Breast augmentation is a surgical procedure for enlarging a woman’s breasts. To create a larger bust line, breast implants are inserted into the body. There are two main types of implants available for breast augmentation surgery in the United States: saline-filled and silicone gel-filled breast implants. Saline implants are made of a silicone shell and filled with a saline solution (saltwater), while silicone implants contain silicone gel. Last year, the Food and Drug Administration (FDA) lifted its restrictions on silicone implants, allowing their use for breast augmentation in patients 22 years or older, and for breast reconstruction in patients of any age.

A great deal of social emphasis is placed on women’s breast size. This may influence why the number of women choosing to have breast augmentation increased by more than 700 percent over a 14-year period from 32,000 in 1992 to 329,000 in 2006, according to the American Society of Plastic Surgeons (ASPS).

Breast augmentation is the most popular type of cosmetic surgery, according to the ASPS. The reasons for electing to have breast augmentation are varied, but most often include:

• Increasing breast size of a woman who may think that her breasts are too small
  
  
• Improving the appearance or size of breasts that have drooped or lost volume following pregnancy or breastfeeding
  
  
• Correcting deformities, such as asymmetry or different-sized breasts
  
  
• Reconstructing a breast after a mastectomy for breast cancer or injury

Breast augmentation is performed by a plastic surgeon, who will review the patient’s implant options (e.g., size, shape). Breast implant surgery often leads to a good cosmetic result, but complication rates are high. Common breast augmentation risks include:

• Rupture, leakage or deflation of the implants
• Hardening of scar tissue around the implants
• Bleeding
• Infection
• Increased or decreased sensitivity in the nipples
• Numbness near the incision
• Calcium deposits around the implants
• Increased difficulty in detecting breast lumps

Breast augmentation is a surgical procedure used to enlarge a woman’s breasts. During the procedure, breast implants made of a silicone shell and filled with a saline (saltwater) solution, or implants containing silicone gel, are inserted into the body to create a larger bust line.

The reasons for electing to have breast augmentation are varied, but most often include:

• Increasing breast size of a woman who may think that her breasts are too small
  
  
• Reconstructing  a breast after a mastectomy for breast cancer or injury
  
  
• Improving the appearance or size of breasts that have drooped or lost volume following pregnancy or breastfeeding
  
  
• Correcting abnormalities, such as asymmetry or different-sized breasts

In 2006, about 329,000 women elected to have breast augmentation, according to the American Society of Plastic Surgeons (ASPS). The ASPS says the large number of women choosing this type of surgery has been growing rapidly since 1992. According to the ASPS, breast augmentation is the most popular type of cosmetic surgery, followed by nose reshaping (rhinoplasty) and liposuction.

These statistics are potentially confusing as they do not distinguish between women who are having a first surgery (either for augmentation or reconstruction) and those who are replacing old implants that have ruptured or leaked.

Although breast augmentation may be used to increase the size and proportion of a woman’s breast or to restore the shape of a breast after surgery or injury, the procedure is not recommended for:

• Women with malignant or premalignant breast cancer (without adequate treatment)
• Women with an active infection in the body
• Women who are pregnant or breastfeeding

Currently, the safety and effectiveness of the procedure has not been established for patients with autoimmune diseases (e.g., lupus, scleroderma), conditions that interfere with healing and blood clotting, weakened immune systems or reduced blood supply to the breast tissue.

In additon, the ASPS advises people who want breast augmentation or any other type of cosmetic surgery to do their research beforeheand, especially check their surgeon’s credentials. According to a recent poll conducted by the ASPS, only 28 percent of patients had checked their surgeon’s credentials. And although 91 percent of patients indicated that they knew what to expect during surgery, less than half of patients could recall being told by their physician about side effects, such as post-operative bleeding, nausea or blood clots.

There are two main types of implants available for breast augmentation in the United States:

• Saline implants. The most common type of breast implant approved for commercial use in the United States. Saline implants are filled with a sterile saline solution (saltwater). If these implants should leak or rupture, the solution is absorbed by the body. Saline implants have not been associated with any risks of disease. They are approved for use for breast augmentation surgery in women aged 18 years or older, and for breast reconstruction in patients of any age.
• Silicone implants. These implants are filled with silicone gel. In the past several years, there has been controversy regarding the safety of silicone implants, which were believed to be associated with connective tissue diseases and autoimmune diseases. Although they were available in the United States beginning in 1962, the Food and Drug Administration (FDA) withdrew silicone implants from the market in 1992 with the exception of use in clinical trials.
  
  But to date, all subsequent studies have failed to show any increased risk of connective tissue diseases and autoimmune diseases among women who have chosen to have silicone implants, and some patients claim that silicone implants feel more natural than their saline counterparts. As a result, the FDA lifted its restrictions on silicone implants last year, allowing their use for breast augmentation in patients 22 years or older, and for breast reconstruction surgery in patients of any age. Even though many other countries have not removed silicone implants from the marketplace, the FDA is requiring companies that manufacture silicone implants to continue conducting long-term studies on their safety and efficacy.

