Breast augmentation with implants is arguably the most important advance in the history of cosmetic plastic surgery [1]. Breast augmentation is one of the most satisfying procedures for both the patient and the surgeon in its almost magical ability to transform human shape. Gratification is often immediate. About one-third of all women are dissatisfied with the appearance of their natural breasts [2].

In part because of its success and popularity, no plastic surgical procedure has received as much public attention, and scrutiny, as breast augmentation. Breast augmentation decreased in popularity in the early 1990s because of media attention regarding the safety of silicone gel implants and the moratorium on silicone gel implants imposed by the US Food and Drug Administration from 1992 to 2006. In the last decade, breast augmentation has regained its popularity, replacing liposuction as the most commonly performed cosmetic surgery operation in the United States [3].

The procedure is by no means perfect. Complications are common and test the patient–physician relationship. Appropriate management of complications is important because the alternative, deflated breasts, is aesthetically unacceptable. Accordingly, this subject is given its own chapter (Chap. 4).

Patient-reported perceptions of the surgical result, including patient satisfaction and changes in quality of life, are essential components of any outcomes assessment [4–6]. Prospective studies of consecutive patients with high response rates are preferred so as to avoid selection bias [7, 8]. Large sample sizes increase statistical power and improve reliability [9]. Perhaps surprisingly for such a popular procedure, there is limited information available from prospective outcome studies of breast augmentation [2, 10–15]. Patient-reported outcome data are either absent [16–19] or limited to overall patient satisfaction scores [20] in published reviews of breast augmentation. It is difficult to reasonably discuss ways to optimize outcomes without such outcome data [6]. Surgeon-reported complication and reoperation rates do not provide this needed information [6].

Cash et al. [2] published the first large prospective study of 360 breast augmentation patients. Unfortunately, there was no discussion of how the participants were chosen and the inclusion rate. Banbury et al. [10] mailed questionnaires to 47 patients and received responses from 25 patients (response rate 53%). Niechajev et al. [12] compared two silicone gel implant brands in 74 patients. Recent studies using the BREAST-Q questionnaire [10, 14, 15] have important methodological limitations (discussed in more detail in Chap. 1) [21]. None of these studies evaluates consecutive patients.

The response rate for mailed surveys is typically low, in the range of 49–66% [13, 22–25], with various levels of completion. Existing generic breast questionnaires may lack sufficient specificity to assess the psychological impact of surgical changes [4, 26]. Quality-of-life measures typically focus on physical symptoms rather than on cosmetic concerns [11]. A commonly used self-esteem scale may be too generalized to detect changes related to the breasts [11, 23]. The BREAST-Q [5] provides three general indices: breast satisfaction, psychological well-being, and sexual well-being [13]. Not surprisingly, breast augmentation patients show improvements in these categories [13–15]. However, many procedure-related questions that may be of clinical interest to the patient and surgeon remain unanswered [6].

Women often inquire as to how much pain to expect and the length of recovery. Limited patient-derived information is available from published prospective outcome studies [2, 10–13]. Implant size and feel characteristics are major preoperative concerns of patients; yet, there is a lack of prospective outcome data evaluating patient satisfaction with either breast size or firmness after surgery in consecutive patients [6]. Nipple sensation is important to women but is often overlooked.

To remedy these deficiencies, the author undertook a prospective study evaluating breast augmentation from the patient’s perspective [6]. Using an in-person interview, an 80% response rate was achieved, satisfying the benchmark for evidence-based medicine [7], with all questions answered in almost every survey. The average survey duration was 11 min (range 3–30 min). Remarkably, survey participation among eligible patients who returned for follow-up appointments at least 1 month after surgery was 100%.

Follow-up times in the author’s study were comparatively short (mean 4.5 months) [6]. Short follow-up times were tolerated to optimize the response rate. Longer follow-up times are generally preferred so as to detect any late complications and to assess the result once swelling has subsided [6]. However, insistence on a long minimum follow-up time, for example, 6 months, lowers the inclusion rate. Cosmetic surgery patients are notoriously unreliable in keeping long-term follow-up appointments, particularly for research purposes [23]. A 37% attrition rate at 1 year is typical [23]. A lower inclusion rate invites selection bias, because the experience of patients returning in long-term follow-up is unlikely to be representative of all patients. Selection bias violates a major provision of evidence-based medicine [7]. Minimizing exclusion criteria is recommended to avoid losing essential patient data [8].

