State of the Art in Breast Augmentation

By Robert C. Wilke, MD, FACS
Board-Certified Plastic Surgeon, Edina Plastic Surgery

Breast Augmentation is the most popular type of cosmetic surgery performed in the United States. It is likewise the most common surgery that I perform in my own practice at Edina Plastic Surgery. The surgery improves the aesthetics of the breast by the placement of an implant to create a size, shape and proportion that fits the patient’s goals.

When performing breast augmentation, as with all procedures, no single technique is ideal for all patients. As a Plastic Surgeon, I strive to customize each procedure based on the patient’s preoperative anatomy and goals to achieve the best possible result for each patient. There are a number of options and choices when considering breast augmentation. At the initial consultation, I take time to discuss these options, including the type of implant, saline-filled vs. silicone gel, positioning of the implant within the breast, incision placement, and, of course, size. This allows us to formulate a plan together so the patient can obtain the outcome she desires.

The implants that we currently use in the United States are either filled with saline solution or silicone gel. The silicone gel implants initially became popular in the 1970’s through the 1980’s, but in the early 1990’s the FDA placed a ban on the use of silicone gel implants due to complaints that the implants may have caused health problems, such as autoimmune diseases like lupus or rheumatoid arthritis. Numerous studies were conducted on silicone gel implants after the ban was enacted. Over the next 14 years, it was determined that there was no evidence that silicone gel implants actually caused any health problems, and the FDA lifted the ban in 2006. I participated in the pre-approval studies with silicone gel implants, and have been using them for the past seven years. The silicone gel implant has one significant advantage over saline implants – the gel will feel softer and more natural. The saline-filled implant tends to feel more firm, and especially in patients with thin natural tissue, there may be rippling along the outer edge of the implant that can be felt through the skin. This is less of a concern in patients that have a more significant amount of natural breast tissue. Saline-filled implants do have some advantages over the silicone gels, however. First of all, there has never been any type of FDA ban placed on saline implants.

The saline implants also cost less than the gels, and they can be placed through a smaller incision (as they are initially placed deflated, then filled once they are in position as opposed to the gels which are pre-filled). Studies are also showing a lower risk of capsular contracture with saline implants. Capsular contracture is when the body responds to the implant with excess scar tissue, causing increasing firmness in the breast which can progress to hardening, malposition, deformity and pain. If this occurs, secondary surgery may be required to remove the scar tissue. A thorough evaluation and discussion is needed to help determine which option is best for you.

There are three incision options that I utilize for implant placement. The implant can be placed through an incision under the breast (near the crease), along the lower areola, or in the armpit. Each technique has certain advantages, and the best option will depend on the patient’s anatomy. I always close the incision in layers using dissolvable sutures. A small scar is unavoidable, but the scar usually becomes nearly imperceptible with time.

Breast implants can be positioned above or below the pectoral muscle. In the majority of my surgeries, I place the implant beneath the muscle. This allows better soft-tissue coverage of the implant and tends to produce a more natural look.

Preoperative sizing is crucial to success in matching a patient’s goals. I spend significant time during the consultation working with the patient to determine the optimal size. We utilize implant sizers, which are implants that can be placed inside a bra, so the patient and I can work together in determining the appropriate size. The implants that I typically use are round in shape. Tear-drop shaped implants are occasionally used, although these can create problems if the implant rotates, and I have simply not seen significant benefits in regards to outcomes when the shaped implants are used. The round implants do have various “profiles”, which are variable implant diameters relative to the volume. This allows better matching of the implant to the patient’s anatomy.

Another technique for breast enlargement that has gotten some recent media attention is fat transfer. This has been described as a “new” technique, but in fact, fat transfer was first performed to augment breasts decades ago, prior to the standard use of synthetic implants. These techniques were unreliable and frequently unsuccessful, and were, for the most part, abandoned once implants became available. There has been renewed interest in fat transfer in recent years, spurred by newer fat injection techniques producing success in facial procedures. One crucial difference, however, is that it takes relatively small volumes of fat, usually several cc’s, to augment a patient’s cheeks or lips, while it may take one hundred times that amount to augment the breasts. It is much less likely that the larger volume of transplanted fat necessary to augment a breast will survive in its new location, and this can result in failure and complications. Fat transfer may be useful for limited breast refinements, especially in reconstructive breast surgery, however significant breast enlargement may be an elusive goal.

Breast augmentation can produce beautiful results that can lead to improvement in a patient’s confidence and self-esteem. In order to get excellent results and minimize risks and complications, it is important to consult with an experienced, board-certified Plastic Surgeon.