then smooth shell implants are the only option.

Are smooth or textured implants the best choice for me?

Cohesive round silicone gel breast implants are appealing in that the gel inside is cohesive (i.e. it is in a solid state and sticks together, as opposed to the liquid silicone gel of older silicone gel implants) but not highly cohesive (that’s what is inside ‘gummy bear’ implants), which makes them the softest and ‘squishiest’ breast implants that are available, and which also makes them the most popular implants with patients. Cohesive (not highly cohesive) implants best mimic natural breast tissue. Highly-cohesive or ‘gummy bear’ implants feel much firmer than natural breast tissue.

Smooth shell breast implants, in patients with thin breast tissue, are perhaps a little less likely to be palpable (and outwardly visible) than textured surface breast implants. This slight difference is less relevant when the implants are placed behind the pectoralis major muscle, which enhances concealment of the implants in the upper pole and cleavage area.

Another important difference is the interaction between the implant shell and the fibrous capsule that one’s body forms around the implants. This fibrous capsule which forms around any implanted medical device does not adhere to a smooth implant shell, so smooth implants are mobile within the implant pocket – which has the advantage of nicely simulating the feel and behavior of natural breasts, but has the potential downside of contributing to implant displacement (‘bottoming out’, ‘lateral drift’) over time.

Textured surface implants are intended to promote friction between the implant shell and the body’s fibrous capsule around the implant, or even adherence of the fibrous capsule (which the body naturally creates) to the surface of the implant. Friction and/or adherence to the implant surface, if it occurs, helps to stabilize implant position and reduce the likelihood of unfavorable implant position changes over time – such as ‘bottoming out’ and ‘lateral drift’. Friction/adherence may also reduce the rate of capsular contracture, which is a positive, but may also increase the risk of postoperative seroma (a fluid collection around the implant).

The process for creating the textured surface of the implant shell varies significantly between the three companies, and as you might expect the performance of each company’s textured surface implants varies as a result of these differences. The least aggressively textured implants (the smallest ‘bumps’ on the implant surface when you image it using a microscope) have the least adherence to the fibrous capsule, but also the lowest risk of seroma. The most aggressively textured implants (the biggest ‘bumps’ on the implant surface) have the highest degree of adherence but also the highest rate of seroma. My personal textured implant preference is to not use aggressively textured implants.

In patients with good breast skin tone and adequate breast tissue to conceal the implants, I think that textured surface round implants are a great choice. I prefer smooth surface round implants when the breast tissues are thin, or when there is some skin laxity but not enough to absolutely require a simultaneous mastopexy. Why? If the breasts are a little droopy, you want an implant that will settle into the somewhat droopy breasts, not one that may tend to stay in a higher position on the chest wall because of the surface texturing.

I also prefer smooth surface implants for patients having an augmentation mastopexy. With breast skin laxity and thinning there is a slightly greater chance of implant palpability and visibility, so my preference is for smooth implants in those patients. If there is better skin and breast tissue tone, then textured surface breast implants are fine for augmentation mastopexy.

You may have read about or heard discussed in the media a form of lymphoma (lymphatic system cancer) called ALCL that is now known to occur rarely in patients with breast implants. ALCL stands for ‘atypical large cell lymphoma’ and it is discussed in detail on another page on this website entitled ALCL: what you need to know. While this very rare (and treatable) cancer appears to be more common with textured surface implants compared to smooth surface implants, the majority of cases have been associated with aggressively textured implants (and older generation implants) which are not used in this practice. Additionally, implant bacterial colonization and low-grade infection also appear to be a likely causative factor or at least promoting factor for ALCL. In my opinion, less aggressively textured implants remain a perfectly acceptable implant option. As with any breast augmentation procedure, they should be placed using techniques that drastically reduce the possibility of bacterial colonization: triple antibiotic irrigation, insertion using a sterile funnel, use of a nipple barrier, not using a periareolar incision, etc. In a study published in 2017 that included 42,000 patients in whom theses anti-infection strategies were used, the rate of ALCL was 0%.

Making the Decision with your Plastic Surgeon

These are general concepts and not necessarily absolute preferences, and many additional factors are evaluated when selecting the best implant for each patient. The thought process behind implant selection takes into consideration not only what is likely to contribute to a successful outcome immediately postop, but also what is likely to remain stable and aesthetically ideal over time. For example, an athletic patient who is a distance runner is often best served, in my opinion, by textured surface breast implants, as the textured surface provides a greater likelihood of the implants remaining in an aesthetically ideal position over years of sustained, high-impact exercise.

The take-home message is this: there are more available breast implant options than ever before, so you want to see a surgeon who has experience with (and therefore some expert opinions about) all of the implants that you are considering. The best decision is always a well-informed decision that takes into consideration all of the currently available options and all of the latest, scientifically-based information about those options. You are best-served, without question, by a board-certified plastic surgeon who is up-to-date on the current breast implant literature and who has a working relationship with all of the FDA-approved implant companies.

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Which Company Makes the Best Implants?

Well naturally a representative from each company would immediately respond “Ours does!”, and of course each company has scientific data which, from their perspective, backs up their claims. The truth is that all four of the currently FDA-approved implant manufacturers make good products, and the differences between them are, with some exceptions, fairly subtle. Competition between implant makers has been a very good thing for the consumer, as each company strives to develop manufacturing advances and new implant features – including completely new implant designs – that provide products that are both safer and more natural appearing.

Some plastic surgeons are loyal to a single implant manufacturer. That loyalty may be because a surgeon thinks a certain company’s implants are the best, or it may be simply a matter of convenience (it’s a lot less work dealing with just one company, and it certainly requires a lot less storage), or it may even be motivated by the availability of cash rebates to the practice for using a large volume of implants. The major downside of working with just one company – and it’s a huge downside – is that it limits your implant selection options.

No single implant maker has an implant available for every possible combination of implant volume, base diameter and projection. So if the goal of a surgeon is to provide each patient with a completely customized implant selection, then one must work with all three companies that manufacture both silicone gel and conventional saline implants (Allergan, Mentor and Sientra), and the newest company to market which manufactures ‘structured’ (multi-chamber) saline implants (Ideal Implant). The great advantage of working with all of the FDA-approved breast implant companies is that it enables a surgeon to provide patients with the widest range of implant options.