There are a number of other variations among implants to accommodate individual circumstances and preferences. These variations include:

• Shell surface type (smooth vs. textured)
• Size (volume contained in the implants)
• Shell thickness (also referred to as the envelope or lumen)
• Fill design varieties (for saline implants)
  
  
• A fixed volume prefilled by the manufacturer
• A volume that can be filled during the operation through a valve
• A volume that is filled after the operation
• Shape (round or contoured)
• Profile (how far it projects forward)

There are a number of factors a woman must consider when trying to determine which type of implant is best suited for her. It is advisable that a woman consider the following factors before the breast implant procedure:

• Implant status. Whether the implants are or are not approved for use in the United States. If they are investigational, the patient will need to become part of a clinical trial to receive a research trial implant.
  
  
• Size and shape. It is important to choose the correct size and shape (round or contoured) depending on the cosmetic result the patient hopes to achieve. Here, the plastic surgeon can offer advice and guidance.
  
  
• Surface of the implants. According to the Food and Drug Administration (FDA), a few studies have shown that textured surface implants, which were initially designed to reduce the risk of capsular contracture, show no such decrease in this complication compared to smooth-surfaced implants. Capsular contracture is scar tissue that develops and tightens or squeezes the implants.
  
  
• Implant palpability/visibility. The feel and look of the implants. Textured implants and larger implants may be easier to feel and see. The same is true when patients have less skin or tissue left to cover the implants.
  
  
• Implant placement. Implants are placed either under the chest muscle (submuscular) or under the breast glands (subglandular). The type of placement may influence the performance of mammograms, breastfeeding or breast self-examination.
  
  
• Variations in surgical incision site. Implants may be inserted through an incision at the bottom crease of the breast, in the armpit, along the lower edge of the areola or the navel.

The pros and cons of each of these factors should be discussed with the plastic surgeon before the procedure. The surgeon who performs the breast augmentation surgery may recommend a particular method or implant depending on the individual needs and concerns of a patient.

Prior to surgery, the plastic surgeon will most likely take a medical history and perform a physical examination to evaluate the overall physical health of the patient. It is important for the patient to share any previous problems relating to the breasts, including breast pain or lumps. Also, the patient should tell her physician about all medications she may be taking to ensure that none of them will adversely interact with medications used during surgery.

During this initial consultation, the surgical technique, the type of anesthesia to be used and the patient’s expectations are normally discussed. The surgery is generally done using general anesthesia (the patient is asleep during the procedure) but can be done using local anesthesia (which numbs only the breast area).

Before the procedure, patients may be asked to donate blood in case a transfusion later becomes necessary (autologous donation). Patients are also typically asked to refrain from eating or drinking for eight to 12 hours before surgery. It is recommended that a patient abstain from smoking because it can delay healing, and avoid taking certain vitamins or aspirin for a period of time prior to surgery. Patients may also be asked to refrain from wearing any jewelry or bringing any valuables to the healthcare center where the surgery will be performed. 

Breast augmentation is often an outpatient surgery, meaning that no overnight hospital stay is required. The entire procedure can be done in an hour or it can take several hours, depending on the patient’s condition, implant choice and other extenuating circumstances.

For breast augmentation, the plastic surgeon makes an incision at the bottom crease of the breast, in the armpit or along the lower edge of the areola. A fourth option, though rarely used, is an umbilical incision. This procedure uses an endoscope (a device with a light attached) for placement of the implants through the patient’s belly button.

The thinnest and least noticeable scar is the incision made in the areola. However, this site of entry can be associated with breastfeeding difficulties later on if the incision severs any milk ducts (tube-like structures that deliver milk to the nipple). Any woman who plans to breastfeed in the future may want to consider an alternative incision site.

To insert and position the implants, the surgeon lifts the breast tissue and skin, creating a pocket either under the breast tissue or under the muscle of the chest wall. Some plastic surgeons prefer placing the implants behind the chest muscle to reduce the risk of capsular contraction, where the surrounding tissue hardens around the implants. The implants are centered beneath the nipple prior to closing the incision with stitches and possibly surgical tape.

Breast augmentation surgery normally lasts one to two hours. In some cases, the surgeon will insert one or more drains (plastic or rubber tubes) into the breast or underarm area. The drains remove blood and lymph fluid that accumulates during healing. Drains usually remain in place for several days.

Immediately following breast augmentation surgery, swelling, pain, bruising and tenderness are common. These complications can last for several weeks and sometimes longer, but should diminish over time. Most complications can be controlled through medication prescribed by the plastic surgeon (e.g., medicine to relieve pain or nausea).

