Essential Breast Augmentation Points To Understand


No two breasts are perfectly symmetrical before surgery; therefore, there will not be absolute symmetry after surgery. The most common problem is to correct asymmetry in volume. For saline implants sometimes I add more fluid to one side, sometimes use two different size implants; for silicone gel implants which are pre-filled at the factory to specific volumes, it is more common to use two different size implants. Another common issue is lowering one breast crease to match the other one. When two breasts start out asymmetric, the skin envelopes are different and there is no way to make them equal, even though sometimes they can be close enough to satisfy even the most discriminating of patients.


It is not uncommon to lose part or all sensation to the nipples and breasts. Usually, this returns after a few weeks to months, but may take up to one year for return of sensation. In rare cases, there can be permanent sensory loss, which may be partial or complete.


Depending on how thin your tissues are, and whether you choose saline (more rippling and wrinkling than silicone gel) or silicone gel implants, you may be able to see and/or feel the edges of the implant through your tissues.

Cup Size is Not Guaranteed

Cup size is extremely imprecise and not standardized. Furthermore, the breast size you have after surgery is the sum total of what you have to start with plus what is added in terms of an implant. The final cup size cannot be predicted with accuracy.

If you choose an incision  other than below the breast (inframammary) and you require another operation on that breast, the incision for that procedure will be need to be inframammary, which gives the best access to the inside of the breast.

How The Appearance of Your Breasts Will Evolve Over Time

Breast augmentation is not a static procedure, the breast tissues change with time in response to the size and shape of the implant and the effects of gravity. The thickness, elasticity and compliance (stretchability) of your tissues come into play as well. As I stated earlier, these changes are out of the control of the patient and surgeon, however, and this is so important – proper decision making in implant selection and pocket dissection can make all the difference between a beautiful result with long term durability and little if any chance of needing future surgeries in the near future, versus a poor result, need for secondary surgeries and the possible creation of permanent, uncorrectable deformities.

Which do you want? Unfortunately, you can’t have your cake and eat it as they say. If you follow the recommendations made for an implant based upon your breast tissues and measurements, then you will follow the first path and have an extremely high chance of experiencing a 24 hour recovery. If you want an implant larger than your breast tissues will easily accommodate, then you are on the path for the second option. It is your decision.

I tell all my patients that their breasts will look somewhat “distorted” after surgery. This is because the breast tissues are tight around the lower half of the breast immediately after surgery. The overlying breast tissues place pressure upon the implant on its lower half. This causes distortion in shape with a tight lower pole, and a squared off side (especially the outer side). As a result of this compression, the volume in the implant is forced upward, giving an excessive convexity to the upper pole of the breast.

Many women see this after surgery and say “wow, I like that fullness”. The fact is, there is too much fullness, it looks unnatural but fortunately, it goes down in time. As the lower breast stretches, the volume of the lower half of the breast increases and the upper half decreases. The excessive fullness decreases and the lower breast volume increases as the breast (fortunately) rounds out. Some women have named this process “drop and fluff”. You can simulate this by placing a balloon over your chest, holding the lower portion with the palm of your hand. Now, press down against the chest with your hand, squeezing the balloon. The upper portion of the balloon becomes prominent. Now, release your hand, the upper part of the balloon becomes less filled.

The rate at which the breasts remodel is in large part determined by how lax the tissues are prior to surgery. The type I breast is much tighter, so it can take 4 – 12 months (4 – 6 months in women who have had children and 6 – 12 months in women who have not had children, but there is no hard and fast rule) to remodel (or “settle”). Type II breasts, which are more lax, may remodel and stabilize in just a few months. In either type breast, as the implant fills the lower part of the breast, the nipple rises and tilts upward with a greater amount of skin showing between the lowest point on the areola and the lower edge of the breast on frontal view, and the upper pole fullness decreases. This is why I tell patients not to spend a lot of money on bras right after surgery, because as the breasts remodel and the lower part of the breast fills out more (the lower pole is the part of the breast that sits within the bra cup) there may be need for a larger cup size. See the examples below:


Type I breast (asymmetric volume) shown 2 days and 4 months after augmentation with 304 cc (right) and 286 cc (left) silicone gel implants placed under the muscle


Type II breast shown 2 days and 4 months after augmentation with 304 cc silicone gel implants placed under the muscle