Sientra and Ideal Implant stand out from the other two breast implant manufacturers in one very significant way: they sell their implants exclusively to board-certified plastic surgeons. The leaders of these two companies are so committed to producing the best possible outcomes for breast augmentation patients that they will only allow their products to be placed by physicians who have completed plastic surgery residency.

In an era where ER docs, family physicians and oral surgeons (among others – and no, I am not making this up, search it online) are offering breast augmentation, Sientra and Ideal Implant are the only two companies that have taken a stand on the issue of which physicians are qualified to use their products. This commitment is respected and appreciated by all residency-trained and board-certified plastic surgeons, and should serve as a bold statement to the consumer that Sientra and Ideal Implant put excellent breast augmentation results ahead of corporate profits.

In my practice I use implants made by all four U.S. breast implant manufacturers. The implant selection is based on biodimensional planning (using measurements made during patient examination), the patient’s lifestyle and activity demands, and the specific aesthetic outcome that each patient wishes to achieve. For any given patient, there is a limited range of implant sizes and profiles that will produce a natural-appearing breast enhancement. In working with all four breast implant manufacturers, I have more options available for each patient.

The bottom line: you can potentially get a great result with breast implants made by any of these four companies. It is really a matter of sorting out, ideally with the guidance of a board-certified plastic surgeon who has a working relationship with all four implant companies, which particular implant type, size and profile is the best choice for your individual needs.

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Cohesive silicone gel implants vs. conventional saline implants vs. structured saline breast implants

Women considering breast augmentation now have the luxury of deciding between three kinds of breast implants: cohesive silicone gel implants (approved for cosmetic use by the FDA in 2006), conventional (single-chamber) saline implants, and structured saline implants. There are a number of pros and cons to consider with each type of implant, however the most important thing to know is that patient satisfaction is very high with all three. You can’t really go wrong with this decision – it is merely a matter of deciding which is best for you personally.

Regarding silicone gel implants, it is important to understand that a cohesive silicone gel implant is a very different (and vastly superior) medical device compared to the older liquid silicone gel implants that were available for cosmetic use in the 70’s and 80’s, but were not approved by the FDA for cosmetic use from 1991 to 2006 (although they still could be used for breast reconstruction). The new cohesive gel implants are manufactured so that the gel material is in a semi-solid to solid state which, means that if the implant’s outer shell fails the gel material does not easily leak out of the implant – as it would with the older liquid silicone gel implants.

The design and manufacturing process for the outer shell has also improved a great deal, resulting in significantly lower implant shell failure rates. These improvements make gel implants much more appealing as long-term medical devices, and because of these major improvements and positive data from clinical trials the FDA cleared them for cosmetic use in 2006.

One very important issue to consider is implant palpability, i.e. whether you can feel the implant or not when you – or someone else – feels your breast. Silicone gel, structured saline and conventional saline implants are soft to the touch and compressible. Most surgeons and patients agree, however, that silicone gel breast implants tend to feel much more natural than saline breast implants, at least in patients who are starting out with a relatively small breast volume (say A to B), and that structured saline implants fall somewhere in between.

Because saline is non-viscous, it tends to allow the edges of the implant to collapse and this makes the implant edges of a conventional, single-chamber saline implant much more easily palpable in a patient who has a small preoperative breast volume. This will be quite obvious to you when you examine samples of saline and silicone gel implants during your consultation.

breast augmentation

Click for more breast augmentation photos

As suggested above, the degree to which this difference is noticeable postoperatively varies a great deal with regard to two factors: the amount of breast tissue that exists prior to augmentation, and the size of the implant that is used. A silicone gel implant’s more natural feel will be much more important to patients who are slender and who fit in an A cup bra preoperatively, as they have less subcutaneous soft tissue and breast tissue to conceal the implant. In such a patient a saline implant is usually very easy to feel through the skin, and may even be visible externally – especially in the lateral aspect of the augmented breast where the tissue covering the implants is the thinnest.

The difference in feel between saline and silicone gel implants will be less noticeable to a patient who is more full-figured and whose pre-operative bra size is a full B or especially a C cup. In some fuller-figured patients saline implants may be undetectable by palpation (meaning they feel completely natural). Saline implant palpability is primarily a matter, therefore, of how much natural tissue there is to disguise the implant.

Another important difference between gel and conventional saline breast implants is what happens if the implant shell fails. If a conventional, single-chamber saline implant ruptures, that breast will rapidly ‘deflate’ as the body absorbs the saline. Most patients have little tolerance for having just one augmented breast, of course, and a saline deflation thus requires a return to the operating room to replace that implant.

When a gel implant fails, there is no change in the appearance or feel of the breast, as the gel material is inert and is not absorbed by the body (and with cohesive implants the vast majority of, if not all of the gel material, remains within the implant’s outer shell). As there is no outward sign that the implant has failed, the only way to discover that a gel implant has ruptured is to undergo a radiologic test such as an MRI, which is the best means currently available for diagnosing silicone gel implant failure.

The FDA recommends that women receiving gel implants have MRIs at certain intervals postoperatively to monitor the status of their implants (this is an FDA recommendation but not a requirement). The cost of an MRI scan (which includes the charge for performing the test as well as a charge for the test being interpreted by a radiologist) can range from $1000-$2000. The FDA also recommends that patients with a ruptured silicone gel breast implant have the implant removed and replaced.

Structured saline implants (the brand name is ‘Ideal Implant’) represent an attempt to create a saline-filled breast implant that is less easily palpable and more life-like than a conventional, single-chamber breast implants Although not quite as breast-like as cohesive silicone gel implants, structured saline implants definitely feel more natural than single-chamber saline implants. And unlike silicone gel breast implants, a radiologic study like an MRI scan is not required to detect a structured saline implant shell failure.

If the outer, smaller chamber of and Ideal Implant leaks and empties then the implant loses a relatively small percentage of its total volume and the augmented breast will appear slightly smaller than the other side, so implant replacement is not urgent. If the larger, inner chamber leaks and empties then the affected breast will appear much smaller than the other side, and immediate replacement of that Ideal Implant will be necessary.

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How many cc’s? – deciding on implant volume

The actual size of a breast implant, measured in cc’s, is really not very descriptive of what a breast augmentation will look like, or what the cup size will be. The augmentation effect of any implant varies in different patients, and is relative to the preoperative size of a patient’s breast and the size and stature of the patient overall. A tall, broad-shouldered patient with small A-cup breasts may require 400cc implants to achieve a C-cup breast volume postoperatively, while a shorter patient with medium B-cup breasts may only need a 200cc implant to achieve a C-cup breast volume.