In some cases, there is more postoperative pain for women whose implants were placed behind the chest wall muscle (pectoral muscle). Any symptoms that may indicate an infection, such as fever or redness of the breast, should be evaluated by a physician.

It is recommended that the patient discuss issues such as scarring, pain and recovery times with the plastic surgeon as these vary considerably among individuals. However, most patients find that they are active within 24 to 48 hours. The scarring from the incisions will be pink and hard for several weeks. Afterward, in a process that may take many months, the scars will begin to fade and possibly even appear to widen to some degree. Eventually, most scars will fade but not disappear entirely.

A post-operative bra, compression bandage or athletic bra is often recommended as it provides additional support during recovery. Many women return to work within five to seven days with the strict instructions that they are not to lift more than 10 or 15 pounds. Women should wait at least two weeks before performing aerobic exercise or other strenuous activities that raise the pulse and blood pressure. Avoiding these activities reduces the risk of bleeding, swelling and bruising. Other exercise that includes weightlifting or contact sports should not resume for at least four weeks.

When considering breast implants either for breast augmentation or for reconstructive surgery after breast cancer, the patient should realize that the implants will have to be replaced within five to 10 years, if not earlier. Breast implants are not meant to last forever. Rupture, deflation or other complications are possible.

Implants that rupture, cause scarring or result in other cosmetic problems are the main reason for replacement. However, it is important to note that although insurance companies almost invariably cover reconstructive surgery, the replacement of implants – even those that have ruptured – may or may not be covered under a patient’s policy.

Although some patients may have implants that take 10 years or longer to rupture or deflate, others may experience problems within the first few months. According to the Food and Drug Administration (FDA), some studies have shown that nearly one-third of women who undergo breast augmentation experienced complications that required a reoperation within five years.

If a silicone breast implant does rupture and the silicone gel escapes the capsule, it is possible for the gel to cause lumps, known as granulomas, to form in the breast, chest wall, armpit, arm or rarely, even distant organs such as the liver. It is difficult and at times impossible to remove silicone gel that has migrated to other areas. In addition, silicone implant ruptures may not always cause symptoms (known as “silent rupture”). Therefore, the FDA advises patients with silicone implants to undergo MRI (magnetic resonance imaging) testing at three years after implantation and then every two years thereafter to screen for rupture.

When a saline implant ruptures, the body absorbs the fluid. Still, if a woman suspects that her saline implant has ruptured she should contact her physician. A number of signs and symptoms may indicate that a silicone implant has ruptured. Patients should immediately notify their physician if they experience any of the following:

• Decreased breast size
• A change in the shape of the implant
• Hard lumps in the areas that surround the implants
• An uneven appearance of the breast
• Tingling, swelling, numbness, burning or any changes in sensations

Oftentimes, women report an improvement in self-image after breast augmentation surgery. Many say that the difference has boosted their confidence and self-esteem. Nonetheless, it is important for a woman to have realistic expectations of what breast augmentation can – and cannot – do. These discussions with the plastic surgeon should include size, feel and overall appearance of how the breasts will look after surgery.

The best candidate for breast augmentation is often a woman who wants to improve her appearance, not strive for perfection. To achieve optimal results, it is best for a woman to be open and honest with her plastic surgeon so that realistic expectations can be set.

Breast augmentation can pose certain health risks. According to the Food and Drug Administration (FDA), which is charged with approving and monitoring the safety of breast implant devices, there are several potential complications. The FDA reports that as many as 40 percent of women who receive implants suffer at least one serious complication within the first three years of the surgery, many of which require additional surgery. Common surgical procedures include implant removal (with or without replacement), repositioning of the implant and biopsy/cyst removal.

Among the more common complications for breast cancer patients is asymmetry (a noticeable difference between the breasts). For all breast implant patients, it is also possible to experience tenderness or pain anywhere in the breast, including the nipple, after surgery. Capsular contracture (scar tissue) is another common problem after breast implant surgery. If the scar tissue surrounding the implants begins to tighten, it may squeeze the implants, causing them to feel hard. This condition can be treated by removing the scar tissue, but sometimes involves the replacement of the implants. Breast tissue atrophy (shrinkage) and calcium deposits that develop around the implants are also common. 

Perhaps the most common problem of all is a rupture or deflation. An implant that ruptures or tears because of trauma, mammography or normal wear and tear allows the contents of the implant (saline or silicone) to leak into the body. If the implants must be removed because of an infection or other reason, a chest wall deformity can result. Breast augmentation can also lead to extrusion, in which the implant begins to break through the skin, as well as delayed wound healing. Other complications may include:

• Galactorrhea. Milk production is inadvertently stimulated.
  
  
• Granuloma. Benign lumps develop as a reaction to a foreign body (the breast implant).
  