Measurement studies show that postsurgical changes in breast shape occurring after 3 months are minimal [27, 28], suggesting that at 3 months swelling has resolved sufficiently for the purpose of measurements, although settling will occur over the long term. The lack of a significant correlation between measurements of breast shape and follow-up times suggests that at 3 months the swelling has sufficiently resolved so as not to constitute an important confounding factor [28]. Therefore, 3 months would seem to represent an appropriate balance of inclusion rate and follow-up time.

The mean time that women consider a breast augmentation before having the surgery is >5 years [6], indicating that the decision for most patients is not an impulsive one. Few women (0.4%) report having the surgery to please her partner; the majority have the surgery for their own reasons [6, 22].

Surgery is performed by the author on an outpatient basis in a state-licensed ambulatory surgery center using total intravenous anesthesia and a laryngeal mask airway. This type of anesthesia avoids intraoperative hypotension and preserves the calf muscle pump, reducing the risk of venous thromboembolism [29, 30]. Patients presenting for cosmetic breast surgery participate in a clinical trial [31] investigating the natural history of deep venous thromboses in plastic surgery patients using Doppler ultrasound screening performed preoperatively, the day after surgery, and approximately 1 week after surgery [32]. Chemoprophylaxis is not used. Patients typically receive cefazolin 1 g IV preoperatively followed by three doses of cephalexin 500 mg p.o. q12h.

The local anesthetic solution injected into the breasts consists of 50 cc of bupivacaine 0.5% with 1:200,000 epinephrine, 50 cc of lidocaine 1% with 1:100,000 epinephrine, and 100 cc saline, resulting in a concentration of lidocaine of 0.25%, bupivacaine 0.125%, and epinephrine 1:300,000 [33]. The usual volume infiltrated into each breast is 60–100 cc. No pocket irrigation is used, other than saline. Nadeau et al. [34] recently published a randomized study comparing bupivacaine with liposomal bupivacaine (Exparel Pacira Pharmaceuticals, Inc. San Diego, CA) in subpectoral breast augmentation and found that liposomal bupivacaine was marginally more effective but not worth the extra cost according to 70% of surveyed patients. A 20 cc bottle of bupivacaine costs about $1 versus $285 for the same volume of liposomal bupivacaine [34]. Notably, the authors [34] administered these agents in the form of irrigation of the pocket prior to wound closure rather than by injection. Standard, nonliposomal bupivacaine injected in dilute form into the breast tissue is absorbed into fat cells and gradually released, acting as a “physiological pain pump [35].”

A recent survey [36] found that the majority (83.9%) of members of the American Society of Plastic Surgeons prefer an inframammary incision for implant placement. A periareolar approach is favored by 12.6% of respondents, and only 3.3% prefer an axillary approach. The umbilical approach, which cannot be used for secondary surgery [20], has few advocates (0.2%). The transareolar and trans-nipple approaches may be used in cases of coexisting nipple protrusion or inversion (Fig. 3.1).

The vast majority (92.2%) of surveyed plastic surgeons prefer a submuscular pocket for implant insertion [36]. Only 5.4% of surgeons report that they most commonly use a subglandular pocket. A subfascial dissection [63], preferred by 2.4% of respondents, remains unpopular [36]. The fascia is much thinner than the pectoralis muscle, providing little additional soft-tissue coverage of the implant [63]. Most plastic surgeons partially (and cautiously, to avoid symmastia [20]) release the lower sternal origin of the pectoralis muscle (Fig. 3.19) [20, 64, 65] to avoid a wide intermammary space (Fig. 3.14).

Moderators at meetings frequently ask panelists which plane they prefer for breast augmentation. The usual choice is subglandular or subpectoral. However, many surgeons today respond “dual plane ”; others (the author included) respond “subpectoral,” which is synonymous with submuscular or retropectoral. “Dual plane” sounds more sophisticated. What exactly does “dual plane” mean?