During the consultation process it is important for patients to be given the opportunity to examine a large number of sample implants to get a sense of how implants vary according to base diameter, projection and volume. Sample implants can be placed in a soft, non-padded bra to give prospective patients a sense of what their postoperative breast profile will be with a given implant volume. Breast forms (silicone gel bra inserts that are concave on their posterior surface, which fit over the breasts to simulate an augmentation) can also be used to give patients a sense of what their appearance will be with a certain number of cc’s added to their breast volume. Sample implants and breast forms placed in a non-padded bra, evaluated both without a shirt on and while wearing a form-fitting shirt, are a very useful means of helping patients to determine what implant volume is most appealing to them.

When a natural breast appearance is the goal, it is helpful in some patients to ‘try out’ different implant volumes and profiles in the operating room. Once the implant pockets have been created, sterile sizers can be placed in the implant pockets and the upper half of the O.R. table raised so that the resulting breast appearance can be assessed with the patient in an upright ‘sitting’ position (chest fully upright) while under anesthesia. These sizers are available not only for each implant size but also for each implant profile (low, low plus, moderate, moderate plus, high, extra high). Pre-filled gel sizers are used for silicone gel implant augmentations, while Inflatable sizers are used for saline implant augmentation. Sizers are especially useful in cases where the surgeon is trying to improve a preoperative breast asymmetry, and implants of different sizes and/or profiles may be the best choice.

Preoperative measurements that are made by your plastic surgeon such as breast base diameter, upper pole tissue thickness and lower pole skin stretch are of critical importance. For every patient there is a fairly specific range of implant volumes that will create a breast profile that would be considered natural-appearing. And for each patient there is an implant volume and profile at which the upper pole of the breast begins to appear unnatural. If your goal is a natural-appearing breast enhancement, make sure that the surgeon you select clearly understands your aesthetic ideal, and that you feel confident that they are committed to and capable of providing you with that kind of result.

There is, of course, a range of implant volumes and profiles for each patient that could potentially produce a plausibly natural-appearing result. While one patient may seek an augmentation that is ‘perfectly natural’, another may be interested in a result that is more on ‘the full side of natural’. Many patients do ask that the largest implant volume be selected that does not produce an unnatural fullness in the upper pole. By using sample implants and breast forms in consultation, and in some cases by using breast implant sizers during the surgery to confirm exactly what breast implant profile and volume produces the best breast appearance, patients can be provided with the closest possible approximation of their preoperative goals, and can be assured of a natural-appearing result.


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Incision locations

Three incisional approaches to breast augmentation have been widely used: inframammary fold (the crease at the bottom of the breast), trans-axillary (underarm area) and periareolar (along the inferior border of the areolas). Many board-certified plastic surgeons – myself included – have abandoned the periareolar incision, as we now know that it is associated with a higher risk of capsular contracture and scar contracture compared to the other two approaches.

The inframammary fold (the crease at the bottom of the breast) is by far the most commonly used incision for placement of breast implants. It always has been, and it always will be. An incision that is planned and executed so that it falls within the inframammary fold is, in most cases, functionally invisible once it has healed and the resulting scar has fully matured. In some cases the preoperative level of the inframammary fold needs to be lowered, and in those instances it is important to use careful preoperative planning to determine exactly where the incision should be made – as one is planning an incision that is below the existing (pre-operative) fold.

The inframammary fold incision has a number of distinct advantages;

  1. The incision is at the periphery of the breast, so one does not have to cut through breast tissue to create the implant pocket.
  2. Direct access to the implant pocket permits full access to the pectoralis major muscle and the greatest number of options for altering pec major muscle anatomy, such as release of inframammary fold and parasternal origin fibers, and varying the degree of muscle separation from the posterior surface of the breast (dual-plane I, II or III dissection).
  3. The greatest number of options for improving preoperative breast asymmetry are available via the inframammary fold incision.
  4. The definition of the inframammary fold can be enhanced via the inframammary fold incision.
  5. If the inframammary fold needs to be lowered, this incision allows the surgeon to redefine and protect the new inframammary fold.
  6. Sutures can be placed that reduce the likelihood of postoperative inferior implant malposition (‘bottoming out’).

The trans-axillary or underarm area incision is also a perfectly reasonable approach to breast augmentation, and it is one I use frequently; however this incision is best reserved for specific patients. The trans-axillary approach is ideal for patients with very youthful-appearing breasts that are close to symmetrical, especially younger women with no history of pregnancy. In patients with small, youthful-appearing breasts the inframammary fold (and thus a scar in that location) can be more easily seen compared to women in which the lower pole of the breast conceals the inframammary fold. This may be a particular concern for patients that are prone to more noticeable scarring.

There are important limitations to know about the transaxillary or underarm approach. There are significant limits to the breast shape and pec major modifications that can be made, there are limits to what can be done to improve asymmetry, and when lowering the inframammary fold there is really nothing you can do to help define, support and maintain the new level of the fold. Also, it is important to know that most breast implant revisional surgeries require an anterior (i.e. inframammary fold) incision.

The patients for whom I use a transaxillary incision are most commonly young women (20’s and early 30’s) with small, youthful-appearing breasts which are roughly symmetrical and which do not require lowering of the inframammary fold to create an aesthetically ideal appearance. Many of these patients have not yet met their life partner, and they are therefore interested in the ‘stealthiest’ approach to breast augmentation. And it is definitely a very stealthy approach, for when a soft, cohesive (not highly-cohesive or ‘gummy bear’) implant is placed through an underarm incision, the breasts feel completely natural and the scar is in most cases impossible to detect.

Breast implants can be inserted through an incision in the belly button area (’trans-umbilical’ breast augmentation), however there are a number of problems with this approach and it therefore is not widely used. Approaching the surgery from such a remote location does not lend itself to the creation of a precisely-defined implant pocket, or the creation of a natural-appearing result, and this approach has a higher rate of complications and reoperation compared to the standard breast augmentation incisions. Most board-certified plastic surgeons do not use this approach.

