Nowadays, women can change or adjust any part of their bodies that they don't very much like. Cosmetic surgeries have made it easier to be more visually appealing and more satisfied with one's appearance. 

Some people may go for a nose job to enhance their facial features. Others, especially Asians, might go for eyelid surgeries to adjust their eyelids and have wider eye fields. One of the most popular cosmetic surgeries is breast augmentation.

Many women have small breast sizes, and they are not satisfied with it. Maybe they want bigger and fuller breasts for reasons that differ from one woman to another.

Plastic surgery has helped those women to get what they want. Women can get what's called "breast augmentation surgery", also known as breast implants or augmentation mammoplasty, to have the look they want and feel better about their appearance. 

However, breast augmentation is not considered a cosmetic surgery only. It can also be done for reconstructive purposes such as after mastectomy for breast cancer. But let us discuss one purpose at a time.

First, let's dive deeper into breast augmentation for cosmetic purposes.

So, what is breast augmentation again? 

Breast augmentation is a surgical procedure which aims to increase the breast’s size, shape, or fullness. Augmentation can be from the placement of an implant under the breast tissue or chest muscles or less commonly, fat transfer to breast augmentation.

Anatomy and Physiology

The female breast is placed on the anterior chest wall, inferior to the clavicle, between the sternum and the latissimus dorsi muscle. The inframammary fold (IMF), also known as the inframammary ligament, is located on the inferior border. The superficial and mammary fascias fuse to produce this fold, which is a dermal structure.

The pectoralis major and minor muscles create the posterior or bottom border of the breast, which is connected to the superior breast parenchyma. The subdermal plexus of arteries supplies blood, with substantial contributions from the internal mammary artery, the external mammary artery, and the intercostal perforators. The intercostal plexus provides the majority of nerve supply, with the third through fifth intercostal nerves contributing the most.

Why is Breast augmentation done? 

As we mentioned, for some women it is a way to feel more confident about themselves, and for others, it is a way to rebuild the breast for different reasons.

Reasons to Breast Augmentation

Breast augmentation might help you in:

• Enhance your appearance if you think your breasts are small or one is smaller than the other, which impacts the way you dress or the size of the bra you use to make them look equal in size.
• Restore breast size after pregnancy, significant weight loss, and breastfeeding.
• Correct uneven breasts after breast surgery for other conditions. In other words, restore the symmetry of the breasts.
• Boost your self-esteem and improve your self-confidence. In 2007, a study by researchers from the University of Florida found that breast augmentations through cosmetic surgery boost women's self-esteem and their feelings about their sexuality.

Despite all these reasons, breast augmentation is mainly considered cosmetic surgery. 

Breast Implants

What is a breast implant? 

• It is a medical prosthesis that is placed inside the breast to augment, reconstruct, or create the physical form of the breast.
• Doctors usually use one of three types of implants including saline, silicone gel implants, and alternative composite implants.
• Different types of implants are used as well. 
• Saline implants are filled with a sterile saltwater solution called saline. The solution is inside a bag or shell made of a specific type of silicon called elastomer silicone. 

Saline Implants

• Saline implants can be filled with different amounts of saline to control the feel, shape, and firmness of the breast.
• The FDA has authorized saline breast implants for breast augmentation in women over the age of 18 and for breast reconstruction in women of any age. These implants have a silicone outer shell filled with sterile saline with the following characteristics:

1. It might be empty at first (and then filled during the implantation operation) or pre-filled.
2. Different sizes are available
3. Have smooth or textured surfaces to their shells
4. Can be used in conjunction with integrated remote-fill ports: Allow for postoperative modification of implant saline volume as well.
5. Less costly than silicone-filled products
6. Implant ruptures quickly detectable
7. Possible visible implant rippling on surface of augmented breast in women with thin breast tissue
8. Saline implants are safe in a way because if they leak, the solution will be absorbed by the body and expelled naturally.

The other type is silicone-gel filled implants

Silicone gel-filled breast implants have been authorized by the FDA for breast augmentation in women aged 22 and above, as well as breast reconstruction in women of any age. These implants have a silicone outer shell filled with different consistencies of silicone gel and have the following features:

• Available in different sizes
• Have smooth surfaces
• More expensive than saline-filled implants.
• They feel more natural than saline-filled implants.
• Less noticeable rippling in thin-skinned augmentations
• Unlike remote-fill ports, they cannot be implanted through a transumbilical incision, but they may be inserted through periareolar, inframammary, and transaxillary incisions.