Selection of Implant Size

Selection of implant size is probably the single greatest concern to women considering breast augmentation. Traditionally, selection of implant size has been made by either the patients preference in size (for whatever reason) or by “sizing” the woman by having her wear a bra and placing implants into the bra to see how large she wants her breasts to be. The main problem with both of these methods is that there is absolutely no consideration made for the size of the patients own breasts, the tissue thickness and the tissue compliance, or “stretchiness”. The above methods can lead to severe errors in implant selection and probably are major contributing reasons to the unacceptable high rate of re-operative surgery in women who have undergone breast implant surgery (the national average re-operation rate at eight – ten years in the Allergan and Mentor FDA post approval core studies was 20 – 40%). In my practice, for the time period of 2006 (when silicone gel implants were re-approved by the FDA) through 2014, my re-operation rate is only about 2%. Clearly, differences in the planning and execution of the surgical process can make a difference in the need for re-operation in breast augmentation surgery!

I take a more scientific and realistic approach to implant size selection. Using detailed accurate measurements of the patient’s current breast size as well as the breast’s tissue characteristics, a more accurate assessment of the ideal implant size for that particular breast can be easily attained. This will yield a breast with the most natural appearance, the least discomfort after surgery, the least numbness, the fastest recovery and the greatest longevity of the cosmetic result. Furthermore, there is the least probability of requiring additional surgery in the future. The breasts simply do not have the ability to stretch indefinitely to accommodate any size implant that you desire. I can only work with the breast tissues that you have and this cannot be changed. Anyone who tells you otherwise is either misleading you or uninformed. Again, you can often force a larger implant into the breast, but then the risk of overstretching the breast, creating deformities increases and then the risk of a re-operation in the next several years skyrockets!

I will try to take into account your wishes and desires regarding the selection of breast implant size, however, if you wish to attain the best possible result from not only the aesthetic standpoint but also the easiest recovery and the least amount of problems later (again, some uncorrectable), then selection of implants based upon measurements is the best way to achieve this.

The system of measurements that I use was originally developed by John Tebbetts, M.D. It is based upon his experience with numerous augmentations. I have been using this system, rather than guesswork or any other unproven method of implant size selection, since June, 2004. The simple fact is that the system works! My three year re-operation rate (for all reasons) for silicone gel filled implants is approximately 2% versus the national average of 15% or more, based upon the data in the pre-market implant approval studies. In other words, do you want a 1 in 50 chance (my method) of needing another operation within three years or a 1 in 7 chance (other methods)? That is what the statistics say. If you want to look at the data yourself, you can look at the Allergan data which shows a 23.5% four year re-operation rate or the Mentor data which shows a 15% three year re-operation rate.

My goal is to achieve the very best possible cosmetic result for you, protect the health of your breast, assure you of the easiest recovery possible and minimize the risk of future surgical revisions. Avoid getting fixated upon attaining a specific cup size as cup size measurements are not standardized, but more at the whim of the garment manufacturer. Rather, focus your attention on attaining pretty, youthful breasts which balance, enhance and rejuvenate your torso, balancing your breasts to your hips and accentuating your waist.

I want you to be absolutely thrilled with the results of your augmentation! I want you to have an easy recovery. I want the quality of your augmentation to last a long, long time. I do want to make it clear at this point that you do have a great deal of input into your surgical plan and therefore your final result. I have several roles in this process. My goal is to educate you so that you can make the best decisions regarding your surgery. Knowledge is power, as they say. I also try to understand what it is that you want to achieve, and after assessing your breast tissues, determine if your desires are in line with what I believe is achievable and advisable. There are three possibilities:

  • You and I are on the “same page”, which means that what you want is realistic, attainable and desirable. This situation is actually the case in the vast majority of my consultations. The result is that we proceed ahead.
  • You desire something that I believe is either not attainable or ill-advised. For instance, you have an “A” cup with a tight tissue envelope and you wish to be a “large C cup” or “D” cup. Is this attainable? Maybe, but the implant would have to be so large that I would lose sleep that the wound would split open or I would permanently damage your tissues by thinning and overstretching them, thus creating uncorrectable deformities. Not to mention the severe pain and numbness as well as prolonged recovery after surgery. In this case we have a discussion. If you still want that larger size, I respectfully bow out and decline to perform your surgery. This situation is actually extremely unusual in my practice.
  • You like what I am recommending, but you really want to go just a little larger, maybe one implant size (not cup size) than I recommend. In this case we will have a discussion. I will advise you of the potential problems associated with going larger than I recommend, but I agree to proceed under the condition that if at the time of surgery I feel that the implant is too large for your breast and the breast is either very distorted or I have difficulty closing the wound, I will back down to the initially recommended size.