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Sub-pectoral vs. submammary implant position

There are three approaches to breast implant pocket creation: subpectoral, subfascial and submammary. In the subpectoral approach, the pectoralis major muscle is elevated from the chest wall so that a portion of the implant resides behind the muscle. In the subfascial approach, only the outer fascia (connective tissue sheath) of the pec major is elevated, so that the pec major muscle lies behind the implant and the anterior pec major fascia lies on top of the implant. In the submammary approach, the pec major muscle and fascia is left undisturbed and the implant pocket is developed directly behind the breast (on top of the pec major).

Currently the subpectoral pocket is the most widely used approach, and it has consistently been the most popular approach as it affords the surgeon and the patient many potential advantages. The submammary approach is a distant second, and the subfascial approach has not gained significant popularity. In my opinion subfascial placement is really not that different, both in terms of postoperative appearance and long-term outcomes, from submammary placement. Before discussing the different approaches in detail, it is important to understand exactly what ‘subpectoral’ means.

‘Subpectoral’, ‘submuscular’ and ‘under the muscle’ are somewhat misleading terms, as in most cases the breast implant is only partially subpectoral. The anatomy of the pectoralis major muscle, when modified surgically as outlined below, is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area and upper pole, sometimes referred to as the ‘social aspect’ of the breast as it is visible in some shirts, blouses, dresses and swimsuits.

In subpectoral augmentation it is important for the surgeon to release the inferior origin of the muscle across the lower pole of the breast, up the border of the sternum medially. The pec major would in most cases cover the majority of a breast implant if the inferior origin was not released, and if left intact the lower aspect of the pec major can create significant (and bizarre-looking) breast implant animation. When the inferior origin of the pec major is released, the inferior fibers retract upward (permanently), so that there is no muscle coverage of the most inferior aspect of the implant and therefore no significant breast implant animation.

‘Animation’ means that when the pec major contracts, the breast implant underneath it moves around – usually upward and outward towards the underarm area. You may have seen breast implant animation at the pool or at the gym, and if you have then you are well aware that it is NOT a cosmetically favorable outcome. Be sure that the surgeon who is performing your subpectoral augmentation can provide you assurance that you will not have obvious breast implant animation postoperatively.

As indicated above, a ‘subpectoral’ augmentation is not totally subpectoral and is in most cases really about half subpectoral. The upper half of the implant is subpectoral and the lower half is submammary. For this reason, a subpectoral pocket is often referred to as a ‘dual-plane’ pocket. In addition, the pec major can be released to varying degrees relative to the overlying breast. The most limited pec major dissection is referred to as ‘dual-plane I’: the pec major released but its inferior border is still below the level of the inferior border of the areola. Further separation of the pec major form the overlying breast can be performed such that the inferior margin of the pec major is at or just below nipple level (dual-plane II) or at the level of the superior border of the areola or higher (dual-plane III).

The more the pec major is released, the lower the likelihood of breast implant animation from pec major contraction, and the more a breast implant will tend to fill out the lower pole of the breast. My personal preference is at least dual-plane II dissection in most patients, as this maintains excellent upper pole / cleavage area implant coverage by the pec major, while minimizing the possibility of visible animation. Subpectoral position, even though it is really partial subpectoral position, is associated with the lowest risk of postoperative capsular contracture. Capsular contracture refers to thickening and tightening of the thin fibrous capsule which the body forms around any implanted medical device, which can make breast implants feel firm or even hard – and in advanced cases can distort breast implant shape and position.

In my opinion there is really only one ideal pocket position for breast implants in an elective cosmetic surgery patient: subpectoral, and specfically at least a dual-plane II muscle release. There are a number of very compelling reasons to place implants behind the pec major, some of which are outlined above, but the most compelling reason of all is the fact that radiologists report that an adequate mammogram is more easily accomplished when breast implants are sub-pectoral, compared to submammary or subfascial augmentation.

An American woman’s current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI. And whether or not you have breast implants you should be performing monthly breast self-examination, and undergoing a yearly examination by your primary care MD.

The second most compelling reason to select subpectoral placement is cosmetic: implants that are placed on top of rather than below the pec major (submammary or subfascial pockets) tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing upper pole breast profile. With implants in a subpectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex.

In some patients who have a fuller breast volume preoperatively one may achieve an acceptable appearance with submammary placement – initially. The potential problem is that as breasts age, the fatty tissue often atrophies and breast tissue atrophies as well, and the area where this is most obvious is in the upper pole and cleavage area. So a submammary implant that was initially well-concealed may, after a number of years, become painfully obvious – in the form of visible implant folds and ripples in the upper pole and cleavage area.


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Attention to detail in breast augmentation

For the experienced and meticulous surgeon who is dedicated to creating natural-appearing breast augmentation results, every breast augmentation patient (and therefore every breast augmentation surgery) is different. There are subtleties of implant selection, pocket dissection, pectoralis major release and modification, breast shaped modification and soft tissue envelope management that all may significantly impact the ultimate outcome of surgery. Careful attention to each of these important details can be the difference between an aesthetically ideal result vs. an average result vs. a disappointing result, one which may require secondary surgery.

Managing the inframammary fold

In many breast augmentation patients, the inframammary fold (IMF) needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola. Ideally the implant should be centered directly behind the nipple-areola complex (NAC). Lowering the IMF requires careful planning, as one wants the scar that results from the breast augmentation procedure to reside within the new IMF, and not above it on the lower pole of the breast or below it on the chest wall.

A potential downside of lowering the inframammary fold is that doing so creates some risk of the original, preop IMF being visible along the lower pole of the breast. This can in some cases be severe enough to create one version of the ‘double bubble’ deformity, where there is a visible demarcation between where natural breast tissue ends (at the original IMF) and where the implant contour begins. Techniques to avoid a ‘double bubble’ appearance include internal, radial scoring of breast tissue at the level of the inframammary fold which allows the IMF crease to expand, and fat grafting of the subcutaneous tissue at the original IMF and immediately above and below it, so that the transition between natural breast and implant contour in the lower pole is no longer visible.

When lowering the IMF, care must be taken to ensure that the new IMF is well-defined and not subject to change over time. Through an IMF incision sutures can be placed that anchor the connective tissue layer of the skin to the chest wall, helping to define and maintain the position of the IMF over time. One must be careful to avoid postop failure of the new IMF and descent of the implant below the IMF, which requires surgical correction if it occurs.

Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an under-filled upper pole, and a nipple/areola complex that appears to sit too high on the breast. This is another problem that creates a distinctly unnatural appearance, and one that requires surgical correction: repair of the inframammary folds by means of inferior capsulorrhaphy (closing down the inferior capsule with sutures), superior capsulotomy (expanding the implant pocket superiorly), and potentially placing a material that will help support the weight of the implant in the lower pole (GalaFORM, Strattice, etc).

Upper pole profile
In profile (side view), the natural-appearing breast is not convex in the upper pole, so an excessively convex and overly full upper pole is a dead giveaway that a woman has breast implants. In addition, inadequate release of the inferior origin of the pectoralis major will allow the muscle to hold the implant in too high a position, and may even cause the implant to displace upwards (as high as the collar bone in some patients) when the muscle contracts. Patients with this problem require reoperation to release the inferior origin of the pec major and/or the inframammary fold, and potentially replacement of the implants with a profile that appears more natural in the upper pole.

It is critical to select an implant profile that creates a natural slope in the upper pole of the breast. For this reason, patients with significant natural breast projection and upper pole fullness preoperatively generally require a low, low-plus or at most a moderate profile implant; while those with little projection and minimal upper pole fullness often require a moderate plus or even a high profile implant to achieve the most aesthetically favorable outcome. While high-profile implants can produce a natural breast profile in some patients, one must be very selective about the use of these implants.

Horizontal implant position and medial / lateral implant projection
The horizontal position of breast implants also requires a great deal of attention, both during the pre-operative planning phase and when the implant pocket is created in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. The result may (or may not) be tolerable in the upright standing or sitting position, but when the patient lays down in supine position (on their back) the implants may fall far to the side and produce little to no anterior breast projection in this position.

Patients with this problem almost always want it corrected, and the treatment once again is surgical: a lateral repair of the implant space (lateral capsulorrhaphy), to restrain the implants from falling off to the side. The natural slope of the chest wall, which varies greatly from patient to patient, plays an important role in lateral implant displacement. When the chest wall slopes steeply to the side, breast implants will always have a tendency to displace laterally.

Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal ‘side by side’ appearance. It is lateral projection of the breasts beyond the lateral border of the chest wall (in frontal view) which, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’. While one does not want to over-dissect the lateral extent of an implant pocket, careful attention must also be paid to ensure that lateral breast projection is not inadequate.

Implant base diameter
Breast implant base diameter is also of crucial importance. The base diameter (the side-to-side dimension of the implant) must be ideal for the preoperative horizontal dimension of the breasts, as well as the breadth of the anterior chest in general. It is obvious that a given implant volume and base diameter that works well for a small-framed patient who is 5’2″ will be completely inadequate for a broad-chested patient who is 5’10”.

One wants to increase cleavage area fullness and lateral breast projection in most cases, and an implant of inadequate base diameter may accomplish only one of those goals, while too wide an implant will be overprojecting in both directions and tends to make a patient appear ‘stocky’ or heavier than they actually are. Careful evaluation of all of these breast and implant dimension issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.

Altering preoperative breast shape
A number of modifications to breast shape are possible during breast augmentation surgery, beyond the mere expansion of breast volume by means of implant placement. Constricted / tight lower poles can be expanded. Tubular breasts can be released and reshaped. Conical areolas can be modified so that they are less projecting. Inadequate cleavage area breast fullness, widely separated breasts and bony-appearing sternums can be improved by means of structural fat grafting of any area where greater natural soft tissue fullness is desirable.

Make sure that the surgeon you select can discuss all possible measures that are available to create the most aesthetically ideal breast augmentation result possible. Attention to these details can be the difference between a breast enhancement that is both stunning and very natural-appearing versus one that is bigger but not necessarily a lot better.

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Breast augmentation after pregnancy, major weight loss and in naturally droopy breasts

Quite a number of the breast augmentation patients in our practice are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some ‘stretching out’ of the breast skin. In many of these patients, a breast implant of moderate size will restore a very pleasing breast contour. These patients are not looking to raise eyebrows at work or around the neighborhood – they just want to discard their padded bras, to have more options when selecting clothing and swimsuits, and to feel better about their appearance in private.

When there is mild to moderate laxity of breast skin and/or loss of breast volume that makes the breasts appear somewhat droopy or ‘deflated’, the addition of a breast implant can ‘fill up’ the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or ‘mastopexy’). This situation often is a result of pregnancy and lactation, but we also see many patients with significant breast skin laxity who have never been pregnant. Breasts are often droopy and lax at the time that they first develop, and can also have this appearance in patients who have never been pregnant but who have experienced major weight loss.

In patients with more advanced drooping of the breasts (the medical term is breast ptosis – the ‘p’ is silent so ptosis is pronounced TOE-sis), particularly when the nipples are pointing downwards, a mastopexy (breast lift) needs to be combined with the breast augmentation surgery to tighten the skin envelope around the implants. In these patients adding a mastopexy to the augmentation plan allows the surgeon to achieve a result that is truly youthful and aesthetically ideal. The result of this surgery is truly liberating for most patients, as most no longer feel the need to wear a bra to bed at night, and can go bra-less in some forms of clothing if they wish to do so.

Mastopexy may also be required when the nipples are still pointing forward or slightly upwards, but much of the lower pole breast volume has dropped below the level of the inframammary folds. This preoperative condition is referred to as ‘glandular ptosis’, meaning that the nipples are not down-pointing but a significant proportion of the glandular tissue of the breasts has ‘bottomed out’ and now resides below the level of the inframammary folds.

Simultaneous breast augmentation and breast lift (mastopexy) is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. An augmentation mastopexy is required when the surgeon’s preoperative assessment is that without a lift, the likely postoperative appearance is that of a breast drooping off of an implant – which is a distinctly unnatural and unappealing breast profile. If you need a bra to hold your breasts up preoperatively, it is quite likely that you will need a mastopexy in addition to your breast augmentation procedure.


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Special considerations: asymmetry, tuberous/constricted breasts, etc

Many patients considering breast augmentation are seeking to not only enhance the volume of their breasts, but to also enhance the shape and/or improve the approximation of symmetry of their breasts. I say ‘approximation of symmetry’ as almost all patients have some measurable breast asymmetry, and perfect symmetry rarely exists.

A multitude of breast shape and symmetry issues can be improved during breast augmentation, and in essentially all cases it is possible to produce an aesthetically desirable breast profile. While many issues can be corrected in a single surgical procedure, more significant size asymmetries and breast shape problems may require a staged approach (i.e. more than a single surgery) to achieve an aesthetically ideal outcome.

