Breast Enhancement Incision Options
Inframammary Incision (underneath the breast)
AdvantagesIt is the easiest approach for the surgeon. It provides very good access to visualize the pocket and to treat bleeding points. Saline or silicone gel implants can be placed through this incision.
DisadvantagesThe scar can be more noticeable because of stretching. Tattooing may be required to camouflage the scar. There is a slightly higher tendency for the inframammary fold to be undermined and create a deformity of the fold (“double bubble”).
AdvantagesThe final scar usually blends in well with the change in color from the areola pigment to the native breast skin. This approach gives good visualization of the pocket. Many breast deformities and asymmetries can be treated through this approach. There is usually good visualization to design the pocket, to treat bleeding points, and to divide the pectoralis muscle if placing implants in a subpectoral pocket or creating a subglandular pocket. Also, less likely, to undermine the breast fold and create a deformity of the fold (“double bubble”).
DisadvantagesSometimes the scar is noticeable and may require tattooing to better camouflage the incision. If the areola is too small it may not be of adequate size to allow for placement of a saline or silicone gel implant. Saline implants can be placed through a smaller areola than silicone gel implants.
Axillary Incision (armpit)
AdvantagesThe incision is not on the breast.
DisadvantagesThe scar can be noticeable when the patient raises her arm. This approach is found to have a higher breast implant malposition rate (especially when performed bluntly without endoscopic visualization). Sometimes it is difficult to gain control of potential bleeding sources from this remote access. It can be very difficult to use this incision for placing silicone gel implants. Tattooing of the scar may be necessary to camouflage it better.
Transabdominal Breast Augmentation (TABA)
AdvantagesThere are no incisions on or near the breast. There is usually good visualization of the pocket and bleeding points. Because an adequate sized tunnel from the upper abdomen to the chest is created, saline or silicone gel implants can be placed through this incision.
DisadvantagesIt is only performed in women without significant ptosis (drooping) of the breast, and who also desire a full tummy tuck. For more information on understanding a TABA, or help deciding if it is for you, visit our blog.
Transumbilical Breast Augmentation (TUBA)
AdvantagesThere are no incisions on or near the breast.
DisadvantagesIt is difficult to visualize the breast implant pocket. If there is any bleeding, an inframammary or periareolar incision needs to be performed to gain access for treatment. Saline implants are the only type of implants that can be placed through this incision; therefore, silicone gel implants cannot be placed through this incision.
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Types of Breast Implants
Textured vs. Smooth ImplantsThere are many different varieties of implants available for New York City patients. There are smooth outer shell implants and textured outer shell implants. Textured implants were created to minimize the risk of capsular contractures that can develop after breast implant placement. The plastic surgery literature has conflicting reports about the efficacy of textured implants. In fact, with regards to capsular contracture rates, many plastic surgeons feel that there is no difference between textured and smooth implants. Some surgeons have reported that textured implants are more prone to develop noticeable ridging when implanted.
Round vs. Anatomical (Biodimensional)Breast implants come in two shapes. Round implants are obviously round with no polarity (meaning no “up or down” position). Anatomical, sometimes referred to as biodimensional, have a “teardrop” shape to the implant. The anatomical implants were created to give a “more natural look” to the breasts, giving some upper pole fullness as well as a full lower pole. These implants have to be placed precisely in the breast pocket. This type of implant does have a polarity (an “up or down” position), and unfortunately has been known to turn. When the implant turns, it can make for a very unusual looking breast.
Subglandular vs. Subpectoral PocketIn general, there are two breast implant pocket locations. The implants can be placed in a subglandular pocket, which is the space between the breast tissue and the underlying pectoralis muscle. The subpectoral pocket is located below both the breast tissue and the pectoralis muscle. Usually, in positioning breast implants in the subpectoral pocket, the inferior and lower medial portion of the pectoralis muscle is detached. So, actually the implant is not completely covered by the muscle. Usually the muscle ends up covering approximately 50-80% of the implant with the remaining breast tissue covering the lower 20-50% of the implant. A recommendation for implant pocket positioning often depends upon the individual patient anatomy. For the majority of patients that have very little breast tissue, a subpectoral pocket is usually recommended. This is because the implant is usually more palpable without adequate soft tissue coverage. The muscle adds another layer of soft tissue to camouflage the implant. Furthermore, the subpectoral pocket is often favored, because it is believed that the capsular contracture rate may be lower than a subglandular location. A subglandular pocket location is often preferred when there is adequate breast tissue volume.
