Breast augmentation with saline or silicone implants has become an increasingly popular option for women either born with a small chest or for those who suffer from the effects of child birth or have gained and then lost a lot of weight. Breast imperfections coupled with the societal preference for a larger bust have caused breast enhancement to become one of the most frequently performed surgeries done by plastic surgeons. The operation can be a challenge to perform as there are a number of decisions the patient and surgeon must make to obtain the best results.
The first and most basic decision is the choice of breast size and the possible need for a breast lift, or mastopexy, in addition to augmentation. Next, the type of implant should be explored. Some people desire the “natural” feel of silicone implants and others prefer the improved projection and lifting obtained with saline implants. The surgeon will usually recommend that the implants be placed in the submuscular position (beneath the pectoralis muscle) although on a rare occasion sub-mammary (beneath the breast tissue and on top of the pectoralis muscle) placement is indicated.
Finally, the incision location is discussed. There are basically four different incisions available: Axillary (armpit), Periareolar (around the nipple/areola), Inframammary (under the breast), and umbilical (through the belly button). Most surgeons will know 2 or 3 of these approaches with the “TUBA,” or transumbilical approach, being the least performed incision due to the limitations of implant placement. In many instances, the transaxillary approach is recommended due to its location in the armpit away from the breast itself, the quality of the scar in the hair bearing skin, and the fact that early implant manipulation to keep the implants positioned perfectly in the submuscular pocket without putting pressure on a breast incision.
Price shopping breast augmentation is a calculated risk as one is by necessity shopping a general anesthetic also. Non-plastic surgeons performing breast augmentation are generally a “one trick pony.” That is, they tend to offer implants and rarely breast lifts (which are harder to do), nor do they offer a selection of incisions as the inframammary scar seems to be the easiest for the amateur surgeon to perform.
The caveat is to always check the credentials of your surgeon as there are no “weekend” courses to teach breast augmentation as there are for other procedures such as liposuction. Also, beware of the “less is more” argument. That is, minimal training as a “cosmetic surgeon” is somehow better than completing an American Board of Medical Specialties Board Certification as a real plastic surgeon. Breast augmentation gone wrong is very difficult to reconstruct and shopping for the cheapest surgeon does not guarantee board certification, clinical judgment, or experience.
Dr. Paul Howard pioneered the use of the endoscope for less invasive breast augmentation surgery with the transaxillary (armpit) incision.