Breast augmentation

Breast Augmentation

Many women are born with small breasts or they may have decreased in size over time due to pregnancy or breastfeeding or significant weight loss. Breast augmentation is the placement of implants behind the breasts in order to make them larger, fuller, more feminine and/or more symmetrical. The goal is to achieve a natural breast and not an unnatural fake-looking “operated” breast as unfortunately we frequently observe today. You are a good candidate for breast enlargement if you are chronically and significantly bothered by the feeling that your breasts are small for your frame or you feel self-conscious when wearing your clothes. You do not need to have a breast cosmetic procedure if you are happy with your breasts.

Introduction and basic information about breast augmentation

Many women are born with small breasts or they may have decreased in size over time due to pregnancy or breastfeeding or significant weight loss. Breast augmentation is the placement of implants behind the breasts in order to make them larger, fuller, more feminine and/or more symmetrical. The goal is to achieve a natural breast and not an unnatural fake-looking “operated” breast as unfortunately we frequently observe today. You are a good candidate for breast enlargement if you are chronically and significantly bothered by the feeling that your breasts are small for your frame or you feel self-conscious when wearing your clothes. You do not need to have a breast cosmetic procedure if you are happy with your breasts.

In breast augmentation it is very essential that each patient’s anatomical parameters are completely individualized. There is not a single surgical technique or specific implant that is compatible with all women. Everything single detail is individualized every single time. At the HAPSI we strive for the best possible result for each individual breast and body type. We must mention that your participation before surgery is important for us in order to understand your wishes in terms of shape and size and to develop the ideal plan for your individual anatomy. During consultation and physical examination we will inform you what can be safely achieved based on your existing breast shape/size, fat amount and skin type and thickness.

Breast aesthetics – the basics you need to know

The most important parameter for a natural-looking breast after a breast augmentation is the upper pole area and upper pole fullness of the breast (which is the upper half of the breast). In a natural-looking breast augmentation, a “natural breast slope” is maintained which means that the chest-to-breast transition is natural and smooth. To make sure that we maintain a natural chest-to-breast transition, the implant size and profile must follow this parameter and should not be too big. Beyond this specific point of upper pole fullness (and if a larger implant is placed) it will start to have a visible upper pole “step-off” and the chest-to-breast transition will start showing the round edge of the breast implants which constitutes an unnatural “operated look” result.

It is mainly this chest-to-breast transition area at the upper pole of the breast that determines the breast augmentation technique selection (above or below the chest muscle) and the implant width, type and projection. In every breast there is a specific cut-off point above which, if we insert a larger breast implant, the implant edge will be visible and the end result will be unnatural. The implant must be smaller than that point and we make the final decision about this during the operation with the aid of special inflatable breast sizers. The sizers are placed inside the breast enlargement pocket and are inflated with saline fluid to the point of maximal breast fullness but without implant visibility (without the “step-off”). Once the ideal sized implant is determined, the sizer is removed and we place the permanent breast implant of the same size with the sizer that we had previously filled.

Natural look – Chest-to-breast transition with smooth slope

“Operated” unnatural look – Chest-to-breast transition with step-off, frequently seen with large implants relative to body frame

At our Center we believe that breast size should follow your body type dimensions. During consultation we obtain detailed measurements of your chest and breast area and we recommend the maximum size that can be achieved in a natural way for your individual anatomy. You will also try several sample implants under a bra in order to better visualize your size result. If permitted by your breast anatomy, we also use the 3D simulation technology in order for you to actually see your new breasts digitally before your surgery.

Most importantly, as mentioned above, during surgery we always use a test-sizer implant which is placed temporarily inside the planned implant pocket and inflated with saline fluid while the surgical bed is lifted in order to also see the effect of gravity on your breasts. This way we can measure the amount of fluid that fills the test-sizer and we then remove it and place the same size silicone implant which will be the perfect sized implant for your individual body and chest anatomy.

It is critical to hide the implant completely and we do several things in order to achieve this like placing the implant under the muscle. Paradoxically, usually the larger your existing breast the larger the breast implant that can be placed as there is more tissue available to cover it. Conversely, the smaller your existing breast the smaller the breast implant that can be placed as a natural breast result is always the goal.

The final breast shape after a breast augmentation has mainly to do with your existing breast tissue and fat as well as the size and shape of the breast implants. The shape of the upper half of the breast should ideally follow the natural chest-to-breast slope as explained above. The middle and lower part of the breast depends mainly on your existing amount of breast tissue and skin and the expected look is discussed in detail with you before surgery.

If your breast skin is lax and you have extra skin on your breasts droop then a breast lift may be needed (with or without implants). However many women only have a small degree of ptosis, do not want visible scars (breast lifts have scars around the nipple an/or a vertical scar) and they may satisfied with a breast implant that fills out most of the breast and lifts the breast a bit. Women must understand that in these cases there may be a small amount of residual droop which is usually noticeable only without clothing. If your breasts have a noticeable droop and you are bothered significantly by it, you should be considering a breast lift procedure most likely combined with a breast augmentation.

Before surgery information

During your initial appointment we will show you animations of how the procedure is performed as well as many before/after pictures from patients that have consented for their pictures to be shown during consultation. We will measure your chest and breasts and discuss with you the different surgical techniques and implants available as well as what may or may not be achievable for your anatomy. Depending on your anatomy, we may be able to use imaging software, which produces graphic simulations of your potential appearance after surgery. We also use silicone sizers and place them under a surgical bra (that we provide) in order to help you understand the possible breast sizes after surgery. We will also inform you about the potential complications associated with breast augmentation and potential long term problems and how to prevent them.