Implant Shape and SizeThere are many different shapes and sizes of implants, which allows for proper selection of the implant to match for the varying shapes and sizes of the patient’s chest. Chest wall base diameter varies; this along with patient cup size volume will impact the choice of implant chosen for a given patient. That is why the manufacturers of the breast implants have moderate profile implants, moderate plus implants, and high profile implants.
Saline vs Silicone Breast ImplantsSince the FDA approval of silicone gel implants in 2006, Dr. Wallach has been offering silicone gel implants in New York City along with saline-filled implants in Manhattan to all his breast augmentation patients. Dr. Wallach, a New York City Plastic Surgeon, was a principal investigator in the original FDA approved study to use silicone gel-filled breast implants under specific criteria. He was also an active participant in the post-approval study for gel implants. Saline and silicone implants are very safe devices. If a saline implant ruptures, the sterile salt water will be absorbed by the patient’s body and the breast will appear flatter. One major disadvantage of the saline implant is that it is more palpable than a silicone implant. The silicone gel implant feels more natural than a saline implant. This more natural feel permits a greater number of silicone gel implants to be placed in a subglandular pocket, more so than the saline implants. However, if a silicone gel implant ruptures, the gel has to be removed along with the ruptured implant.
Form-Stable Cohesive Gel ImplantsForm-stable cohesive gel implants are also called “Gummy Bear” breast implants. These are implants that are silicone gel but are cross-linked a bit differently than the more common gel implants so that they are more cohesive or solid for the breast augmentation procedure. Therefore, if the implant shell ruptures, the gel inside will be stable in shape and will not ooze or leak. In fact, when the implants are cut with a scissor for demonstration purposes, the gel does not leak, it acts like Jello when sliced. All three major manufacturers of breast implants have a form of form-stable cohesive implant. The two more popular implants being studied include Mentor’s CPG anatomic shaped implant, and Allergan’s Style 410. The implants are textured and have a teardrop shape. They are still not approved for general use and are only being used for research. Sientra is another breast implant company, and they were recently given FDA approval to sell their cohesive gel implants. Advantages- no oozing if the implants rupture, there is potential for less rippling, and they may maintain their shape better than the less cohesive gel implants. Disadvantages- they may rotate on their side, they require a longer incision to insert them in the pocket, they feel less natural as compared to less cohesive gel implants, and they are more expensive than the less cohesive gel implants. A breast augmentation New York City procedure usually takes between one and two hours with a recuperation of about one week. Patients are instructed to avoid aerobic exercise for three weeks and heavy lifting or strenuous exercise for six weeks. This is to minimize the risk of early problems with the implants such as hematoma (blood collection) formation. Dr. Wallach has presented his findings and has written several papers on the subject of breast augmentation and limited access surgery in several peer-reviewed plastic surgery journals. Dr. Wallach has also given an instructional course to fellow plastic surgeons on his preferred techniques of breast augmentation at the American Society of Aesthetic Plastic Surgery (ASAPS) national meeting. If you would like more information about Dr. Wallach and his success with New York City Breast Augmentation procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.
Frequently Asked Questions about Breast Enlargement
What is the difference between a breast lift and augmentation?
Many patients who have sagging breasts come into the office desiring breast implants thinking that adding volume to the breasts may also lift them. However, implants mainly add volume. They do not lift the breasts to any significant degree. The nipple areola complex will often stay close to the same position as where it started. If a patient has sagging breast tissue and the nipple areola complex is low, then a formal lift is most likely required. There are patients that can benefit from a breast augmentation and only need a small lift of the nipple areola complex. In those cases, I often do a circumareoolar lift, or what some refer to as a doughnut mastopexy. It is a nice procedure that can help balance asymmetries for some women, but again it has to be for the right indications. More formal lifts may employ a lollipop incision often using a vertical pedicle, or in those patients with a lot of loose skin, an inverted T or anchor incision is used. It is definitely tailored to the different individuals needs and discussed at the time of consultation.
Am I a good candidate for a breast augmentation?
In order to determine if a patient is a good candidate for a breast augmentation, they would need to be seen in the office and have a formal physical examination. During the exam, I want to learn about the goals of my patient to determine what size implant might be appropriate for her. We discuss the different options including shapes, sizes, textures, and contours of the various implants. Discussion of the various differences between saline and silicone implants are discussed as well. We review pocket placement, incision design, and various nuances based upon an individual’s anatomy. Most commonly, patients come in with hypomastia, or in lay terms small breasts, and desire larger breasts. This is common in the younger patient in their early 20’s. I also see many women who have had children and their breasts have changed and sometimes become involuted. They commonly want more volume to restore the breasts as they looked prior to pregnancies. This is often in patients in their 30’s and early 40’s. But I have seen women who are older that want larger breasts as well.