  
• Hematoma. Swelling, pain and especially bruising may result from a collection of blood around the surgery site.
  
  
• Iatrogenic injury/damage. Excessive handling or possibly damage caused by surgical instruments to the implants.
  
  
• Infection, including toxic shock syndrome (TSS). Infections are not uncommon after any surgical procedure. However, an infection that does not respond to antibiotics may force the removal of the implants until the infection has been cleared up. In rare cases, TSS can create a life-threatening bacterial infection within the body. Any patient experiencing sudden fever, vomiting, diarrhea, fainting, dizziness or a sunburn-like rash should seek immediate medical attention.
  
  
• Inflammation/irritation. A normal reaction from breast augmentation surgery includes swelling of the breasts and possibly the entire chest area.
  
  
• Malposition/displacement. A number of factors can cause the implants to shift, including poor initial placement, trauma or capsular contracture.
  
  
• Necrosis. Dead tissue around the implants, which, in turn, can lead to infection. The dead tissue can be caused by smoking, chemotherapy, radiation, excessive heat, cold therapy or the use of steroids.
  
  
• Nipple/breast sensation changes. These changes in the sensitivity of the breast and nipple can be mild to severe and temporary or permanent.
  
  
• Palpability/visibility. The implant is said to be palpable when it can be felt through the skin and visible when it can be seen through skin.
  
  
• Ptosis. This undesirable cosmetic result is a sagging or drooping of the breast.
  
  
• Redness/bruising. Redness and/or bruising are a common side effect of many surgical procedures.
  
  
• Sagging. Breast implants will not prevent the breasts from sagging after pregnancy or following extreme fluctuations in weight.
  
  
• Scarring. All incisions heal by forming a scar, but the degree will vary from patient to patient.
  
  
• Seroma. The watery portion of blood pools around the implants or at the site of the incision, causing swelling, pain and possibly bruising. Though it may heal on its own, if it does not, a drain may need to be inserted.
  
  
• Unsatisfactory style/size. The end result can, at times, be cosmetically or aesthetically displeasing to the patient or physician.
  
  
• Wrinkling or rippling. At times, the implants can wrinkle or have ripples that are noticeable through the skin.

Many of these complications can cause varying degrees of pain or discomfort after breast augmentation surgery. Improper placement, surgical technique, improper size or capsular contracture can lead to pain and tenderness. Any patient experiencing breast pain should consult her physician. 

Women choosing to have their implants permanently removed may experience dimpling, puckering, wrinkling, breast tissue loss or other cosmetic changes. Patients should be aware that many of these changes cannot be reversed.

One of the most important lifestyle considerations with breast augmentation is that women with breast implants will require additional surgery. The implants will have to be replaced within five to 10 years, if not earlier.

Women should also be aware that breast implants may interfere with mammograms, breastfeeding or breast self-examinations. Women who have had breast implants will still need to have regular screening for breast cancer. However, breast implants may affect the performance and the interpretation of mammograms. Additionally, women with implants are at risk of having them rupture during the compression required to perform a proper mammogram.

A woman who has had breast implants should notify the mammography center in advance as there are adjustments that should be made, including allowing additional time for the mammography. Some physicians may recommend obtaining a mammogram from a medical facility that performs a large number of mammograms in order to more easily locate technicians and radiologists who are skilled in such examinations. Some offer special techniques, additional x-ray views or even MRI (magnetic resonance imaging) scans to produce a clear image. It is best to discuss screening options with a qualified physician.

When a new lump or abnormal finding is revealed on a mammogram, a biopsy may be used to investigate the discovery. It is essential for healthcare professions to take extra care during this procedure to avoid puncturing the implant.

It can be difficult for women to distinguish between breast tissue and the implant during breast self-exams. In order to ensure that the implant does not interfere with the effectiveness of the exam, patients are encouraged to ask their surgeon to help them make the distinction.

Many women who seek to have breast augmentation take part in physical activities ranging from swimming to tennis. These energetic patients may be concerned about loss of normal muscle function and maintaining an active lifestyle after breast augmentation surgery. Research has found that the strength and movement of the chest muscles are not significantly affected by the surgery, according to the American Society of Plastic Surgeons (ASPS).

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions regarding breast augmentation:

1. What will my breasts look like after surgery?
   
   
2. What type of implant (e.g., saline, silicone) do you recommend for me?
   
   
3. Where will the scars be?
   
   
4. Will the scars be noticeable?
   
   
5. Do you have pictures of what my breasts might look like afterward?
   
   
6. What risks do you see with this type of procedure?
   
   
7. Is there any way to reduce my risk of complications?
   
   
8. How soon can I return to work after surgery?
   
   
9. When can I resume my normal activities?
   
   
10. What if I’m unhappy with the results?
    
    
11. How will I know if the implants are leaking?