When an implant is placed subpectorally, about two-thirds of the breast implant is covered by muscle; the inferolateral portion remains subglandular simply because of the triangular shape of the pectoralis major [64]. Total submuscular placement requires elevation of the serratus anterior and rectus abdominis muscles, limiting lower pole expansion, and is not recommended [20, 65]. Compared with subglandular augmentation, subpectoral implant placement achieves greater tissue coverage, a more natural appearance of the upper pole [20], less wrinkling [66], and possibly less risk of capsular contracture [20, 65–67]. However, subglandular placement may be a valid alternative, particularly in women with adequate breast tissue, and it avoids an animation deformity. Distortion of the breast during pectoralis muscle contraction is common (77.5% of patients) after a subpectoral breast augmentation, but rarely severe [68]. Nevertheless, this possibility should be discussed with patients, especially those for whom daily exercise is part of their lifestyle or livelihood (e.g., fitness enthusiasts, body builders, personal trainers).

Tebbetts’ dual plane modification was meant to free plastic surgeons from having to choose between subglandular and submuscular implant placement [66]. In his words, one could “combine retromammary and partial retropectoral pocket locations in a single patient to optimize the benefits of each pocket location while limiting the tradeoffs and risks of a single pocket location” [66]. In theory, surgeons could have their cake (a submuscular plane) and eat it too (still expand the breast skin envelope to treat women with glandular ptosis). In all patients, the implant is placed subpectorally. In Type 1 , there is no prepectoral dissection, so that Type 1 (representing 60% of patients [66]) is not really a dual plane dissection. In Types 2 and 3, a prepectoral dissection extends around the pectoralis border to the level of the inferior (Type 2) or superior (Type 3) areola margin [66].

Conceptually, a subglandular implant might be expected to expand a deflated skin envelope without being limited by the pectoralis muscle, avoiding a snoopy deformity (sometimes inaccurately called double bubble ), which is characterized by breast tissue that appears to slide off the implant [39]. In practice, however, even large implants fail to prevent a snoopy deformity in women with glandular ptosis [39]. These women are more effectively treated with an augmentation/mastopexy [28, 39].

Tebbetts [66] believes that a partial prepectoral dissection elevates the pectoralis border, improves breast shape in patients with glandular ptosis or constricted lower poles, and also elevates the nipple. Gryskiewicz [69] promotes this approach for the treatment of women with mild ptosis, the “in-between” patient. An unfilled prepectoral dissection plane is likely to scar together shortly after surgery [70]. It is possible, although unproven, that the pectoralis border moves up as a result of the dissection. It remains unclear whether breast shape is affected by elevating the pectoralis border. In a patient treated with a traditional subpectoral dissection (Fig. 3.20), horizontal and vertical breast dimensions are substantially increased, but the nipple is only slightly elevated. These changes are similar to a patient treated with a Type 3 dual plane dissection (Fig. 3.21). There is no evidence that the pectoralis muscle, released at the inframammary fold and partially released from its lower sternal origin [64], restricts breast expansion [70].

In a cadaveric study, Sanchez et al. [71] found that the width of the pectoralis muscle at its origin is variable and narrow, and its medial border is typically <1 cm from the midline, leaving little margin for error when releasing the muscle. The authors [71] recommend preserving the sternal fibers and releasing the inferior portion of the origin instead, as recommended by Tebbetts [66]. The incidence of symmastia in my own series, which included cautious release of the lower sternal origin, was 1/522 (0.2%) [72].

A recent survey [36] interpreted dual plane responses as synonymous with subpectoral; the methods do appear equivalent in their effect on breast shape (Figures 3.20 and 3.21). Dual plane, which implies two planes, is really a misnomer – the implant inhabits only one plane [70]. A plane that starts under one tissue and continues under another is not a dual plane . For example, a sub-superficial musculoaponeurotic system (sub-SMAS) facelift dissection starts subcutaneous and continues under the SMAS. Surgeons call it a deep plane, not a dual plane.

In secondary breast augmentation , the pocket is usually expanded superiorly to accommodate the new implant at a higher level on the chest wall. Implants typically settle over time, or the patient may request a larger size. By using a supra-IMF approach and judiciously releasing the inferior and lower sternal pectoralis origin, the implant may be correctly situated slightly high on the chest and allowed to settle [40]. A common error is placement of the implant at the desired level without taking into account the normal implant settling and the expected downward migration of the inframammary fold [73]. Reoperation for implant malposition is unusual (1%) [72]. Importantly, this approach avoids the double-bubble deformity.