Should I get a breast augmentation?
I think that deciding to undergo a surgical procedure requires a lot of thought. Fortunately, breast augmentation is a very safe procedure and I would say that patients are usually very happy they elected to have this done. I think that one has to do their research. They should learn about the types of implants available, the incisions used, the pocket position, and the potential risks, to name a few. Just as important, the patient has to find a doctor and his staff that she feels comfortable with and feels will give her a good result and proper preoperative and postoperative care. This may require a patient to meet with several doctors before deciding on a specific surgeon.
Are silicone implants better than saline implants?Both saline breast implants and silicone breast implants are excellent products. The FDA has approved the use of silicone gel filled implants in adults 22 years of age or older. There are advantages and disadvantages to both. Saline implants can be placed through a smaller incision than silicone implants because they are inflated inside the breast pocket. Minor volume discrepancies between the two breasts can be adjusted by filling the saline implants with different volumes of fluid, but yet using the same shaped implants. If a saline implant deflates, the sterile saline water gets absorbed and it is usually easy to tell that it deflated. However, saline implants are usually more palpable than silicone filled implants. Saline implants also have a fill valve which can be palpable. Silicone implants are pre-filled and do not have a palpable fill valve. Silicone implant volumes cannot be adjusted in the operating room because they cannot be opened during the procedure to be filled. Most patients feel that silicone implants feel more natural.
What is the recovery time for breast augmentation surgery?
Breast augmentation surgery is a fairly straight forward procedure for most patients. Routinely, these are performed as an outpatient in my accredited office based surgery facility. Patients go home in a loose fitting zip up sports bra and often can go back to light duty fairly quickly after surgery. I most commonly perform breast augmentation using the submuscular pocket using the dual plane approach. In most cases, especially in very thin patients, I think that this adds more soft tissue coverage over the implant especially in the upper pole. Most patients can go back to light aerobics within about three to four weeks. Often they can do vigorous exercise like sit-ups and weight lifting within six to eight weeks. It is important to be seen in follow-up before moving forward with the various activities.
Will a breast augmentation lift my breasts?
Commonly patients present to my office often after having children, requesting that their breasts be restored to their pre-pregnancy appearance. Many of these patients have involution or loss of breast volume. In those patients that do not have breast sagging, implants are an excellent choice. One fallacy is that many patients believe that if breast augmentation is performed in this type of scenario, it somehow lifts the breasts as well. In general, implants do not lift the breasts to any significant degree. Implants only restore lost volume. If a patient needs a lift, then implants alone will not accomplish this. But, sometimes fewer incisions are required for a breast lift. In other words, a patient who has a breast augmentation will perhaps get a nice result with a lollipop type incision instead of an inverted “T” or anchor type incision. Or if they were a candidate for a lollipop type lift without implants, with implants they may only need a circumareola lift.
Can I have silicone gel implants instead of saline filled implants?As of November 17, 2006, the FDA has approved the use of silicone gel implants for patients that desire a breast augmentation. Patients have to be at least 22 years old to receive the gel implants for primary breast augmentation. So now along with the saline-filled implants, there are even more implant choices for patients desiring a breast augmentation.
What incision can be used to place the breast implants?There are many different ways to perform breast augmentation. The incision can be placed in the armpit (transaxillary), under the breast (inframammary), at the border of the areola and breast skin (periareolar), through the umbilicus (transumbilical), and even through an abdominoplasty incision when performing an abdominoplasty (transabdominal). Each location has its pros and cons.
Will I have normal nipple sensation after the surgery?Many patients will have some change in sensation after the surgery; this is often due to swelling that usually resolves after four to six weeks. However, about 15% of patients will have a change in sensation that persists after one year.
Does the choice of incision location affect nipple sensation?There have been no scientific studies in my opinion to definitively prove that incision location affects sensation. However, many plastic surgeons postulate that sensory changes may be related to the size of the implant used. That is, the larger the implant the more likely sensation will change. This may be due to the stretching of the tissues in the pocket that needs to accommodate the larger implants, and therefore stretching the sensory nerves may affect the function of these nerves.
Will I be able to breastfeed after an augmentation?It is difficult to predict whether or not an individual will be able to breast feed after augmentation. Some women who are very small breasted to begin with can produce a lot of milk, while some very large breasted women cannot. Inevitably during surgery some of the parenchyma is divided to create the pocket for implant placement. However, there are many patients who can breast feed. Again, this depends upon the individual patient.