Asymmetry and Implant Selection

Plastic surgery is as much an art as it is a science, and there are occasionally special circumstances that will require me to deviate slightly from the recommendations based upon the analysis of the breasts and tissue characteristics as described above. The most common reason for this is breast asymmetry.

Normally, based upon the system of measurements that I use, a larger breast requires a larger implant than does a smaller breast. This only makes sense. However, in a case of easily visible asymmetry, if you place a smaller implant in the smaller breast and a larger implant in the larger breast, the volume difference between your breasts will be exaggerated after surgery. Therefore, quite the opposite is done: a smaller implant is placed in the larger breast, and a larger implant in the smaller breast.

  • Side note: Silicone gel filled implants are pre-filled by the manufacturer so that in order to achieve two different implant volumes, two different size implants must be used. On the other hand, saline implants are filled at the time of surgery. Therefore, in the case of saline implants, for small volume differences, usually 20 cc or so, the same implant can be used but one implant is filled to a slightly greater volume than the other one. Surprisingly, these small volume differences can make a visible improvement in the overall quality of the surgical result.

When using two different implants for asymmetry, the limitation is that the smaller breast is limited by how large an implant can be placed into that breast without damaging or distorting it, as well as preventing the opposite larger breast from looking underfilled by placing a smaller implant into the larger breast. No matter what, when there is visible asymmetry preoperatively, even if two different size implants are placed in an attempt to equalize the volume after surgery, the breasts will still be asymmetric after surgery. In the majority of the asymmetry cases where I have utilized two different size implants, there is significant improvement overall in the degree of asymmetry. In some cases the degree of asymmetry was so little that it was barely recognizable. Often, the smaller breast with the larger implant will be “perkier”, with greater upper breast fullness and the larger breast with the smaller implant will have more droop. The asymmetry may or may not improve over time. My goal in these cases is to equalize the volume of the breasts as much as possible so that when you are supported by a bra or bathing suit top you appear fairly symmetrical, or as much as possible depending upon the degree of asymmetry before surgery.

Asymmetry of the Chest Wall

This is fairly uncommon, but I do have several such cases. If your chest wall (rib cage) is asymmetric, there will be asymmetry of the breasts. Even if the amount of breast tissue is even on both sides prior to surgery, if there is asymmetry of the rib cage, one breast will sit further inward than the other, which may give the appearance that the other breast is larger. Also, on the side where the rib cage is “sunken in”, the augmented breast on that side will most likely be positioned more closely towards the midline (breastbone), with less lateral protrusion than the other side. This is not easily correctable, if at all without first reconstructing the rib cage (prior to the augmentation procedure).

3-D Computerized Simulation

3-D computerized simulation is a wonderful technology to give a woman an idea of what she might look like with breast implants prior to undergoing such surgery. Emphasis on the word “might”. I make it very clear that I do not use this technology to allow a woman to try on implants to see what implant looks best on her; that totally violates the concept of fitting the implant to the woman’s breast based upon her breast size and tissue characteristics. However, once I examine a woman and take appropriate measurements, I then make a determination as to which implant size is optimal. I can then use the simulation software with that ideal size implant selected. I want to make it very clear that your final result will look different than what you see using computerized simulation. The purpose of the simulation is simply to give you a rough approximation as to how you look with breast implants, understanding that your final result will look different than the simulation.

Breast Implants Won’t Last Forever

Breast implants are mechanical devices, and as such, will not remain intact forever. The failure rate of these devices is very small, but it is possible that in your lifetime you may experience a device failure. In the case of a saline implant, this will result in leakage of saline (salt water) which your body will absorb as it is a natural component of your body. You will notice your breast diminish in size, usually within a few days, after this happens. The treatment options are to do nothing, replace the deflated saline implant with a similar one, remove both implants and not replace them, remove both implants and replace them with new, similar, saline implants or to remove both implants and replace them with silicone gel filled implants. The latter is the option that most of my patients choose as the silicone gel implants feel much more natural that the saline implants do.