We need to obtain information about your medical history, previous surgeries or medications that you are on. You will be asked whether you have a family history of breast disease and about your recent mammogram if you had one. If you decide you would like to proceed with surgery then you can come back for a second appointment to ask any further questions. You will receive a prescriptions for pain medications or antibiotics. You can come back for another visit before your surgery if you feel you have more questions or concerns.

If you smoke, you must stop smoking at least 2-3 weeks before surgery and for several weeks after surgery. Aspirin and certain anti-inflammatory drugs can cause increased bleeding, so you should avoid taking these medications for at least 7-10 days before surgery. We will provide you with additional preoperative instructions including the basic preoperative tests that are routinely performed before surgery (blood tests and electrocardiogram usually).

Surgery information

The surgery takes place at JCI-accredited hospitals with specialized day-stay units. Once you reach the hospital you will be taken to the registration area and then to your hospital room. The surgeon will evaluate you before surgery in order to place the preoperative surgical markings and also answer any last minute questions you may have. The consent for the surgical procedure must also be completed by both you and the surgeon at this time. You will then be taken to the preoperative area where the Anesthesiologist will place an intravenous line for the administration of the anesthesia medications. You will then be taken to the operating room. Your safety is our number one concern during surgery and anesthesia and please do not hesitate to ask the Anesthesiologist any anesthesia-related question you may have.

Breast augmentation is performed under mild general anesthesia and the Anesthesiologist that will be giving the anesthetic will be with you at all times. The operation takes approximately 90 minutes, and at the beginning and the end of the procedure local anesthetic is injected in order to minimize your postoperative pain.

Breast augmentation incisions are usually 4cm long and in most cases are made at the lower breastfold (inframammary crease) which is the recommended incision site for significant clinical but also for aesthetic reasons. Below please find more detailed information regarding the 3 breast enlargement incision options available:

This incision in created at the lower end of the breast at the breast crease. We recommend this breast enlargement incision as we believe it is medically the safest and the most efficient technique. The access to the breast implant pocket (BLUE ARROW IN PICTURE) through this incision is the least traumatic to the breast as there is no contact with the breast tissue or gland and no violation of the breast tissue. The only tissues that are opened are the skin, fat and the pocket where the breast implant is going to be placed. This breast enlargement technique is the most “anatomical” technique and has no impact on your future mammograms, breastfeeding or overall breast health. This breast enlargement technique offers direct visibility of the pocket creation and implant positioning. The scar fades and after several months it is barely noticeable. In patients with deep breast folds, the scar is completely hidden by the breast. Finally this technique offers the best approach if additional breast surgery is required in the future and for treatment of cases of tuberous breasts.

The periareolar breast enlargement technique has the disadvantage that in order to access the breast pocket, the surgeon needs to create a tunnel from the nipple all the way back to the breast and this tunnel needs to be dissected very close to the breast tissue (BLUE ARROW IN PICTURE). This usually injures the breast gland and in some cases the tunnel goes through the breast gland. This approach can potentially injure the breast ducts and increase the risk for infection and capsule formation and also create internal tissue scarring and changes in your future mammograms. These changes may cause unnecessary future concerns or even warrant unwanted breast biopsies. We consider this breast enlargement technique more traumatic for the breast tissue as it may also cause an increased incidence of changes in nipple sensation. The scar is at the edge of the nipple and is often visible as is located at the central focal point of the breast. Finally, with this technique women also have a risk of problems with future breastfeeding.

The transaxillary (armpit) breast enlargement incision has the disadvantage that the scar may be visible while wearing your swimsuit as the armpit is exposed. Also there is no precision during the surgical pocket creation and many times the implants are placed in a high-set position which can cause an unnatural result. Additional surgery, such as removal of scar tissue from around the implant (capsulectomy), is very difficult with this approach. There is also a risk of scar tissue band formation under the axillary scar. This technique was used in the past more frequently when the saline inflatable implants were only available but today we very rarely use this technique at the HAPSI.

Information regarding the Transumbilical Breast Augmentation (TUBA technique)
We do not recommend this incision and we do not perform this technique. It requires the creation of a long tunnel from the umbilicus (belly button) all the way up to the upper chest which creates significant trauma for many tissues and creates the breast implant pocket in a less precise manner. Only saline filled implants can be placed with this approach which have a harder feel and an unnatural look compared to the silicone implants and are extremely rarely used today.

Implants need to be covered adequately in order to achieve a natural result that does not look fake or “operated”. Below is a picture of the basic breast anatomy in order for you to understand the surgical techniques for implant placement in breast enlargement / augmentation.

There are basically three layers of “soft tissue” making up the breast:

  1. the outer layer is skin
  2. the middle layer is fat
  3. the deep layer is the breast gland/ducts

(note that behind the breast is a flat chest muscle called the pectoralis muscle)

These first 3 layers are the “soft tissues” of your breast and they should not be changed during a plain breast augmentation surgery. They are the layers used for coverage of the implant and in many cases they are the only tissues hiding the implant.

In women with thick layers of “soft tissue” (skin, fat and gland) there is good padding to cover the breast implants. In such women, extra coverage by the pectoralis major muscle may not be needed.

However, many patients’ soft tissues are thin that there is a risk of breast implant visibility or rippling, especially over the years as the overlying tissues become thinner. In these cases, it is preferable to cover the implants with the additional layer of the pectoralis muscle. The muscle does not cover the entire breast implant but it does cover the upper and middle parts of the implant (approximately 60-70% of the implant). However this matters as specifically these two are the areas where it is critical to have a smooth chest-to-breast transition and avoid the “step-off” of the visible implants that give the unnatural look that unfortunately we frequently observe today in women that have undergone breast augmentation.

