Breast augmentation is the most popular cosmetic surgery procedure performed worldwide [1–5]. Teenage patients may account for up to 4% of breast augmentation [6, 7]. Breast surgery for cosmetic reasons is not commonly performed on patients under 18 years of age, and it should be performed only after careful discussion with the patient and family [6].

Breast begins to form at 5–7 weeks of fetal development as a bilateral thickening of the ectoderm (mamillary line) which extends from the axilla to the groin and involutes shortly after forming [8–10]. The limited portion in the thoracic region of the embryo remains (at the level of the fourth intercostal space) and forms the basis for development of the neonatal breast [8–11]. The connective tissue of breast is derived from the mesoderm [10]. During normal development, the breasts remain quiescent until puberty (grows at the same rate as the body), and the growth begins usually at an average age of 11 years (8–13 years) [6, 8, 9]. Breast development (five stages by Tanner) is generally completed by 16 to 18 years of age [3, 6, 8, 11].

In adults, breasts are in position between the second and third and seventh and eighth rib; medially there is sternal edge and laterally midaxillary line [9, 10]. The portion of breast that projects into the axilla is termed the tail of Spence [9]. The nipple is normally located over IV intercostal space, laterally from the midclavicular line [1–3, 9, 10]. Beside the skin and subcutaneous tissue, the breast is made up of parenchymatous and stromal tissue [3, 9, 10].

The breast is supplied by a vascular network consisting of the internal mammary, lateral thoracic, intercostals arteries, subscapular, and thoracodorsal arteries [1, 3, 9, 10]. Sensory innervation has three major nerve distributions (anterolateral intercostals, medial intercostals, and the cervical plexus) [1, 3, 9, 10]. Multiple groups of lymphatics drain the breast, and it is parallel with venous drainage [9, 10].

Psychological and developmental characteristics of each patient have to be evaluated [3, 5, 6]. A careful medical history (earlier breast problems, breast Ca, allergic reactions) and physical examination (chest wall deformity, spinal curvature, asymmetry of breast size, nipple and inframammary fold (IMF) position) has to be performed for each patient [1–5]. Indications for augmentation mammaplasty in pediatric population are breast hypoplasia (unilateral and bilateral), breast deformity as a part of Poland’s syndrome, tuberous breasts, and failure of breast development due to a trauma [8, 11, 12]. Cosmetic indications are extremely rare [6].

Preoperative markings are made with the patient in the upright position, using the IMF, the nipple areola complex (NAC), and the suprasternal notch as key landmarks [2, 4]. The breast width (BW), the breast height (BH), the distance from the NAC to the inframammary fold, the distance from the suprasternal notch (SSN) to the NAC, and the intermammary distance (IMD) have to be measured [2].

Both the patient and the parents have to be informed about the risks, benefits, and treatment alternatives [1–3]. Pediatric patients in most cases want to have natural appearance of the breasts [6–8, 12].

There are two implant materials: saline- and silicone-filled implants [1, 2, 4, 5, 13]. Implants are round and anatomical, with wide variety in width, height, and projection [2, 4, 5, 13]. Essentially there are two types of round implant shell: smooth and textured [2, 4, 5]. Anatomic implants are all textured by design (to minimize malrotation) [2, 5].

Breast augmentation in pediatric population can be performed for either unilateral or bilateral deformity, and basic approach is similar to adults [1–6, 8, 12]. There are four distinct variables requiring decision in the preoperative process: implant type, implant size, incision location, and pocket plane [1–5, 14]. Three types of incision are commonly employed in breast augmentation, transaxillary, inframammary, and periareolar, and each approach has its own advantages and disadvantages [1–5, 14]. Transumbilical approach is only possible with empty implants that are inflated [2, 4, 5, 14].

The inframammary approach is most popular since it permits complete visualization of the implant pocket (for both subglandular and subpectoral plane), and it allows any type of secondary surgery (Fig. 4.1a–e) [1–5, 14]. The incision should be placed in the predicted location of the new inframammary fold, mostly lateral to the breast midline [1, 2, 4]. For patients with significant hypoplasia, placement of the incision can be difficult (Fig. 4.2a–d) [4].