In this implant, if there is leakage, the gel either stays in the shell or gets out of the shell into the implant pocket. This may or may not lead to implant collapse. Patients who choose this type of implants should check up on the implant more often in comparison to those with saline implants.

MRI and ultrasound scan are used to check the condition of the implant.

The last type of implants, the alternative composite implants, are filled with different types of substances such as polypropylene, soy oil and other materials. 

• These implants are typically placed empty, and the surgeon then uses a tiny port to administer the required amount of sterile saline to inflate the implant. After that, the port is withdrawn, and the implant has a self-sealing tab for the port insertion site. Because saline implants generally have a 25 to 50 mL range indicated by the manufacturer, the surgeon has a lot of leeway in filling them to varied quantities.
• Some saline implants are filled by the surgeon during surgery, while others are prefilled by manufacturers; nevertheless, prefilled saline implants are not widely utilized in the United States.
• The implant's exterior shell might be smooth or textured. Texturing is utilized in shaped implants as well as certain spherical implants. Texturing aids in the prevention of rotation in shaped implants and has been proved in certain studies to reduce the occurrence of capsular contracture when the implant is placed in the subglandular pocket.
• Texturing does not appear to reduce the occurrence of contracture when put in the submuscular pocket.
• The implants can be positioned either above or below the pectoralis muscle. Subglandular and submuscular are other terms for the same thing. Each strategy has merits and downsides.
• The selection is influenced by the patient's anatomy as well as the surgeon's inclination. There is no one method of placement that is universally recognized as the best, and this should be established through collaboration between the patient and the surgeon. The inframammary crease, transaxillary, and peri-areolar sites are also common places for access incisions.
• This surgery is most commonly performed under general anesthesia, however it can also be performed under sedation or even local anaesthetic in some instances. Breast augmentation is an outpatient procedure that typically takes 45 to 90 minutes to complete. Recovery is typically quick, with most people able to return to light work and activities within a week. It may take up to 6 weeks to return to full activities.

Saline versus silicone gel

• When compared to silicone-filled goods, saline implants are less expensive. Some goods can also be filled via a remote port, allowing a surgeon to install them via a transumbilical route. Furthermore, if an implant ruptures, it is generally more obvious. However, in individuals with thin breast tissue, there is a greater risk that implant rippling will be evident on the enhanced breast's surface.
• In comparison, silicone implants are more expensive, but they are usually thought to have a more natural feel, and rippling in thin-skinned augmentations is less visible. These cannot be implanted through a transumbilical incision, but they may be inserted through periareolar, inframammary, and transaxillary incisions.

How we do breast augmentation surgery?

• The procedure itself will take about one to two hours and is performed under general anesthesia or local anesthesia with oral sedatives. You can discuss this with your surgeon to decide the best type of anesthesia for you.
• Breast augmentation can be done in several ways.
• Your surgeon can access the breast via the incision under the breast, known as the inframammary fold, the areola, known as the nipple incision, or via the armpit which is known as the trans axillary approach.
• No doubt that your surgeon will discuss all these options with you to determine the best option that suits you.

Surgical incisions and dissection planes

• Inframammary, periareolar, transareolar, transaxillary, and transumbilical incisions are the five surgical techniques used to place breast implants.
• Breast implants can be put subglandular, submuscular (under the pectoralis muscle), or in a dual plane with the superior section covered by muscle and the inferior part under the gland.

Breast Augmentation Risks

Breast augmentation, just like any other surgery, has some risks and complications, including: 

• Scar issue, which distorts the shape of the breast implant.
• Infection at the site of the incision.
• Changes in the nipple and breast sensation due to nerve damage. The nipples may become more sensitive, less sensitive, or completely numb. It can be temporary or permanent. 
• Implant site changes.
• Implant leakage or rupture.
• Breast implant-associated anaplastic large cell lymphoma. The U.S Food and Drug Administration has identified a possible association between breast implants and an uncommon type of immune cell cancer called anaplastic large cell lymphoma. However, that doesn't mean that the implants necessarily cause this condition. Therefore, further research is needed to confirm or deny this association.
• Breast implant illness. After the breast augmentation surgery, some patients reported systemic symptoms including fatigue, memory loss, skin rash, trouble concentrating and thinking clearly, and joint pain. This relationship between the implant and the symptoms is not totally understood. However, the removal of the implants may improve these symptoms. Research is still ongoing to determine the association between breast implants and these symptoms. 
• Creases or folds in the implant. 
• Rotation of the implant within the breast. This rotation results in an abnormal shape. 
• Rippling of the implant. This happens when the implant is covered by a thin layer of tissue only, which sticks to the surface of the implant. It is very difficult to treat. 
• Not being able to breastfeed or producing slightly less breast milk than you would without a breast implant. 