Accurate preoperative evaluation, careful surgical planning and attention to detail during the surgical procedure are all crucial elements in achieving this goal. It is of utmost importance for the surgeon to clearly outline to each patient the issues that need to be addressed (and in what sequence), whether or not it is practical to accomplish all of the goals in one surgery, and the outcome that is expected from any individual surgical procedure.

Minor breast size asymmetry
Breast asymmetry is extremely common, and in fact essentially all pairs of breasts have some identifiable and measurable asymmetry. So the goal of surgery is not to create perfect symmetry, as that usually does not exist in nature, but rather to produce the closest approximation of symmetry that is possible.

In some cases it is possible to improve breast size asymmetry by using implants of different volumes and/or profiles. For these cases it is extremely helpful to try out different implant sizes and profiles during the breast augmentation surgery using sterile sizers. The surgeon must patiently and carefully evaluate a variety of implant sizers intra-operatively with the patient in the upright sitting position, in order to determine the combination of implants that produce the closest approximation of symmetry.

Silicone implants are prefilled and therefore of a fixed volume. So with one particular implant line you might wish you had a 290cc implant volume for the right or left breast, but have to choose between 275cc and 300cc. That situation speaks to the advantage of working with all three US gel implant manufacturers, for at a given implant base diameter you have the widest selection of implant volume and implant projection measurements if you are able to choose from the implant portfolios of three different companies.

In some cases breasts appear asymmetrical because of asymmetries in the shape and projection of the chest wall, even though the actual breast tissue volume may be equal or quite similar. This scenario may mandate the use of different size implants in order to produce the closest approximation of overall breast symmetry. If one side of the chest wall is more projecting, that side may require a less projecting implant than what is selected as ideal for the opposite side. The side with the more projecting chest wall may require a moderate profile implant, for example, while the less projecting side requires a moderate plus or high profile implants.

Major breast size asymmetry
If there is a significant difference in breast volume, and one attempts to address that difference solely by using implants of different size (which is not a good idea), then the inherent differences in the breasts end up being exaggerated by the breast augmentation surgery. The smaller breast with the larger implant will tend to appear youthful and perky-appearing, while the larger breast with the smaller implant will in comparison appear somewhat droopy, and this difference with only get worse as the patient ages. Not a pretty picture.

So for some patients with major size asymmetry it is necessary to reduce the volume of the larger breast by performing some form of breast reduction on that side (hence the somewhat confusing term ‘reduction augmentation’). Other patients may require a breast lift on one side and a breast reduction on the other, in addition to placement of implants. Equalizing the natural breast volume allows the surgeon to utilize implants of the same or similar size.

With implants of the same or similar size in place, and one side reduced so that the breasts have approximately the same volume of natural breast tissue, the rejuvenated breasts will not only appear close to symmetrical immediately postop but will also tend to age in a similar fashion and remain close to symmetrical over time.

Tuberous breast / constricted breast
Tuberous breast and its milder form, constricted breast, are fairly common breast shape abnormalities. Tuberous breasts tend to be narrow at the base and are overly projecting for their size, and this phenomenon may occur on one or both sides or to varying degrees on each side. In its mildest form, the lower pole of the breast is underdeveloped or may even appear constricted – sometimes referred to as a ‘constricted lower pole’. In severe cases the breast is conical in shape and is sometimes described by the patient as looking like a ‘torpedo’ or a ‘Snoopy dog’. Tuberous breasts can be perky or droopy.

Regardless of the degree to which a breast appears tuberous, it is possible to dramatically improve the appearance of the tuberous breast during augmentation surgery using a number of specialized surgical techniques. While I do not use a periareolar approach for primary augmentation of non-tuberous breasts, that approach can be useful in tuberous breasts. In some cases a periareolar incision has advantages over the inframammary fold approach, as it allows direct modification of the sub-areolar area – including mobilization, transposition and even removal of sub-areolar breast tissue when required.

Circumareolar excision of central breast skin excess is required in some cases, which can also serve to reduce an excessively large areolar diameter if present. If circumareolar skin excision is required, then it makes sense to perform the augmentation procedure through the periareolar incision. Fat grafting is another important means for tuberous breast shape improvement, as it provides a mean for expansion of the breast volume peripheral to the tuberous central breast.

Many patients with severely tuberous breasts have said to me that they have never removed their bra in an intimate setting. Careful patient assessment, thoughtful planning and attention to detail during the surgical procedure can produce a dramatic and life-changing improvement for most patients with tuberous breasts.

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Recovery and downtime

The recovery from subpectoral breast augmentation used to routinely be a rather unpleasant experience, but it no longer has to be. Almost all of our patients leave The Plastic Surgery Center with little to no pain, can shower the night of surgery, and experience a 24-hour return to routine, non-strenuous activities of daily living. Out-of-town patients who are travelling with a friend or family member may fly home the day after their breast augmentation surgery. We ask those that are travelling alone to plan on flying home two days after surgery.

During subpectoral augmentation a space for the implants must be developed behind both pectoralis major muscles, and a major portion of each muscle’s inferior origin must be released. Surgery performed directly on a muscle will in most cases produce significant and potentially prolonged postoperative pain, and that is certainly can be true for sub-pectoral breast augmentation – unless a number of preventative measures are taken.

Our protocol includes the following measures that have a synergistic effect that result in the major reduction of, or complete elimination of, postoperative pain:

  1. Preoperative administration of three non-narcotic oral medications that have been shown in randomized, blinded clinical trials to reduce the need for postop narcotic pain medications
  2. Pre-incision injection of all incision sites with a combination of local anesthetics
  3. Minimally-traumatic surgical technique, using low-power electrocautery for surgical dissection and hemostasis (hemostasis is the medical term for the prevention of bleeding from tissue surfaces including the highly vascular pectoralis major muscles)
  4. Injection of an extra-long-lasting local anesthetic (Exparel) into the inferior margins of the pectoralis major muscles (in the area where they have been divided using electrocautery)

As most of our breast augmentation patients never require postop narcotic pain medication, we do not routinely prescribe it for this surgery. We provide patients with a non-narcotic anti-inflammatory pain medication called Celebrex (generic name celecoxib) to take twice a day for the first five days regardless of symptom level. Most patients report little to no pain in the evening following surgery, and perhaps some mild discomfort on postop day one, two and three. Patients can resume all routine, non-strenuous activities of daily living immediately after surgery, and can begin pec major range of motion exercises (arms above head and behind back) on the evening of their procedure.