Therefore, there are two general categories of breast enlargement surgical techniques and they are divided in relation to the pectoralis major muscle:


Each of these two main categories of techniques has subtypes in order to individualize the breast implant placement depending on the specific anatomy of your chest and breast. The breast enlargement subtype selection by your surgeon is very important as it can significantly affect the look and feel of your breast. Only plastic surgeons with significant knowledge and expertise in breast enlargement surgery are able to appropriately choose and efficiently execute the different types of breast implant placement techniques. At the HAPSI we utilize all the breast enlargement techniques described below, depending on the individual anatomy of each patient.

Pectoralis muscle


  1. Subglandular breast enlargement technique
  2. Subfascial breast enlargement technique

The breast implants are placed beneath the breast gland and in front of the muscle. This technique is appropriate for women that have adequate breast gland and fat in order to cover the implants. This breast enlargement technique provides a faster recovery compared to the under-the-muscle technique. In some cases fat transfer is used in combination with this technique (composite breast augmentation) in order to add extra padding for ideal and complete implant coverage, especially at the upper breast pole.

This technique is very similar to the previous one (subglandular). Here, a thin sheet of tissue which covers the muscle is used which is called the “fascia” of the muscle. This fascia theoretically has some of the benefits of the under-the-muscle technique and some surgeons consider this technique having the advantages of both the above-muscle and under-muscle techniques and advertise it as such. However, the fascia layer of tissue is very thin and many times it is barely visible so most breast experts believe that this technique is the same as the subglandular technique. Studies have shown that the fascia’s thickness is only 0.297 of a millimeter, so the clinical significance of the “subfascial” technique is probably negligible.

At the HAPSI, when we place the implants above the muscle, we use this technique only if the fascia is thick enough to become a reasonable layer of coverage for the implant. Basically, if the fascia is there and it’s thick enough, we use it.
Picture: Fascia of the muscle: Note the thin white layer of tissue covering the implant.

There are 3 types of “under the muscle” breast implant placement techniques:

  1. Subpectoral / submuscular breast enlargement technique
  2. Dual plane breast enlargement technique
  3. Muscle-splitting breast enlargement technique

In this technique the breast implant is placed under the entire pectoralis muscle and the main benefit is that it can smooth over the upper edge of the implant avoiding the “step-off” effect which can be obvious if you are very thin. This technique is more painful in recovery and there may also be some bruising after surgery. It should be noted that the muscle does not cover lower 30% of the implant because the muscle is cut low and retracted upward, so the lower poles of the breast implants are covered with only breast and fatty tissue coverage. The main disadvantage of the subpectoral placement is the high rate of “breast animation deformity” that occurs which is the undesirable movement of the implants when the chest muscle is contracted forcefully. For this reason at the HAPSI usually we prefer the dual plane or the muscle-splitting techniques described below.

This is a combination technique in which part of the breast implant is under the muscle and part of it is over the muscle (and under the breast gland). There are some technical variations of this technique depending on the percentage of muscle coverage of the implant. Main component of this technique is adequate dissection and release of both the muscle and the gland overlying the implant. The dual plane technique is good in women who are relatively thin but have some breast tissue at the lower breast in order to adequately cover the implant.

During this technique, the muscle is split in the middle and only its upper half is used to cover the implant. It is designed to provide muscle coverage over the upper portion of the breast while the rest of the implant is above the muscle (and under the gland/fat). It is helpful in minimizing the risk of the “breast animation deformity” that can occur when the muscle contracts with the under-muscle technique.

In breast enlargement, the old technique for inserting silicone implants into the implant pocket is to push and squeeze the implant through the small incision in a rough and traumatic manner. This can cause small injuries to the implant that can potentially lead to future rupture of the implant shell and leakage of silicone. Additionally this technique can contaminate the breast implant with skin bacteria and lead to increased risk for capsular contracture as proven by several medical studies. With pushing/squeezing, the incision needs to be pulled open with retractors which induces trauma to the incision opening which may have an effect on scarring.

At the HAPSI we use a very specialized technique for breast implant placement, the Funnel technique. This technique utilizes a special cone device that places the implant in the surgical pocket without the surgeon touching it. This technique does not require pushing and squeezing of the implant and causes no trauma to the implant or skin. The breast implant is kept sterile without contamination by the skin which decreases the risk for capsular contracture. Since the skin is not pushed open with forceful retraction, this eliminates skin tissue damage and lowers significantly the chance for unfavorable scarring. At the HAPSI we routinely use this device for the placement of breast implants.

When surgery is completed, you will be taken into the recovery area for 30-40 minutes where you are awake but will continue to be closely monitored. Your breasts will be wrapped in surgical dressings and/or a surgical bra. You will be able to go home after 4-5 hours, unless you and your surgeon determines that you will stay in the hospital overnight which happens if your pain is more than expected (less then 10% of women undergoing breast augmentation). It is very important that you contract your leg muscles or walk for several minutes every 30-60 minutes in order to reduce the risk of blood clot formation on the lower extremities.

After surgery / Recovery information

There is moderate pain and discomfort for the first 2-3 days and many women describe the type of pain similar to the discomfort that they feel after a very intense workout of their chest muscles. After the first couple of days, the discomfort becomes more of a slight pulling sensation with mild on/off burning and most patients are fine using only anti-inflammatory medications.

