Breast Augmentation

Breast Augmentation FAQ

Most women do a lot of research about breast implant surgery before ever consulting with a plastic surgeon. There are countless websites, and almost everyone has friends who have had the procedure and have an opinion on how it should be done. The amount of information can be overwhelming and sometime difficult to understand. I have put together some of the most frequently asked questions about breast implant surgery to help you navigate through the process. I hope you find this information useful.

Elizabeth Kinsley, M.D.


The risks associated with breast implant surgery are the same as with any surgery. Bleeding and infection can occur but are exceedingly rare, and every precaution possible is taken to avoid these. There are also risks associated with anesthesia, but again, in a healthy woman, these risks are negligible.

The main risk that is particular to implant surgery is capsular contracture. The body will form a capsule around any foreign object, so capsular formation is a normal process. At times, for reasons mostly unknown, this capsule will thicken and distort the implant. At worst, it can result in the implant being misshapen or malpositioned. Fortunately, this occurs in a very small (1-2%) of patients. A medication may sometimes improve or resolve the tightening caused by a contracture, and sometimes surgery is required to release the tightened capsule.

The implant can also become malpositioned over time, even without a contracture. This is often seen with submuscular placement, where over time the implants are pushed downward and out to the side over time.

One of the main things that can be done to avoid complications is meticulous surgical technique. A bloodless field is very important, and the implant is never touched- the implant is taken from the sterile container and placed into a funnel (like a pastry bag) and into the pocket without touching it.

BOTTOM LINE: Capsular contracture can occur at any time but is treatable.

Above or Under the Muscle?

Your breasts are above the muscle, and this is where I prefer to put the implants- where your breasts are. If a patient selects saline implants, or if they are very thin and have little chest coverage, a sub (under) muscular placement is used.

Some patients think the muscle will “hold up” the implants over time, but this is simply not true. In order to place the implant under the muscle, the bottom part of the muscle is released, so there is no attachment for the muscle to hold the implant up. If the muscle is not released, the implant will be positioned unnaturally high on the chest, with the breast tissue hanging from it.

In my opinion, the only reason to place an implant under the muscle is to camouflage the ripples of a saline implant, or on a woman that has virtually no tissue on the chest to cover an implant.

The recovery for either is not bad, but the subglandular placement (above) is far easier.

BOTTOM LINE: If possible, above the muscle is preferable


As a surgeon, I generally prefer silicone implants. This is not to say that I do not ever use saline implants- in fact, I have performed thousands of augmentations with saline implants. I prefer to use silicone implants because the feel and look is more natural, and the risk of the implant “failing” is very, very small. Also, because the silicone gel is more viscous than the saline, there is less rippling, and therefore the implant can be placed in a subglandular (on top of the muscle) position. More on placement later.

Many patients have friends who insist the implant must be placed behind the muscle, but personally, I think this is just leftover thinking from the days when the only implant available was saline. Saline implants ripple, and if placed in front of the muscle on a thin woman, the rippling would show terribly. That is why submuscular, or behind the muscle, placement was first performed- to camouflage rippling from the saline implants.

The silicone implants available today are considerably different from the old silicone implants. The outer shells are very durable and difficult to damage. As a test, I gave some to my two young sons and let them play dodgeball, basketball, frisbee, you name it, and see what would happen. The implants did fine through all of this, and I was surprised, pleasantly, at how durable they were. One of the dogs did finally catch an implant and the home testing ended, but it impressed to see what kind of abuse the implants would handle. By the way, saline implants wouldn’t last a day in my house.

BOTTOM LINE: I prefer silicone but use saline if patient desires

Implant Shape and Texture

Before the introduction of the modern silicone implant, most implants used were round. Anatomical, or teardrop shaped implants, are now becoming increasingly popular and are available in an incredible assortment of sizes and shapes to match any woman’s body.

Basically, we speak of implants in terms of “cc’s”, that is, the volume they hold. Round implants have the same height as width, but vary in projection. The projection is the measure of the implant from front to back- or how much it sticks out from your chest. Commonly used terms are moderate, moderate plus, high, and even ultra high implants. The selection of which implant to use can take more time than the surgery itself, but it is the most important step of the process.

In general, an implant should be matched to fit a woman’s breasts, but there are exceptions to this. As a woman ages, the breast become wider, and upper volume is lost. In this case, a more narrow implant with higher projection could be used to minimize the width and give the mature breast more “perk”.

On the opposite end of this is the woman with a vey wide separation of the breasts at the sternum. In this case, choosing an implant with a wider base may actually decrease the appearance of separation at the sternum and improve the cleavage.

Throw into this mix the newer shaped silicone implants. The come in almost every conceivable combination of height, width, and projection. In the past, I advised patients that the increased cost of an “anatomical” saline implant was not worth it. These implants tended to become turned or malpositioned, and did not look very different from a round implant. The newer silicone shaped implants are the ultimate “custom” implants. They come in every combination of width, height and projection, and are made of a more viscous gel that is referred to as “form stable”. That means that the implant will hold it’s form. These can give amazing results, but come at an increased cost. For some woman who have thin tissue or mild sagging, or those that want the most natural look, the increased cost is money well spent.

As you would expect, textured implants have a rough surface, and smooth implants have a smooth surface. Textured surface implants are supposed to have a decreased rate of capsular contracture, although the evidence to support this has not been clear, and in the past, textured implants have been more problematic than smooth in terms of complications. Again, with the latest generation of textured, gel implants, this may not be the case. I do not hesitate to use a textured silicone implant, whereas I would rarely if ever use a textured saline implant.

BOTTOM LINE: There are a lot of choices. Don’t stress! It is my job to figure out which one will work best for you!

Incision site

The implants can be placed through an incision in the breast crease- called inframammary, or through the nipple area- periareolar, or through the armpit- transaxillary. Any of these incisions are fine, and they all heal very nicely. If repeat surgery is ever needed or desired for any reason, however, it is very difficult to work through the armpit or nipple incision. For this reason, I generally use the inframammary incision.

BOTTOM LINE: The inframammary incision is the preferable


This can be the most difficult part of the process. The first thing to realize is that implants don’t come in cup sizes, so you cant just order up a B or C cup and it will happen. Next, bra cup sizes are all over the place. You may be a 34C in one bra and a 36B in another. Even with the same manufacturer, you may wear different cup sizes. It is impossible for me to say what cup size you will be after surgery. With almost 20 years of experience doing this, and actually having shopped for bras myself, I have a good idea of what women mean when they say a B or C or D cup. The important thing to remember is that you are adding the implant to what you already have- so if your friend got a certain size implant and you loved how they looked, getting the same exact size may not give the same result if your breasts were different to begin with.

At the consultation, I ask the patient if they could pick a cup size what would it be, then work from there. Considering skin laxity, chest width, body shape, asymmetry, etc., together the patient and I will make a size selection. I think the approach of letting the patient try on implants, 3D imaging, and a thorough understanding of what the patient wants, the old recommendation of “going up a size” can be tossed out the window. The implants currently used are much more sophisticated than the implants of just a few years ago. So my tendency is to spend some time in the consultation and get it right the first time. I don’t believe that bigger is always better: I believe that right is always better.

BOTTOM LINE: This is the hard part. Understand that there may not be a “perfect” solution and that a number of implants may give a very pleasing result

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