Patients are seen in the office on postop day one, two or three. Those who work in an office environment usually return to work two to three days following the surgery. Stay-at-home moms should arrange some help with toddlers for the first two to three days after surgery. Exercise is limited to casual walking only for the first two weeks; in weeks three and four some light exercise is permissible.

Patients can gradually increase their isometric exercise level in the second month (weeks five through eight), however it is a full eight weeks before patients are allowed to return to activities that require forceful, repetitive, sustained pec major contraction – such as pushups and heavy weight lifting. Impact exercise may be resumed at 12 weeks postop, and it is important to ensure that the breasts are well supported in snug-fitting sports bra (or two) when first returning to impact exercise such as running or high-intensity cardio training.


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Avoiding capsular contracture

You may have heard of someone’s breast implants ‘turning hard’, or maybe you have breast implants and they are no longer (or have really never been) soft and movable like natural breasts. It is not the implants themselves that turn hard, of course; what has really happened is that the fibrous capsule which the body forms around the implants has tightened and thickened, making the implants less mobile and causing them to feel firm (and eventually, in some cases, even hard). The medical term for this phenomenon is ‘capsular contracture’.

The best approach to capsular contracture is a preventative one, and if a number of scientifically-proven techniques and materials are used when the primary breast augmentation surgery is performed, the likelihood of capsular contracture should be very low. In our practice, we rarely see patients in follow-up who have evidence of capsular contracture.

Any time a medical device is implanted in the body, whether it is a pacemaker or a breast implant or an orthopedic device or anything else, the body responds by forming a thin fibrous membrane around it. In most cases this membrane or ‘capsule’ stays thin and soft, but in some cases over time the capsule may tighten around the implanted medical device and thicken.

Since breast implants are soft objects that are placed in a relatively superficial position, capsular contracture can make a normally soft and movable breast implant feel increasingly firm, unmovable and even hard to the touch. In advanced stages of capsular contracture, the capsule can even distort the shape and position of a breast implant. Capsular contracture can be treated, but the treatment is a fairly significant surgical procedure, so avoiding capsular contracture is not just about keeping augmented breasts feeling soft and life-like, but also about avoiding another trip to the operating room.

Capsular contracture can occur on one or both sides, and while it can develop early (weeks) or late (years) after a breast augmentation surgery, in the vast majority of cases it is evident fairly early following the procedure. So the good news is that once you are six to 12 months out from your surgery, if your augmented breasts are soft and supple then they are likely to stay that way for the long term.

It has been shown scientifically that most cases of capsular contracture are primarily a response to the presence of bacteria on the implant surface that have very low ‘virulence’, which means that they are not the kind of bacteria which would usually produce an actual infection with obvious physician signs of infection such as redness, tenderness, swelling and fever.

These bacteria can adhere to the implant surface on the day that the implants are placed, and gradually become established as a bacterial ‘biofilm’ on the outer shell of the implants. The resulting low-level inflammatory response over the weeks, months and even years following the breast augmentation surgery can stimulate the cells that make collagen (called fibroblasts) to make more collagen – thickening the capsule and stimulating it to contract and tighten around the implant.

It is not an obvious infection; there are usually no symptoms that this is going on until the implant capsule tightens and changes the way that the implants feel, and taking oral antibiotics will not prevent the process or reverse it. The source of these non-virulent bacteria is thought to be the patient’s skin, or the milk duct and gland system of the breast that lead to the nipple, as both are normally colonized with low-virulence bacteria.

Because plastic surgeons have an increasingly detailed understanding of why capsular contracture occurs, there are a number of measures that can be taken to significantly reduce the likelihood that it will happen following breast augmentation surgery. Several of these techniques are discussed in the adjacent section describing ‘Dr. Law’s philosophy on preventing capsular contracture’.


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Revisional breast augmentation surgery

There are four main reasons for reoperation in breast augmentation patients (the medical terms we use are listed in parentheses):

  1. The augmented breasts become firm and less movable (capsular contracture)
  2. The implants don’t remain in an aesthetically ideal position (implant malposition)
  3. You can see the implants through the skin and breast tissue (implant shell visibility)
  4. The patients thinks that their augmented breasts are too big or too small (implant size dissatisfaction)

Our practice treats a significant number of patients who schedule a consultation with us because they are dissatisfied in some way with the results of a breast augmentation they have had in the past. If you are one of these patients, the good news is that the results of your surgery can almost always be improved, and in most cases quite dramatically.

Capsular contracture
Traditionally, one of the most common and most frustrating to patients and surgeons has been capsular contracture, which is addressed in detail in a section above. If you have a contracture, you are at a somewhat higher risk for contracture following a second or third surgery, so it is of utmost importance that a number of things be done differently from your first surgery to minimize the risk of developing capsular contracture again.

Implant malposition
Another potential problem is an unfavorable change in implant position, which can be related to a number of issues: the dimensions of the implant pockets may not be ideal or symmetrical, the pectoralis major muscle may be inadequately released and thus holds the implants too high (and can cause them to ‘jump’ upward and outward when the muscle contracts), and one or both implants may even shift in position over time which results in positional asymmetry.

Examples of position problems include ‘bottoming out’ (the implants stretch out the lower poles, or descend below the inframammary folds), ‘lateral drift’ (implants that fall too far to the side when the patient lies flat), and synmastia (aka symmastia, which means the breast implants meet in the cleavage area and there is no longer a clear separation between the breasts).

If the implant pockets are dissected too far laterally, the implants may appear too far apart on the chest wall, and may fall off to the side of the chest when a patient is in supine position (lying on their back). It is important to understand, however, that many patients have a chest wall shape which slopes steeply in a lateral direction, and in these patients some lateral drift in supine position is essentially impossible to prevent.

If the pockets are not dissected far enough laterally, the implants appear too close together and do not project enough to the side to create the upper third of an ‘hourglass figure’. Again, this may be impacted by the underlying shape of the chest wall, for in some patients the chest wall slopes steeply inward towards the sternum, and in these patients the implants will always tend to sit medially towards the cleavage area and under-project laterally.