No, there is no need for drains after a breast augmentation procedure and they are extremely rarely used.

If the breast implants are in front of the muscle your recovery will be fast and most patients can perform most regular activities within 3-4 days. If the implant needs to be placed behind the muscle then you will be sore for an additional 3-4 days. Most patients can expect to be back at work after a week. The pain medication required is usually anti-inflammatories and we also prescribe some stronger pain medications to use “as needed”, but these are rarely used by most patients. The wounds are closed with absorbable sutures so there is no need for suture removal. It is preferable to wear a surgical bra for the first 3-4 weeks as this will provide some stability in the area and will give you the sense of protection and make you feel more secure.

You will be seen again the day after surgery, then after 3 days and then ten days to two weeks following the procedure. Ideally we should follow-up on your progress again at 4 weeks, 2 months, 3 months, 6 months and 1 year after surgery. You will then require an annual check up visit.

For the first month the breasts are generally swollen and the implants ride a bit high. It may take two to three weeks for the implants to drop down into the surgical pocket and for your breasts to look more natural. However, you should be socially presentable 7-10 days after surgery, even with light clothing. Sometimes there is some bruising that usually resolves within the first week after surgery. Also the incisions are a bit red in the beginning and it may take several weeks to months for the red line of the incision to become pink and then a pale white line which is barely visible in most cases.

We recommend that you keep the scars dry for the first 7-10 days until the incision has sealed and completed the initial phase of healing. This is due to the fact that the implants are foreign bodies and we want to minimizeth chance for infection as much as possible.

Light activities can be resumed almost immediately and you should be able to drive only 7 days after surgery in most cases. You can go back to low impact exercise such as walking and bike riding 10-12 days after surgery. However, all intense exercise like swimming and bouncing exercises like running should be avoided for at least 4-6 weeks. This allows for the normal internal scar tissue to form to support the implant and minimize the risk of it dropping more than desired. If your implant is under the muscle you should avoid heavy chest exercises for 6-8 weeks.

Implant information

Breast implants contain medical-grade silicone. This is the type of silicone that is used for several other medical devices and implants used in other medical specialties like orthopedics. The outside cover of the silicone gel breast implants is made of semi-solid harder silicone and the inside silicone is a thick cohesive substance like gel (“gummy-bear” implants). If cut, the cohesive implants’ silicone does not drip like liquid silicone used to leak in the older generation silicone implants. Saline breast implants’ outer shell is made out of silicone and inside they are filled with a salt-water (normal saline). At the HAPSI we very rarely use saline implants due to their firm, rigid feel and unnatural overall result. The much softer silicone gel implants is a much more natural alternative than saline and they are both equally safe.

Silicone Gel Breast Implant cut in half showing cohesive gel properties also called “gummy bear” breast implants.

Breast implant selection requires a detailed discussion of your goals and an examination with measurements of the area. Although we believe that round implants is the best choice for most women, in some patients teardrop silicone implants are better. Implant selection is a critical step in your breast augmentation experience and be assured that we will spend all of the time you need in order to help you make the best choice.

Round breast implants: The round-shaped breast implant is the most common implant design and remains the most frequent choice for women undergoing breast augmentation. Round implants are available in a very large range of base diameters and degrees of projection in order to match any woman’s breast and body type. The advantage of round implants is that they make the breasts fuller at the upper pole and at the cleavage. However, care must be taken to avoid large implants for your anatomy as this can create too much projection and fullness and result in the “fake” implant look (“step-off” at the upper pole) which is unnatural and not aesthetically pleasing. At the HAPSI we do not place large breast implants (large relative to your anatomy) that result in this unnatural look and we will explain in detail the reasons you should avoid it.

These breast implants are shaped as a “tear” and are designed to maintain their shape and come in a wide variety of teardrop shapes. For example, some are designed as “tall” and some are “wide”. Teardrop silicone breast implants are a great option for some women. They are usually recommended for very slim women that have minimal to no breast tissue as they provide a smoother chest-to- breast transition and avoid the implant “step-off” at the upper pole. They are also a good option in some cases of breast ptosis in order to provide a better breast uplift at the lower pole and the nipple. There have been many studies that showed that for the vast majority of women there is no difference in the cosmetic result between round and teardrop implants. However, we definitely still use them on some women if we believe that they can provide a superior result for them.

Not all round breast implants are the same as they are available in various shapes and dimensions in order to accommodate different chest and body types. Three measurements are necessary in order to decide the ideal breast implant for your individual anatomy:

  • The diameter, which is the width of the base of the implant and its size is determined by you own chest width and breast width.
  • The projection or “profile” of the implant which is the distance an implant projects outward from the chest wall, ie how “pointy” it is. A natural breast must have adequate projection to look full and feminine but not too much as this can create the over-projected “operated look” that is very obvious especially at the cleavage, even with clothes.
  • The volume. Volume is the actual size of the implant (the amount of space the implant occupies and is measured in cubic centimeters (c.c.’s) or milliliters(ml).

For a specific breast implant volume, the low profile implants have the least amount of projection and the high profile implants have the greatest amount of projection. Moderate profile breast implants (and moderate-plus implants) project in between the high and the low profile implants. At the HAPSI we frequently use the moderate and moderate-plus profile implants in order to achieve the most natural results and only rarely use the high or low profile implants. Usually the moderate (and moderate-plus) profile implants fit the average size patient the best. Moderate profile implants tend to create nicely proportioned, natural appearing breasts. The high profile implants may result in pointier breasts and low profile implants may result in a less projecting and wider breast.