What size breast implants should I get?I always tell prospective patients who email me this request that I cannot predict the exact size of the cup in a bra because bras do not always match up to the volumes of implants. Furthermore, the implants appear differently on different patients. A good “guesstimate” is to perform a “BAGGY TEST” once the potential range of volumes is discussed with me during consultation.
What is a baggy test?A baggy test is a test that I sometimes have patients do at home after discussing breast implant options to “nail down” a volume that they might be happy with for breast augmentation. Basically, patients get a plastic bag that can twist-tie. I have them fill up the bag with either rice or water. They fill a measuring cup to the suggested volume and then pour that volume in the bag and tie it. They then put on a loose fitting bra, preferably one that they want to fill, and then add the filled bag into the bra cup. Then they put a tight t-shirt on over the bra to see if they like that volume. Changing the volume as suggested in specific increments may help in the decision making process for the final implant volume. It produces a rough estimate and seems to work for my patients in most cases.
What type of breast implant is best for me?Today we have so many options for breast augmentation. Not only do we have saline, or sterile water filled implants, but we also have silicone filled implants both with cohesive gel and form stable silicone gel. Furthermore, we have different surfaces covering the implants. This includes both smooth and textured surfaces. There are also different implant profiles including low profile, moderate profile, high profile, and ultrahigh profile. Besides round implants, we also have available biodimensional or anatomic shaped implants. This variety gives patients many different options to choose from.
Is a “gummy implant” better than silicone?Gummy implants are form-stable implants. They differ from the more common cohesive gel implants in that they are firmer. The form-stable implants maintain the structure of the gel if the implant ruptures. The analogy used is the consistency is like “jello.” If the implant is cut in half, the gel does not ooze. The form-stable implants available in the U.S. are all textured and have a Bio-Dimensional shape. Because of their somewhat lack of pliability, a larger incision is required to insert them as opposed to the incision size used for the cohesive gel implants or the saline implants.
Should I get an anatomical shaped implant?Anatomical shaped implants or biodimensional implants have a tear drop shape to them. In the U.S. they are all textured. These are great implants for some patients. The main disadvantage in my opinion is that they can rotate a bit and may not stay in the orientation that they were placed in the operating room.
What is a TABA?TABA stands for Trans-Abdominal Breast Augmentation. This is an approach using the abdominoplasty incision to gain access for insertion of breast implants. I have used this technique in patients that underwent a mommy makeover. A mommy makeover usually refers to a procedure that a woman has after completing having children. It usually entails a combination of a breast procedure and a tummy tuck. A TABA is great for a patient that wants a tummy tuck and a breast augmentation at the same time and they do not have breast ptosis (sagging.) A small pocket is created, extending up to each breast from the upper aspect of the elevated abdominal flap. Once this is completed, the implants are placed into the pocket. The advantage is that there are no incisions on or near the breast. Saline or silicone breast implants can be placed through this approach.
What is a TUBA?TUBA stands for TransUmbilical Breast Augmentation. This was a very popular procedure when only saline implants were available on the market. A small incision is made in the umbilicus and a tube is maneuvered into the space up to the breast fold. Using an endoscope to visualize the pocket position, an implant is then inserted. Because a small tunnel is used, saline implants are the only ones inserted this way. Disadvantages include the limited access afforded by this technique which limits the ability to treat bleeding, or allow for precise pocket dissection. Silicone implants cannot be placed through this approach.
Can I get a breast implant without a lift?In general, if you need a breast lift then you need a lift. Implants provide more volume and will not raise the nipple to any great degree. Sometimes a patient can have a circumareolar lift in which an incision is made around the border of the areola to raise it higher on the breast mound. If the patient needs more of a lift, then a vertical or inverted “T” type closure can be performed. It really depends upon the patient’s anatomy.
What breast implant volume is best for me?Choosing the right breast implant for an individual is a complex decision process. First, patient’s goals are of prime importance. What size do they want? What shape are they looking for? What type of projection are they looking for? etc… But a very important factor is the patient’s overall anatomy. How wide is the chest wall? What volume of breast tissue do they have? How loose is the skin? How thick is the skin? to name a few. Once all this information is taken into consideration, a range of implants are selected for possible use. I will often have the patients perform a “baggy test” at home to see if they like the volume chosen. Then in the operating room, I will have several different sizes and shapes of implants to choose from based upon all these factors, and then use the information obtained during consultation and what I see in the operating room to make the final decision.