Two recent studies describe suture techniques to control the inframammary fold [37, 74]. Campbell et al. [74] use 3-0 Vicryl (Ethicon, Somerville, NJ) deep fascial sutures to reinforce the IMF and report no complications in 600 patients and implant malposition in fewer than 1% of patients. Similarly, Montemurro et al. [37] describe a “stable reset” of the IMF, using Quill barbed sutures (Surgical Specialties, Wyomissing, PA). These authors [37] report that 1.15% of their 436 patients experienced bottoming out and 1.38% had a double bubble , although the patients were evidently nonconsecutive and the inclusion rate was not reported [75]. Neither study [37, 74] used measurements or compared their results with controls.

It is uncertain whether large sutures, such as slow-absorbing 0 PDO Quill [37], are beneficial. Wounds are known to heal by a “one wound” concept [76], not respecting tissue layers. Scar tissue seems to morph (cheese-wire) around sutures. At reoperation, permanent sutures are typically loose [77]. The strength of the bond depends on the scar tissue, not the suture [78].

Measurements reveal that the IMF drops after breast augmentation (Fig. 3.22) [73]. Three months after surgery, it has descended 0.71 cm on average (range 0.06–1.55 cm) in patients treated with smooth, round, subpectoral saline-filled implants inserted through an inframammary incision, and no extra reinforcement [73]. Textured implants are designed to adhere to local tissue and resist movement [79]. However, reports of bottoming out in some patients [37] and photographs (Fig. 3.23 and Fig. 3.27) suggest that textured implants do settle [40].

In truth, the operator may have little control over the descent of the IMF [40]. The IMF descends gradually (Fig. 3.22). A recent cadaveric study introduces rib fixation using absorbable anchors [80]. In view of the dynamic nature of the IMF [73], a static repair may appear unnatural over time. Reinforcement of the IMF potentially increases the risk of hematoma or implant damage [74], and causes more patient discomfort [37].

Examples of implant settling are provided in Figs. 3.24, 3.25, 3.26, and 3.27.

Breast size is a primary concern for women undergoing breast augmentation [6]. Limited information is available regarding patient assessment of postoperative breast size [12, 81, 82]. The mean implant size for my study patients was 390 cc (Figs. 3.28 and 3.29) [83], very similar to the mean implant volume reported by Lista et al. (385 cc) [84]. Breast implant manufacturers report that the average breast implant volume is approximately 390 cc, and most women choose a larger size when undergoing implant replacement (Sarah Eason, sales representative, May 2016, Mentor Corporation (Mentor Corp., Santa Barbara, CA), Personal communication; Jeff Shoenfeld, sales representative, May 2014, Allergan Incorporated (Allergan Inc., Irvine, CA), Personal communication). Although breast size has long been a source of controversy for surgeons [85, 86], most patients prefer convexity [87]. In my study of 225 patients (mean implant volume 390 cc) [6], only three women (1.4%) would have preferred a smaller size, versus 29 patients (13.2%) who would have preferred a larger size. By contrast, a multicenter study of saline-filled implants reported that 23.3% of women treated with a mean implant size of 275 cc would have chosen a larger volume [81]. The data clearly support the use of breast implant sizes that exceed conventional recommendations that, for example, implant size should generally be limited to approximately 350 cc, ostensibly for the patient’s benefit [85]. Indeed, plastic surgeons have been paternalistic in telling patients what size is best for them, rather than having their patients inform them [6, 83]. Figure 3.29 shows the distribution of breast implant sizes in 225 patients. The bell-shaped curve reflects a normal distribution and is characteristic of many biological parameters, such as height, weight, or body mass index.

Many experienced plastic surgeons insert implant sizes as high as 800 or 900 cc in some patients [47, 84]. Approximately 1% of my patients choose implants of this size. Clinical decisions rest on the risk-to-benefit ratio . Even if there were an increased risk (which has not been demonstrated), women who desire larger breast sizes may be willing to trade more risk for more benefit. Surgeon size prejudices should not keep them from achieving their goals; it is their choice after all [83]. Of course, it may not be possible to achieve an extreme breast size in one operation. In a thin, nulliparous woman with very small breasts and no ptosis, it may not be possible to exceed a volume of approximately 450 cc [83].

Transgender patients (Figs. 3.30 and 3.31) perceive the breasts as a strong image of the female gender [88]. Not surprisingly, larger than average implant volumes are usually indicated, and a second operation may be needed to obtain the desired size (Fig. 3.31). These patients report high levels of satisfaction after surgery [88].