During your consultation we will review low, moderate and high profile implants with you and explain how they relate to your body, measurements, and the breast shape you wish to achieve.

One of the most frequent concerns of women scheduled for breast augmentation is selecting the correct size of breast implants. Sizing is a very critical issue that needs to be addressed in every detail as implant shape and size will determine the end look of your breast and chest area. We have extensive experience helping women with breast implant sizing. The most important dimension for determining breast size is breast width which is measured in a straight line from the cleavage area to the outer breast. Another important consideration is the thickness of the tissues of your breasts. A woman with thick breast tissues may be able to accommodate a wider and larger implant than a woman with thin breast tissues. In thin patients, wide implants are more likely to stretch and thin the tissues, leading to less padding over the implant and causing implant visibility or rippling. The implant’s projection is the other critical factor for a successful and natural breast augmentation.

The breast implant sizing process generally takes into consideration the following variables:

  • Your personal wishes in terms of size and shape of the breast
  • The detailed measurements of your chest and breast
  • Trying on breast several implants during your consultation. Trying on implants will give you an idea of the size range you prefer and you will have plenty of time to try implants during your consultation.
  • The surgical technique that is appropriate for you
  • The implant type that is appropriate for you
  • 3D Imaging during your consultation
  • Often, a representative photo of the desired breasts is useful to convey the look you want to achieve.
  • Sizer implants during surgery: intraoperative sizer implants before placement of the final implants. This the ultimate implant try-on, where we try different implants in the operating room. This is a simple thing to do and only adds a few minutes to your surgery. After the implant pocket is surgically created within your breasts, the sizing implant is placed. Then the results are assessed and we choose the size that is closest to your wishes and your anatomy. Once the correct breast implant profile and size are determined, the sizing implants are removed and the final breast implants are placed.

A note regarding very large breast implants frequently seen on magazines or social media:

We must mention that very large breast implants will obviously look unnatural and will put you at risk for problems as they will likely cause accelerated aging of the breasts that may lead to sagging, tissue thinning, implant visibility and the need to re-operate to treat these issues. In many cases, such problems may not even be correctable with additional surgery. We frequently hear from new patients the quote “all of my friends have told me they wish they went with bigger implants.” But, what most women don’t discuss with their friends are the issues they face when very large implants were used and problems that have occurred. If women shared their experiences with large implants, then many patients undergoing breast augmentation would be less inclined to choose them. At the HAPSI we do not place very large implants relative to your anatomy as this does not express our breast cosmetic approach and our overall approach to aesthetic plastic surgery.

Breast implants consist of an outer silicone rubber shell which surrounds the inside silicone gel. Smooth breast implants have an outer silicone rubber shell which is very smooth, shiny and slippery. Smooth implants do not attach to the surrounding body tissue and are usually freely moveable within the tissue membrane that is naturally formed by the body around the implant and is called a capsule.

Textured breast implants have an outer silicone rubber shell with a rough and irregular surface almost like sand paper. Textured implants attach to the tissue capsule around them and are less likely to move.

One problem that can occur after breast augmentation is when the tissue capsule or membrane surrounding the breast implant becomes very thick and tight. This condition is called capsular contracture and causes the breast to feel hard. In the 1980’s textured breast implants were developed with this rough surface like sandpaper because some research suggested that breast implants with a rough surface were less likely to cause capsular contracture. However, more recent prospective studies found none or minimal difference in the rate of capsular contraction between textured and smooth implants with the newer surgical techniques and precautions used.

Since it was shown that BIA-ALCL lymphoma is a potential complication of only textured implants (although a very rare complication) , we have made it standard practice at the HAPSI to use only smooth surface breast implants for cosmetic purposes. Please see below for more details on BIA-ALCL.

When textured or smooth breast implants are placed beneath the chest muscle in a patient with adequate breast tissue overlying the muscle it can be impossible to feel the difference between the two. However, textured breast implants have a thicker wall than smooth implants and thus can feel a bit firmer on thinner women. In addition, textured implants are more likely to have palpable folds and ripples. Thus in very thin people with little breast tissue, if the textured implant is placed on top of the muscle it is more likely to be felt than a smooth implant.

There are some implants that come only with a textured surface. The anatomic (shaped or teardrop shaped) breast implants are only made with a textured shell in order to “stick” on the surrounding tissues and prevent their rotation. Additionally the textured implant shell is firmer and holds its shape better than a smooth implant. Therefore, if you need a shaped breast implant you will have to have a textured surface breast implant. Textured breast implants are also often used to replace implants after removal of a capsular contracture in an attempt to prevent its recurrence.

Teardrop shaped textured breast implant

Recent studies have reported that a very rare lymphoma tumor called BIA-ALCL has been discovered to occur around the shell of textured (not smooth) breast implants. Please note tat this tumor has only been found associated with textured breast implants and no cases have been found associated with smooth surface breast implants. The occurrence of this tumor when textured implants are used has an estimated risk is 1 in 30,000 and has been described to occur usually between 4 to 8 years after the textured implants are placed. The first sign is swelling due to fluid buildup and most cases have been successfully treated with removal of the textured implant and the capsule and tumor. Although the occurrence of BIA-ALCL Lymphoma is very rare, the fact that it does not occur with smooth walled implants pushes us to favor smooth walled breast implants for elective, cosmetic breast augmentation.

Your decision to choose between textured and smooth breast implants can only be made during your consultation with a plastic surgeon very experienced in breast augmentation. Your plastic surgeon will explain the differences and help you decide. Most likely if you are having standard round breast implants you will choose a smooth breast implant. However, if you and your doctor chose a teardrop shaped breast implant you will definitely need to have a textured breast implant.