What profile breast implant is right for me?Choosing the right breast implant profile is best performed in person during a physical exam and a discussion of the patient’s goals. Implants used to come in only one shape and with increasing volume the implant got wider and had more projection. Now for any volume there are several different shapes to choose from. We have moderate profile implants, moderate plus implants, high profile implants, and ultrahigh profile implants. So as the profile changes, and for the same volume, the base width of the implant becomes narrower and the projection becomes greater.
How do you treat rippling of a breast implant?Rippling of an implant happens more commonly in thinner patients that do not have a lot of soft tissue coverage over the breast implant. For patients that have subglandular breast implants, this can happen along any surface of the implant. With implants under the muscle, the upper pole has more soft tissue coverage because it not only is covered by the skin and breast gland, but in addition it is covered by the pectoralis muscle. Patients with submuscular implants tend to have rippling along the lower pole where the muscle does not cover the implant. Treating rippling depends upon the breast implant pocket position. If the implant is subglandular, then perhaps placing them submuscular can help. In addition, the lower pole will still need more coverage. This can be achieved with an acellular dermal matrix (ADM), most commonly Strattice. This matrix adds another layer of coverage over the implant and incorporates into the surrounding soft tissue. Some surgeons may offer fat injection as another alternative to thicken the soft tissue surrounding the implants to decrease the rippling.
What is a double bubble and how do you treat it?A double bubble is a breast deformity that occurs when an implant either is too wide for the native breast mound and does not drape appropriately over the implant, or when the implant drifts down below the natural inframammary fold. For the former situation, one can have the lower pole of the breast “opened up” by scoring the gland so that it re-drapes better over the implant, or placing a smaller implant in the pocket that matches the breast base diameter better. This also may require a capsule repair to accommodate the smaller implant. For the latter situation, if the implant drifts down below the natural fold, it may be because the inframammary fold was undermined during the original surgical approach or the implant pushed through the weak inframammary fold. Either way, a capsulorrhaphy or pocket repair will need to be performed. Sometimes a smaller implant is recommended as well to be replaced into the pocket. Some surgeons will also use an acellular dermal matrix (ADM) to provide extra support for the pocket repair.
How do you treat a capsular contracture?The body forms a natural barrier around implants of all types. Usually this pocket stays pliable and soft for most patients. However, for some, the capsule around the implant can become tight. One theory regarding the cause is that there is a low level bacterial count in the pocket, leading to a biofilm layer that causes the capsule to tighten. This tightening is called a capsular contracture. Rates of capsular contracture are reported to be between 5-15%, and there is a high risk of recurrence once it develops and is treated. Treatment of a capsular contracture usually entails removing the implant, removing as much of the capsule as possible, and then replacing with a new implant. There have been some reports that suggest placing the implant in a submuscular pocket may decrease the risk of contracture. In addition, some reports suggest that using an acellular dermal matrix (ADM), like Strattice may help reduce the risk of recurrence.
What is symmastia?Symmastia is a condition in which the natural central depression over the sternum that separates the two breasts is violated and the area lifts up to give the appearance of one very large breast. This happens as a result of implant malposition, more common when implants are placed in a subglandular pocket. Usually in a submuscular pocket, the implant is “blocked” or restricted from moving more medially because of the natural insertion of the pectoralis muscle on to the sternum. Symmastia may develop in individuals when the surgeon attempts to produce more cleavage for the patient. Treatment of symmastia often includes a capsulorrhaphy or pocket repair. Some surgeons may add an acellular dermal matrix (ADM), such as Strattice to reinforce the pocket repair. If the implant is in the subglandular plane, placing it in a submuscular plane may be beneficial.
Textured vs smooth breast implants?
How do you treat breast implant malposition?Malposition of a breast implant can entail a lot of different concepts including lateralization, medialization leading to symmastia, and bottoming out inferiorly. In all cases the pocket has to be adjusted so that these problems do not recur. Sometimes the creation of a new pocket is necessary and is called a neo-subpectoral pocket. Many times the old pocket can be used, and repair or tightening of the pocket can be performed which is called a capsulorrhaphy. In some instances, an acellular dermal matrix (ADM), such as Strattice is used to reinforce the pocket repair.
Can I have more cleavage?Cleavage is defined by the space between the two breasts that lies over the sternum. The patient’s anatomy dictates the amount of cleavage they can have. Wider implants may help improve the cleavage. Some surgeons will place the implants in a subglandular plane to improve the cleavage. When the pocket is made too aggressively medially, then symmastia may develop. When implants are placed under the muscle, the cleavage is limited to the insertion point of the overlying pectoralis muscle, and so the amount of cleavage achieved can be limited.