Breast augmentation is one of the most popular aesthetic procedures performed in the US where over 300,000 of these procedures are done annually. Many patients perform a great deal of research prior to meeting with me, but others appear to be making the decision to proceed on a whim! My goal is to help anyone considering this procedure to be fully informed about their options. Many of the early decision that are made about your procedure can have a tremendous impact on how long you enjoy your first set of breast implants.

Did you catch that last line? Yes, I said, “your FIRST set of implants.” It is a fact that most women that choose to have breast augmentation ultimately have more than one breast implant related surgery during their lifetime. In fact, revisions rates are reported to be as high as 20-40%. When I read statistics like that, I wonder why anyone has the procedure done! To be clear, I am not going to write here about implant durability issues. Those have improved a great deal over the last fifteen years. This article is about making pre-operative decisions that reduce your likelihood of needing near term breast implant revisionary surgery for reasons unrelated to implant durability issues. Implant malposition, scar tissue, excessive tissue thinning, rippling and breast drooping are the issues at hand.

The easiest thing to prevent is breast implant malposition because most malposition occurs because the original implant that was selected was too big for the patient’s frame or tissues. Many surgeons are still willing to put in whatever size implant a patient requests. If the implant moves into an unfavorable position, they assume the patient will come back to them and have another surgery. I prefer to spend time educating my patients about why bigger isn’t better. Should they choose to disagree and seek treatment elsewhere, I am ok with that.  In some cases, patients have come back to me FOR their revisionary surgery after I warned them about going too big at the outset. It has been proven that implants larger than 350 cc’s have an inordinately higher incidence of dropping below the fold under the breast or moving out to the side, widening the cleavage gap. This of course can depend on the patient’s frame and quality of tissues. Seek a surgeon who measures and assesses your tissues very carefully before suggesting an implant size range for your consideration.

Scar tissues development around implants is called a capsular contracture. It can make the breast feel firm, cause pain, or distort shape. It is now felt to be caused by bio-film, or small amounts of bacteria tracked onto the implant at the time of insertion. This occurs more commonly when implants are inserted through the armpit or nipple, or are placed on top of the muscle. Ask your surgeon about their protocol to attempt to prevent this problem as there are well-established steps that should be employed intra-operatively. If they don’t seem to have a protocol in place, move on.

Excessive thinning of tissues can be present pre-operatively, or can be caused by large implants, especially if they are placed on top of the muscle. In patients with extremely thin tissues, extreme caution has to be utilized in selecting implant size, type and position. Frank discussions should be had about the likelihood of visible rippling in the short and long term. The potential use of scaffolds that can be inserted at the time of breast augmentation to lessen the likelihood of rippling should be discussed.

Finally and my least favorite type of pre-operative planning mistake is when patients are told they can avoid a breast lift if large implants are placed on top of the chest wall muscle. Think about this for one second. If you put a bowling ball in a sock, does the bowling ball stay up, or does it drop to the lowest point possible? Skin is stretchy and adding weight stretches it faster. Any lift you get from an implant on top of the muscle is very short-lived. Not only will a lift be required down the road, but it will be more complicated (think more expensive) after the first surgery was done in this manner.

Safety and prevention of complications and revisions are my top priorities when providing a surgical treatment plan to potential breast augmentation patients. Do your homework and get it right the first time! You will be happy you did.


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