Risks of breast augmentation

Complications from Breast Enlargement Surgery are rare. By far most patients that undergo this procedure experience a very safe recovery and enjoy a beautiful long-term result without problems as the satisfaction rate of this procedure is one of the highest among plastic surgery procedures. However, complications can occur and the following is a list of local complications and adverse outcomes from the official FDA website (United States Food & Drug Administration) which is the regulatory authority for breast implants in the United States. Most of the complications listed below happen at a rate smaller than 1% with the most frequent being capsular contracture which happens at a rate of approximately 4-5%. The complications are listed alphabetically, not in order of how often they occur and most of complications listed are issues that patients almost never experience.

Implant Complications, FDA official information (update June 16, 2020)

The breasts are uneven in appearance in terms of size, shape or breast level.

Breast Pain
Pain in the nipple or breast area.

Breast Tissue Atrophy
Thinning and shrinking of the skin.

Calcification/Calcium Deposits
Hard lumps under the skin around the implant. These can be mistaken for cancer during mammography, resulting in additional surgery.

Capsular Contracture
Tightening of the tissue capsule around an implant, resulting in firmness or hardening of the breast and squeezing of the implant if severe.

Chest Wall Deformity
Chest wall or underlying rib cage appears deformed.

Leakage of the saltwater (saline) solution from a saline-filled breast implant, often due to a valve leak or a tear or cut in the implant shell (rupture), with partial or complete collapse of the implant.

Delayed Wound Healing
Incision site fails to heal normally or takes longer to heal.

The skin breaks down and the implant appears through the skin.

Collection of blood near the surgical site. May cause swelling, bruising and pain. Hematomas usually occur soon after surgery, but can occur any time there is injury to the breast. The body may absorb small hematomas, but large ones may require medical intervention, such as surgical draining.

Iatrogenic Injury/Damage
Injury or damage to tissue or implant as a result of implant surgery.

Infection, including Toxic Shock Syndrome
Occurs when wounds are contaminated with microorganisms, such as bacteria or fungi. Most infections resulting from surgery appear within a few days to a week, but infection is possible any time after surgery. If an infection does not respond to antibiotics, the implant may need to be removed.

Response by the body to an infection or injury. Demonstrated by redness, swelling, warmth, pain and or/loss of function.

Lymphedema or Lymphadenopathy
Swollen or enlarged lymph nodes

The implant is not in the correct position in the breast. This can happen during surgery or afterwards if the implant moves or shifts from its original location. Shifting can be caused by factors such as gravity, trauma or capsular contracture.

Dead skin or tissue around the breast. Necrosis can be caused by infection, use of steroids in the surgical breast pocket, smoking, chemotherapy/radiation, and excessive heat or cold therapy.

Nipple/Breast Sensation Changes
An increase or decrease in the feeling in the nipple and/or breast. Can vary in degree and may be temporary or permanent. May affect sexual response or breast feeding.

The implant can be felt through the skin.

Breast sagging that is usually the result of normal aging, pregnancy or weight loss.

Bleeding at the time of surgery can cause the skin to change color. This is an expected symptom due to surgery, and is likely temporary.

A tear or hole in the implant’s outer shell.

Collection of fluid around the implant. May cause swelling, pain and bruising. The body may absorb small seromas. Large ones will require a surgical drain.

Skin Rash
A rash on or around the breast.

Unsatisfactory Style/Size
Patient or doctor is not satisfied with the overall look based on the style or size of the implant used.

The implant can be seen through the skin.

Wrinkling of the implant that can be felt or seen through the skin.


Complications are one of the reasons you must be extremely careful when select your plastic surgeon. Doing your homework in terms of surgeon selection is by far the most important choice you will make if you plan to undergo breast enlargement surgery.

American-Board Certified surgeons spend a very large part of their surgical training and maintenance of certification on how to adequately prevent, diagnose and effectively manage potential surgical complications. ABPS surgeons work very diligently and meticulously in order to prevent complications and utilize the most updated medical knowledge and current surgical techniques for this purpose. The rigorous evaluation and examination of doctors certified by the American Board of Plastic Surgery requires that all US-certified doctors undergo in-depth continuing medical education focused specifically on patient safety and clinical complication prevention and management. ABPS surgeons have profound knowledge on how to avoid complications and deal with them in the best way possible. ABPS surgeons use only FDA-approved medical devices and breast implants. Here at the HAPSI we also only use implants that have been fully approved by the FDA after the prolonged required process of research and data collection focused on patient safety.

Breast augmentation has been around for several decades and is the most common plastic surgery procedure. In addition many breast reconstructions with implants are performed annually worldwide. Whether used for augmentation, replacement, or reconstruction, the majority of breast implants used are silicone gel implants. By far most women with silicone gel breast implants are satisfied with their result and their decision to have this procedure and do not have issues. There is, however, an ongoing history regarding implant safety and possible link to disease, especially more recently with the usage of textured implants and their association with BIA-ALCL lymphoma.

Breast implants have been used since 1961. In the 1980s to 1990s, many women and the media blamed silicone breast implants as a cause for autoimmune disease and breast cancer. As a result in January 1992, the FDA prohibited the sale of silicone gel implants in the USA and only allowed saline implants until further research. In 1999 after extensive research analysis, the Institute of Medicine (renamed National Academies’ Health and Medicine Division) independent experts concluded that there was no link to other medical conditions such as cancer, connective tissue disease, autoimmune disease or other systemic illness. Simply put, these illnesses were “no more common in women with breast implant than in women without implants”. As a result, the FDA allowed silicone breast implants back on the market and in November 2006 when the FDA finally gave full approval for silicone implants made by Allergan and Mentor.

