Of course, patients interested in breast augmentation would for the most part prefer a natural breast augmentation.  Does this mean the results look “natural” or that the augmentation uses natural tissue without implants?

Natural breast augmentation can mean:

1. Breast augmentation with structural fat grafting
2. Breast enhancement pills or creams (worthless in this plastic surgeons opinion)
3. Breast enlargement with a suction device (Brava device)
4. A natural appearing result with breast implants.

Of these, fat grafting is currently what most people are referring to when they use the term “natural breast augmentation”.

The idea is simple.  Fat and associated stem cells are harvested from other areas of the body and injected into the breast for augmentation.  Undoubtedly this works, but only to a small degree.   This is controversial and currently very few plastic surgeons offer this type of natural breast augmentation.

There are major problems with this procedure that need to be fully worked out before someone like myself would feel comfortable doing the procedure on a patient.

The most compelling issue is the diagnosis and treatment of breast cancer.   When the fat is injected there is always some of the tissue that does not survive the transfer.  This can lead to “fat necrosis” which could be confused with breast cancer on mammography.  This may lead to “too few” or “too many” biopsies of concerning areas.

Areas of fat necrosis could feel firm, defeating the goal of “natural breast augmentation”

The procedure, at best, results in a modest breast size increase.  In my experience, most patients who desire breast augmentation are looking for a more significant change than “natural breast augmentation” can afford.

Fat grafting is fickle and requires significant knowledge and experience to get it right.

I can not recommend “natural breast augmentation” at this time.  If you choose “natural breast augmentation”, please choose a board certified plastic surgeon who is comfortable with the procedure.  (There are very few).

Patient question:

Hi Dr. Yates, You do great work. What incision you prefer and why? Do you think periareolar incision has a higher chance of loosing nipple sensitivity? I saw most of your example are crease incision. Please also advise the BA fee, saline & silicone. Thank you.

Dr. Yates Reply:

Personally, I think of the three major decisions: 1) type of implant, 2) size of implant, and 3) location of scar, that the scar location is by far the least important.  As I am sure you have read I do not prefer the armpit or belly button incisions for their lack of accuracy, leaving the periareolar and crease incisions.  I used to believe that the periareolar incision had the opportunity to hide better because of the anatomic boundary between nipple and skin that you could hide the scar.  I think the crease is even a better anatomic boundary.  However, If the crease incision starts at the crease it usually ends up a little above it on the breast which is not desired.   It does take some skill and experience to allow the final scar to END UP at the crease.

Yes there is a slightly higher risk of issues with nipple sensitivity and also breast feeding with the periareolar incision.

The cost of breast augmentation in my office is $4100 for saline and $5200 for silicone.   My fee has not changed substantially in 6 years and it will likely increase at the first of the year when I audit my fee schedules.

Smooth round memory gel implants by Mentor are my current preferred choice for silicone implants.  I received a fax from the company yesterday that they have manufactured eight new size options.  Two of these are in high profile implants 475 cc and 750 cc.  Four of these are in a moderate plus profile 425 cc, 475 cc, 525 cc, 575 cc, 650 cc and 750 cc.

As opposed to saline implants, silicone implant come pre-filled.  Previously silicone implants came in 25 cc intervals starting at 100 cc to 450 cc in high profile and 400 cc in moderate plus profile.  Above that, the implants came in 50 cc intervals to 700 cc.  This meant that for patients choosing implants above 400 cc they would have to jump up considerably to the next size.  These new implants fill in some of the gaps giving patients and plastic surgeons more options.  Good job Mentor, but what took so long.

Accuracy is the key

There is a lot of discussion at the time of breast augmentation consultation regarding the scar.  In my opinion “where is the best place to hide the scar?” is an important question but an even more important questions is “through which incision is breast augmentation most accurate?”

There are three main incisions for breast augmentation, around the nipple, under the breast crease and in the armpit.  There are two other uncommon incision choices, through the belly button (TUBA) and through an abdominoplasty incision.

Implant pockets must be symmetric

The most important variable that determines the outcome of breast augmentation is the quality of the implant pocket created.  For perfect results, these pockets have to be perfect.  Not just close.

Although no plastic surgeon (including myself I hate to admit) could ever expect to achieve a perfect result every time, the odds are much better through incisions close to the implant pockets.   Those being the crease incision beneath the breast and the incision around the nipple.  The other incisions are great in theory but just not as accurate.

Rather than assessing the pocket size, spacing and symmetry with the surgeons gloved fingertips simultaneously, the pockets are assessed individually with a long instrument.

Imagine the task of simply writing your name.  The armpit incision would be the equivalent of holding the end of a 3 foot long pen.  The belly button incision would be the equivalent of a 10 foot pen in the dark.

Breast incisions are more accurate

The scars around the nipple and under the fold heal very well and are generally not bothersome to patients.  For saline implants, they are about 1″ long, for silicone about 3″.  If they are well placed they hide very well.  I do not charge for scar revisions and can count the number of these scars I have had to revise on one hand!

• Large implants on a short patient just make them look heavy.  Conservative sizing is important.
• Large implants on the very thin patients look “augmented”, top-heavy and generally overdone.
• Large implants are best suited for medium to tall height patients who have wide hips and larger lower bodies.
• Symmetry in nature is beautiful.  There was a recent study published in Plastic and Reconstructive Surgery that looked at body type.  Photos of the same woman were “morphed” at various heights and builds.  Patients with thin hips were found to be most beautiful with small to medium breasts and the opposite was true with fuller hips.  “The top should match the bottom”.