‘Bottoming out’ can mean one of two things: that the weight of the implants has stretched out the lower pole skin and breast tissue, allowing the implants to sit too low and sometimes making the nipples appear to be too high on the breasts; or that the implants have broken past the inframammary fold (IMF) and now a portion of one or both implants is below the IMF.

Treating malposition often involves temporarily removing the implants and making adjustments to the capsular space that tightens it (called capsulorrhaphy) or that releases it (called capsulotomy). Implants of a different size and dimension may be required. The inframammary fold may need to be repaired, and in some cases an additional biocompatible (meaning ‘accepted by the body) material may need to be added to help support and maintain implant position over time. Examples include GalaFORM and GalaSHAPE surgical scaffolds, and Strattice.

One additional form of implant malposition applies to shaped breast implants only, and that is shaped implant rotation. Shaped implants that have rotated should be removed and replaced with round implants. For a number of reasons that are outlined elsewhere on the website, this practice no longer places shaped implants for any first-time or revisional breast augmentation surgery.

Implant shell visibility
If the implant shell is visible through a patient’s breast skin, or the thinner skin adjacent to the breast, then a breast augmentation never appears truly natural. Avoiding implant shell visibility is primarily a matter of not using implants that are too large for a patient’s natural breast tissue to conceal. In most cases of implant shell visibility, the breast implant volume, implant projection or implant base diameter (and oftentimes all three of these implant measurements) are too large for the patient’s natural breasts.

In slender patients with small breasts (and really for the vast majority of our patients), subpectoral augmentation is the only appropriate choice. In some cases, the implant shell is visible because the implant – even if it is of an appropriate volume – was placed in a submammary (on top of the pec major muscle) position. In these patients, moving the implant from a submammary to a subpectoral position is usually effective in concealing the implant shell in the cleavage area.

Structural fat grafting can also be effective in helping to conceal visible implant contours in any area of the breast, particularly in the cleavage area, the upper pole and along the outer edge of the breast. Fat can easily be harvested from the abdomen, flanks or thighs and grafted into areas where the soft tissue coverage of an implant is not adequate.

There are many implant factors that must be taken into consideration when managing visible implant folds and ripples. Whether or not an implant is likely to develop ‘folds’ or ‘ripples’ that are visible through the skin is impacted by the nature of the implant fill material and the percentage fill of the implant shell. So correcting implant shell visibility may also involve removing the existing implants and switching to a different implant option.

Some silicone gel implants are easily deformable, which makes them very soft to the touch when implanted, but which also has the disadvantage of making them more likely to fold at the surface and not fully maintain their round shape. The higher the percentage of gel implant fill (and they are filled at the factory, of course), the less likely they are to fold or show ripples at the surface, but the more firm they will feel.

The same is true of saline implants, which are filled with saline in the operating room. Likewise, the more ‘cohesive’ the gel in a silicone gel breast implant, the more it will tend to maintain its shape – but the firmer it will feel. So there are pros and cons to implant fill percentage and the degree of gel implant ‘cohesivity’. All three US gel implant manufacturers offer implants with different degrees of cohesivity, so many options are available when planning implant removal and replacement.

Implant size dissatisfaction
Some postop breast augmentation patients feel that their implants are too big and make them feel very self-conscious, while others feel that their implants are too small and that their expectations for a shapelier figure have not been met. Increasing breast implant volume is one of the more straightforward breast augmentation revisional procedures, as long as the implant volume selection produces a plausibly natural position. Reducing implant volume can be more challenging, as in these cases the pockets must be tightened to accommodate smaller implants.

Keys to success in primary and secondary breast augmentation
The keys to achieving an aesthetically beautiful and natural-appearing breast augmentation result are the same, whether the surgery is the initial placement of breast implants or a secondary procedure to correct any of the potential breast implant problems outlined above:

  1. Thorough preoperative assessment including measurements made in standing position and sometimes in supine position as well.
  2. Examination of a wide variety of samples implants and breast forms, both in a bra and while wearing a form-fitting shirt over the bra (for patients that do not currently have implants in place).
  3. Adherence to biodimensional planning principles – the concept that the measurements of the natural breast and chest wall directly impact the implant size and profile that are appropriate for each patient.
  4. The willingness to take a staged approach to breast enhancement in instances where that is beneficial.
  5. The willingness to deflate existing saline implants or remove existing silicone gel implants in some cases, and to re-evaluate the patient a week or two later to confirm the ideal plan for secondary breast enhancement. This is not required in all cases, but is extremely helpful in some.
  6. The use of supportive / protective materials (GalaFORM, GalaSHAPE, Strattice, etc) when indicated.
  7. Adherence to surgical principles and practices that have been demonstrated as effective in scientific studies published in peer-reviewed scientific journals (the practice of ‘evidence-based’ medicine).
  8. Meticulous attention to detail in the operating room. The surgeon should never be in a rush, and should never leave the O.R. until the breast appearance is the best it can possibly be.
  9. Frequent follow-up in the early postoperative phase, and intermittent evaluation over the course of one year. For travelling patients, some of this follow-up can be conducted by phone with postop digital photographs and video submitted securely by the patient.
  10. Rigorous attention to a postoperative recovery protocol that includes a gradual, logical return to full-effort exercise over 12 weeks.

Regarding the issue of reoperation, these three things you ABSOLUTELY must know before your breast augmentation surgery…

  1. There is no way around the fact that ALL breast augmentation surgeons, even the most meticulous and experienced ones, have some patients who return with a breast implant problem that requires surgical correction.
  2. By following the principles outlined above, it is possible to avoid the need for reoperation in the vast majority of breast augmentation patients.
  3. Because the need for reoperation is a possibility, although ideally a remote one, make sure that your breast augmentation surgeon can clearly describe to you the approaches that they use to minimize the likelihood that you will require a return trip to the O.R. to fix a problem with your breast implants. And, just as importantly, make sure that the practice policy for reoperation in breast augmentation patients is clearly explained to you – including any expenses that will be your responsibility.


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The Big News in Breast Implants is Small


Raleigh Breast augmentation specialist Dr. Michael Law discusses natural breast augmentation and breast augmentation in Raleigh.

Breast Enhancement and Augmentation – In the Media

For more information about breast augmentation or breast implants or if you would like to schedule a breast augmentation consultation, please contact the Raleigh, North Carolina office of Dr. Michael Law today!

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