The post-approval ten year FDA study of Silicone Gel implants was completed in 2016. This was the largest study of breast implant outcomes to date. Below is the official statement of FDA as of October 2019 in relation to breast implants and other diseases:

“Some women with implants may have experienced health problems such as connective tissue diseases (such as lupus and rheumatoid arthritis), trouble breastfeeding, or reproductive problems. There is currently insufficient evidence to support an association between breast implants and those diagnoses.”

FDA, October 23,2019

“Breast implants illness” (BII)

Many patients ask if there is an association of breast implants with generalized illness symptoms like fatigue, joint pain etc. There has been extensive research on this subject as well and below please find the official statement of the US FDA :

“Additionally, some women have also reported health problems, such as fatigue, memory loss, rash, “brain fog,” and joint pain. Some patients use the term “breast implant illness” to describe these health problems, and some patients report that their symptoms have improved when the implants were removed. The symptoms and what causes them are poorly understood, and there is currently insufficient evidence to support an association between breast implants and symptoms referred to as BII. But researchers are investigating these symptoms to better understand their origins.”

However, there are some risks associated with all breast implants and you definitely need to know about the following three which are explained below in detail.

  1. Capsular contracture (increased scar tissue around the that may harden, move or squeeze the implant) which happens at a rate of about 5% of patients with breast implants.
  2. Breast implant associated-anaplastic large cell lymphoma (BIA-ALCL), which is a cancer of the immune system that happens very rarely to patients with textured implants. At the HAPSI we only place smooth implants for breast augmentation/uplift which have not been implicated to BIA-ALCL.
  3. Additional surgeries may possibly be needed in the future due to implant failure. Rupture (tears or holes in the shell) of silicone gel-filled implants (the risk is 1% per year so the cumulative risk in 20 years is 20%).

After breast implant placement, a thin layer of scar tissue forms around the implant which is like an internal thin sheet of collagen that surrounds the implant and stabilizes its position. This does not cause problems and it is actually a normal reaction of the body to any implant device, including implants used in other medical specialties like orthopedics etc. However in a small percentage of patiens (approximately 4-5 %), this capsule becomes thick and tight, causing the implant to become rigid and firm and the breast may become distorted. When this happens, it usually occurs in one breast only and there are several degrees of capsule formation depending on its severity. Specifically, there are four grades of capsular contracture as measured by the Baker scale:

  • Grade I: Soft capsule around the implant with no cosmetic distortion, and the breast is soft of minimally firm.
  • Grade II: There is noticeable hardening around the implant, but the breast cosmesis is normal.
  • Grade III: The breast is firm and starts to look cosmetically distorted or pushed up.
  • Grade IV: The breast is hard, sometimes causes discomfort or and visibly significantly deformed.

Most cases of capsular contracture develop within the first 2 years of the breast augmentation procedure. Although it is not a serious health issue that causes disease, capsular contracture is one of the most common complications with breast augmentation and you need to know about it.

The causes of capsular contracture are not entirely clear and it may occur as a result of a slight infection or hematoma around the implant following your breast augmentation surgery.

Capsular contracture prevention cannot be guaranteed, but there are several techniques that we use in order to minimize a patient’s risk of developing capsular contracture:

  • Strict sterile surgical protocol in order to minimize bacterial contamination
  • The use of the Keller Funnel in order to place the implant
  • Glove change before handling the implants
  • Extra betadine prep of the surgical field and incision before inserting the implant
  • Triple antibiotic irrigation of the implant pocket and the implants
  • Complete hemostasis during surgery and minimal blood loss at the surgical field.
  • Extremely gentle handling of the tissues and the breast implant.
  • Intravenous antibiotics during the procedure and oral antibiotics after the procedure in an effort to decrease the chances of subclinical colonization of the space around the implant.
  • Post-surgery massage or compression exercises as part of your aftercare.
  • Avoid large implants as they usually cause increased scar tissue reaction
  • Placing the implant under the pectoralis major muscle may discourage the growth of excessive scar tissue around the implant probably due to the decreased contact between the implant and breast tissue when this approach is used. This is not clear according to several recent studies that show that subglandular and submuscular have similar contracture rates.

The treatment of capsular contracture for mild cases (Baker I & Baker II) is usually conservative and includes focused massage of the breast in order to soften the capsule. Other non-surgical methods include closed capsulotomy (which we do not use or recommend), and oral medication like Singulair. These methods have been used with varying degrees of success. Recently, the possibility of using ultrasound to treat this difficult problem has come under evaluation. At this time, the main treatment for capsular contracture of advanced capsule (Baker Grades III and IV) is surgical, and generally involves removing the implants, removing the scar tissue, changing implant pocket (above / below the muscle) and placing new breast implants. Recent studies suggest that placing a special mesh called acellular dermis around the implant significantly reduces the chance for recurrence of the capsular contracture.

Recently, textured silicone gel implants (not smooth silicone implants) were implicated and linked to a rare form of cancer called Breast Implant-Associated Anaplastic Large Cell Lymphoma, BIA-ALCL. This is a rare cancer, usually curable with surgery and exclusively related to textured silicone gel implants and not smooth implants. BIA-ALCL symptoms may include breast enlargement, asymmetry, lump in breast or armpit, pain, overlying rash, breast hardening, or late larger fluid collection typically more than one year after implant placement. Diagnosis is made by analyzing the seroma fluid or by biopsy with specific CD30 immune staining tests. Fortunately, simply removing the implant and surrounding capsule (capsulectomy) is curative in most cases.