Silicone gel filled implants are different than saline implants. If there is a tiny hole in the implant, it is likely that the silicone gel will not leak from the implant. However, if there is a tear in the implant shell, the gel may leak out. All implants, saline or silicone stimulate the body to produce a thin scar “capsule” around the implant. Should there be a leak in the implant, the capsule will contain the gel. Even if there is a tear in the capsule, which would be very unusual, silicone (gel filling or the implant shell) is biologically inert which means that there is no reaction between your body and the silicone.

How will you know that your silicone gel implant has failed? The current FDA recommendation is to obtain a MRI examination of the breasts three years after breast augmentation surgery and every two years thereafter. This is probably overaggressive as silicone gel implant failures are extremely rare in the first several years after implantation. Furthermore, ultrasound is a far less expensive and easier initial test for implant failure. When should you be concerned about your implants? If you notice a change in the way your breasts look (i.e. asymmetry), a change in the way they feel, a new mass or “lump” or pain in your breast, you should see your doctor to have this evaluated. For more information on MRI’s and breast implants, see Silicone Breast Implants – Are Routine MRIs Really Necessary?

Do breast implants need to be routinely replaced?

The answer is no. As long as you are doing well, and having no problems with your implants, they do not need to be routinely replaced, despite the rumors that exist to the contrary. It is true that as time goes on the risk of developing an implant related problem will increase, that is simply a matter of probability with all mechanical devices. If you buy a new car, the chance of it needing to have the engine repaired will increase the longer you own it and the more you drive it, however, you would not routinely replace the engine if it is running properly. It is advised for you to undergo routine follow-up of your breasts to evaluate your implants, just as you would have routine follow-up of your breasts to have them checked for other diseases as well. Fortunately, should you need an implant replacement; it is usually not a difficult procedure.

Do breast implants cause cancer?

The answer is no. This question has been extensively studied and there is no association between breast implants and breast cancer. In fact, when women with breast implants are diagnosed with breast cancer, the survival data is the same as for those of women without breast implants.

Do breast implants cause autoimmune disorders?

Again the answer is no. This question has also been extensively studies and there is no such association between breast implants and autoimmune disorders such as lupus, rheumatoid arthritis and scleroderma.

Anaplastic Large Cell Lymphoma (ALCL)

Recently, the Food and Drug Administration (FDA) has reported that there may (not proven) be a connection between breast implants (both saline and silicone gel) and a very rare cancer of the immune system called anaplastic large cell lymphoma. As of July 2019, here have been approximately 400 reports of patients in this country and a total of 600 cases worldwide out of an estimated 5 – 10 million women who have breast implants. This translates to an incidence of 1 in 8000 or so women. In this particular disease, the scar tissue lining of the implant develops the lymphoma cells. This is NOT a form of breast cancer. Women who have developed this have presented to their doctors with complaints of swelling, lumps, asymmetry or breast pain. They generally presented years after the original implant surgery. Treatment consists of removing the implant and the scar tissue capsule; the breast itself is not removed. Currently, the FDA is studying this disease to determine if there is any such association between it and breast implants. Again, the connection between the disease and breast implants is not yet proven. You can obtain more information on ALCL on the FDA web site.

Are concerns about size common after surgery?

Although a very positive experience overall, any significant change in body appearance can be emotionally stressful. You may experience emotional good days and some not as good. It is not uncommon after surgery to wish that you were “a little bigger” or occasionally “a little smaller” but usually these thoughts disappear over the next several weeks to months as the breasts soften, assume a more natural shape and feel more a part of you. My re-operation rate is well below the national average and requests for implant size changes after surgery are exceedingly rare.

Initially after surgery it is hard to visualize how your breasts will look when they finish remodeling. After surgery, your implants will seem high. What is really happening is that the lower portion of the breast is not expanding as much as the upper portion. As time passes, and the lower breast tissue relaxes and stretches (an appropriate amount), the distribution of implant volume in the upper breast diminishes as the volume in the lower breast increases. This will result in a much more natural appearing breast. Also, understand that bra cups often contain the lower portion of the breast. So as more volume redistributes to the lower breast with time, your cup size requirement may increase, or your bra may fit more snugly. In this regard it is advisable not to invest much money in bras right after surgery until your breasts stabilize in shape. For women who have not borne children, this may take a year or so, and for women who have children, it may take as little as three months or so. All this depends upon how compliant or “stretchy” your breast tissue is to begin with.

To summarize my approach and my goals for you, I strive to find the ideal size implants for your breasts based upon your breast tissues so as to provide you with the best aesthetic result, the greatest longevity of that result, the easiest recovery and the least chance of needing a re-operation.

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