Making the Right Choice

By: Dr Gennaro Selvaggi
Created on 12th January 2010

Award-winning plastic and reconstructive surgeon,
Dr Gennaro Selvaggi explains how he guides patients into making the right choices when deciding to have a breast augmentation

Breast augmentation is the most commonly performed breast procedure, with probably more than 40 patients receiving this procedure daily in London. The surgical technique is very standardized, but still the surgeon's preference and the patient's wishes play a major role in the final outcome.

Before going ahead with this procedure, patients need to think about the following important points: implant size, natural versus fake look, scar placement, silicone or saline implants, the patient's anatomy, possible asymmetries, future plans.

Implant size
Smaller implants have the following advantages: a more natural look, less risk of rippling and delayed sagging of the breast over time, compared to bigger implants.

Apart from fulfilling the patient's desire to have very big breasts (e.g. 32DD, 34E), the only real advantage of having a bigger implant (bigger than 380 cc) is the possibility, sometimes, to avoid a nipple lift or a full mastopexy (uplift of the entire breast), when the nipple or breast is sagging because it is ‘empty' (mainly after pregnancy).

The bigger the implant, the worse the breast will look over time, because more thinning of the breast tissue will occur. Patients going for larger implants are more likely to have further surgery in future, with possible re-augmentation with smaller implants coupled with a breast lift (with extra scars). Many glamour models can be an example of this situation.

It is also important to be aware that a bigger implant, in the majority of cases, is not the way to avoid a mastopexy or breast uplift if that is what is required for that patient.

Natural versus fake
A more natural look is achievable in different ways: going behind the muscle (or with a dual plane technique), using a tear drop shape implant (for a minor number of patients) and using smaller implants.

The ‘stuck-on' look is mainly due to the implants being positioned in front of the muscle. Few patients prefer this more fake look, but they can have it if there is enough tissue on the thorax and breast to provide the implants with adequate coverage.

Sometimes, it is better to go behind the muscle, even with slightly bigger implants. Allocating the implants behind the muscle gives more protection to the implants and, subsequently, reduces the risk of rippling.

From a cosmetic point of view, going behind the muscle gives a better slope on the upper part of the breasts. However, if a round shape is desired then it can be achieved using round, slightly larger implants.

Scar placement
Most surgeons and patients agree that the inframammary scar (where the scar is placed in the crease underneath the breast) is the best incision. This incision gives good exposure to surgeons when creating the pockets for the implants and, from the patient's point of view, the scar is easily covered.

Peri-areolar scars (around the nipple) are also known to heal well, but patients are scared to lose nipple sensitivity, while scars under the axilla (under the arm) can be more prone to infection and give a sub-optimal view to the surgeon performing the procedure.

Trans-umbilical incisions (through the navel or belly button) have also been performed, but this procedure is done in a very limited number of places in the world, and has the following disadvantages: the procedure takes much longer, the pocket dissection is more complicated and only saline filled implants can be used.

Silicone or saline
Silicone implants are nowadays most commonly used. Silicone has been demonstrated to be very safe. Saline filled implants are limited to cases where a special skin expansion is needed (e.g. in some breast malformations or for reconstruction after breast cancer).

Patient's anatomy
The patient's breast and chest wall anatomy should be considered. In most cases, modifying a chest asymmetry is impossible and not worth doing.

Patients need to choose if they want to have more symmetrical breasts after a breast augmentation, or if they prefer to leave the differences between the two breasts as they are.

A difference in size can be ameliorated using different size implants or using saline filled implants; asymmetry in the areola can be corrected by lifting up or moving the original asymmetric areola.

If a major difference is present, with one breast being much more sagging than the other, a full mastopexy might be required. If not corrected, the asymmetry will just become more noticeable after a breast augmentation.

Future plans
It is important to discuss a patient's future plans, particularly if they wish to have children. Pregnancy and breast feeding has such an impact on a woman's breasts that if a patient needs to have a mastopexy or any work on asymmetric nipples done then it might be preferable to delay that aspect of surgery until after they have completed their family.

In conclusion
Generally, a surgeon should listen to the patient, and understand her wishes and life plan, then the surgeon should propose the available options, and then they decide together on the final surgical plan.
CS&AM