The only way to make the risk for BIA-ALCL zero is to place smooth implants which are the only types of implants we currently place at the HAPSI for breast augmentation and breast uplift.

For detailed official information for the public regarding BIA-ALCL, please follow the following link of the FDA:

Breast implants today are more durable than ever before as they have a solid and firm silicone outer shell. However, breast implants can rupture and there is about 1% rupture rate per year (therefore in 20 years there is a cumulative risk of 20%). This can happen due to stress such as pressure from capsular contracture or from mechanical trauma like an accident. Implants can also rupture due to the manufacturing issues although this is rare. Most implant ruptures happen 10 – 15 years after the initial surgery an if a rupture is suspected the surgeon must be informed promptly and a breast MRI must be performed as it is the best study to determine if it has truly happened. Ruptures can happen inside the breast capsule (intracapsular) or outside (extracapsular) which causes more significant body reaction due to the leaked silicone. As a ruptured implant often does not cause any symptoms there may be many women with ruptured implants and don’t know it.

Although breast implant rupture sounds very concerning, in reality there is no health risk to the patient. Modern silicone implants are cohesive gel implants (“gummy-bear”) and they do not drip down to include many tissues like older versions of silicone implants. Basically they rupture is seen during testing or is felt as a small soft lump. If a rupture is diagnosed, we definitely recommend complete implant removal and replacement in order to prevent possible infections or cosmetic issues.

Because there is a potential for leakage, we suggest that our patients come in from time to time so we can monitor the condition of their implants. As always, we encourage our patients to routinely monitor breast health as instructed by their gynecologist and through breast MRI. The FDA guidelines recommend patients to monitor their silicone implants with an MRI scan at 3 years and then every two years to make sure their implant is not ruptured.

ABPS surgeons and HAPSI surgeons use only FDA-approved breast implants. The FDA (United States Food & Drug Administration) is the regulatory authority for breast implant assessment in the United States. Implants become approved by the FDA after a long process of research and data collection regarding their structure and their clinical effect on the human body.

Long-term information

The implant position will not change over the years although they may move slightly downwards due to gravity. The main changes that you will notice will mainly have to do with your overlying breast tissue, fat and skin which will definitely change and the shape alterations depend on the amount of overlying tissue and skin. If you have small breasts and minimal skin, your overall breast shape will not change much. However, if you have significant amount of gland, fat and skin overlying the implant, over the years you may notice increased droopiness (ptosis). At some point you may consider a breast lift, in which case the implants will be left at the same position and will most likely not need to be changed. Therefore the duration of the results achieved through surgery are variable and meantime implants may require removal or replacement for other reasons like leakage.

There is no need to change your breast implants every 10 years if there is nothing wrong with your breast. If you’re happy with your breast augmentation and there are no issues, then you don’t need to have your implants changed. If there is a problem with your breast implant, you will notice it, feel it as a lump or you will find out by your diagnostic tests (MRI, mammogram or ultrasound).

Mammograms must be performed routinely (annually) after breast enlargement for women in the appropriate age range (usually over 40). The technician should be aware of your implants so that specialized techniques and possibly additional views can be taken if needed. Mammograms are generally not affected and modern mammography techniques are able to visualize your entire breast without problems. Also, there is no effect on breastfeeding or the ability to produce milk after a breast enlargement if an appropriate technique is used.

FDA guidelines recommend patients to monitor their silicone implants with an MRI scan at 3 years and then every two years to make sure their implant is not ruptured. As mentioned above, all women should undergo their regular screening mammography annually according to their age.

What is the fat transfer breast enlargement & the composite breast augmentation?

The isolated fat transfer technique for breast enlargement is indicated for women that want a small increase in size. Fat grafting, or fat transfer, has long been performed as a facial rejuvenation procedure for areas requiring volume restoration. More recently, fat grafting is a viable option for enlarging the breasts thanks to the improvements in fat harvesting and grafting techniques.

During the procedure, fat is harvested from a donor area like the abdomen by using liposuction. Once an adequate amount of fat has been gently aspirated from the donor area, it is prepared and then grafted to the breasts. Incisions are very small like needlesticks and most patients require only local anesthesia and intravenous sedation. The fat transfer process, although demanding for the surgeon, is fairly simple for the patient and requires little recovery time.

Immediately after natural breast augmentation with fat transfer, your breasts will typically appear larger than they will be after you’ve reached your final results, as about half of the fat that is originally grafted to the breasts will be reabsorbed by your body. The fat that remains provides a permanent natural breast enlargement result that offers an increase in breast size of about one cup size in each breast (from A to B size, from B to C size).

Fat transfer breast enlargement can potentially lead to over-absorption of transplanted fat and to contour irregularities or breast lumps. Other risks include localised fat necrosis, development of single or multiple cysts, calcium deposits and false-positive mammograms.

Composite breast enlargement is when we combine breast implants and fat grafting. The breast implant provides the main breast volume, but fat grafting conceals the implants and decreases implant visibility. This way you may have a smoother chest-to-breast transition and a more natural result and it’s mainly indicated for women that do not have enough breast tissue to cover an implant or if breasts are significantly asymmetric. Grafted fat can also be used to widen the breast or to correct the shape of tuberous breasts, since fat grafting can be injected where the breast is hypoplastic or constricted.