It can be very difficult for a patient to adequately communicate the final breast size that they are looking for, particularly when they often aren’t entirely sure themselves.  A few tools are available to help a patient feel comfortable with their decision

• Review pictures, look for patients with your similar build and breast size.  Record the size of implants they got and start making notes.
• There are commercial breast implant sizers available to wear in your bra.  You can wear them in different situations and with different clothing styles.  There are a few available, I have provided a link to one such sizer.  They cost about $60 and come with a bra and variety of sizers.
• 3D imaging is helpful to visualize the size on your body.
• If you don’t want to pay for sizers, simply filling plastic baggies with rice or water will do.  Measure the amount that gives you the result you are looking for.  A little less convenient but a good option.
• Make sure there are open lines of communication between you and your plastic surgeon.  Personally, I feel that natural looking augmented breasts are far superior to “done” or augmented looking breasts but that is only my opinion.  This is one place that I give a great deal of responsibility to the patient.  Of course, if they choose a size that I feel would be a problem we discuss the reasons for this.  Patients are generally good judges of what is best for them when armed with information.

Breast augmentation is a fairly routine procedure in most plastic surgeons offices.  There are risks associated with every procedure.  There are a number of steps that can be taken with breast augmentation to help to minimize these risks.

1) Unhappiness with size.  This one is largely the responsibility of the patient.  Although your plastic surgeon can recommend a certain size based on his perception of your goals and your body frame, in reality your goals may change after surgery.  Many women have fears about going too large before the surgery and as a result are conservative with their choice.  After surgery many feel they should have gone larger.  My recommendation would be to go as large as you feel comfortable.

As an editorial side note, I actually believe that most augmented patients choose a size that is too big for their frame.  Symmetry in nature is beautiful.  The circumference of the breast matching that of the hips is what I would consider ideal for any patient (take a tape measure and try for yourself).

2) Deflation/ rupture.  Saline implants deflate if they fail whereas silicone implants rupture.  For saline implants this risk can be minimized by overfilling the implant.  The deflation rate has been found to be much less significant in fully filled or over filled implants.  Under-filling or filling to only the minimum fill volume can lead to a “fold flaw” similar to a crease on a newspaper where the implants simply wear out from the repeated folding.

3) Rippling.  Rippling is a visible or palpable irregularity of an implant through the breast or skin.  Silicone implants are less likely to ripple because they hold their own shape better.  Additionally, overfilling saline implants helps avoid rippling as well.  Thin patients with small breasts generally have a higher risk of rippling and in some cases are better candidates for silicone implants to help prevent this

4) Capsular contracture.  There are a number of factors that lead to hardening of the breast over time.  Silicone implants are more likely to have contracture.  Low grade infection, hematoma, and placement above the muscle are also risk factors.  I prefer to give patients antibiotics before and after breast augmentation and I place the implants in an antibiotic solution before augmentation to help minimize infection risks.

5) Implant displacement.  The key is proper pocket formation.  For this reason I do not prefer the “remote” incisions; armpit or particularly the belly button.  They are simply less accurate.  Success should be measured in terms of millimeters with this operation.  The patient has some responsibility in this one as well.  In the first few weeks after surgery, over doing it can cause implant displacement and limiting aggressive physical activities for 6 weeks is important.

6) Nipple numbness.  This is actually quite uncommon in my practice.  Avoiding cutting along the course of the nerves to the nipple is the key.  Occasionally there will be temporary numbness from stretch of the implant over particularly large implants.

The two major manufacturers of breast implants are Mentor and Inamed (Allergan).  Both have an excellent lifetime warranty of their implants that comes standard.  Patients are automatically enrolled for the standard warranty.  Both also provide an additional “extended warranty” for an additional fee.  Mentor has an excellent new promotional program for their MemoryGel™ implants

Allergan Medical

Allergan’s standard program is called ConfidencePlus™

• Applies to all implants placed after April 1, 2002
• Automatic enrollment free of charge
• Lifetime product replacement
• Saline and silicone implants covered
• 10 years of financial assistance of up to $1,200 if replacement is necessary (for surgeon, anesthesia or facility fees)

Allergan’s extended program is called ConfidencePlus™ Platinum

• $100 enrollment fee
• Up to $2,400 financial assistance if replacement is necessary
• Replacement of the other implant at the surgeons’ request

Mentor Corporation

Mentor’s standard program for saline implants is called the Mentor Advantage Limited Warranty 

• Applies to all implants placed after May 1, 2005
• Automatic enrollment free of charge
• Lifetime product replacement
• Replacement of the other side at the surgeons’ request
• 10 years of financial assistance of up to $1,200 if replacement is necessary (for surgeon, anesthesia or facility fees)

Mentor’s extended warranty for saline implant is called the Mentor Enhanced Advantage Limited Warranty

• $100 enrollment fee within 45 days of surgery
• Up to $2,400 financial assistance if replacement is necessary

Mentor has a new program called the Mentor Premier Advantage Limited Warranty for MemoryGel™ silicone breast implants.

• Limited time offer May 1, 2009 to December 31, 2009
• Free of charge
• Lifetime product replacement
• Replacement of the other side at the surgeons’ request
• 10 years of financial assistance of up to $3,500 if replacement is necessary (for surgeon, anesthesia or facility fees)

If you have breast implants that have ruptured or deflated, they may be covered by the manufacturer.  You may file a claim by contacting the product evaluation department to see if they are covered.  The number for Allergan Medical to submit a claim is 800-624-4261.  For Mentor the number is 866-250-5115.