Surgeons do not know what causes contracture, although many assume a sub-clinical or low-grade infection, which can produce inflammation and a capsule biofilm, which can cause contracture. Staphylococcus epidermidis and Propionibacterium acnes are the most often identified bacteria from breast implant capsular contracture investigations.

Capsular contracture is rated on a scale of 1 to 4, with severe cases necessitating surgical correction or possibly implant removal. It is critical that individuals undergoing this operation understand that many women who have breast implants may require further breast surgery at some time in their lives.

There have recently been indications that women who get breast implants are more likely to be diagnosed with anaplastic large cell lymphoma (ALCL). The precise link between implants and ALCL has yet to be discovered, although it may be more frequent with a specific sort of texturing on the implant.

Before your breast augmentation surgery, you must understand the whole process and discuss with your surgeon everything including the type of the implant, the type of anesthesia, and the preparation before the surgery.

You will also consult with your surgeon about the size, feel, and shape you want. You should also review the written information about the type of implant you choose carefully. 

You need to keep in mind some facts about breast augmentation and breast implants. For example: 

• Breast implants won’t prevent your breasts from sagging as you age. If you already have sagging breasts, your surgeon will recommend a breast lift along with breast implants. 
• Breast implants won’t last a lifetime. Implant rupture is possible. Besides, the average lifespan of an implant is 10 years. And as your body changes and as you gain or lose weight, the way your breasts look will change as well. These situations can lead to other surgeries. 
• Mammogram screening will be more complicated than usual. If you have breast implants, in addition to a mammogram, you will need additional screening tests and views. 
• And as we mentioned before, breast implants can interfere with breastfeeding. 
• Some insurance companies, or almost all of them, don’t cover breast augmentation surgeries unless it is medically necessary such as after mastectomy due to breast cancer. So, be prepared to deal with all the expenses including future surgeries and tests. 
• If you decided to remove your implants, you might need additional surgeries. You might need a breast lift or another corrective surgery to help restore the old appearance of the breasts. 
• You will need to screen for silicone breast implant rupture. The FDA recommends routine screening with breast MRI five to six years after placement of the silicone implant to check for implant rupture. After that, a breast MRI is recommended every two to three years. Ultrasound can be an alternative method to check for implant rupture. You can discuss with your surgeon the suitable method of screening for your case. 
• You might need a baseline mammogram before your surgery. 
• Your surgeon might ask you to take some medications before the surgery or to avoid some medications, for example, your doctor might ask you to stop aspirin or other medications that can increase bleeding. 
• If you are a smoker, your doctor will ask you to stop smoking for about four to six weeks before and after the surgery. 

Another important point you need to keep in mind when you are considering breast augmentation surgery is that you can still get breast cancer after having breast implants. This means that you need to be aware of how your breasts look and feel after the surgery so that if any abnormal lump or change appears on your breasts you can report it to your doctor. 

In addition, you should still have your regular breast cancer screening after having breast implants. But the technician will do the mammogram in a different way to allow the breast tissue to appear. 

Equipment

Breast augmentation surgery generally only necessitates the use of basic operating room equipment. Some surgeons prefer to use a lit retractor to see within the breast pocket made for the implant, while others prefer to use a headlamp. When using the umbilical or axillary methods, an endoscope or other specialist equipment may be required.

Some surgeons may propose inserting the implant through a customized implant sleeve. This may make implant placement simpler and is part of the no-touch method, which allows for as little contact of the implant as possible. This may reduce the possibility of implant damage and bacterial infection.

Breast augmentation recovery essentials

Breast implants are not designed to last forever, although most firms provide a 10-year warranty in the event of a rupture. On physical examination, saline implant rupture is frequently more easily identified than silicone implant rupture. As a result, the FDA recommends that women with silicone gel implants have breast imaging with MRI three years after implantation and every other year afterwards to identify silent rupture.

Patients who have saline implants should follow their prescribed mammography routine for breast cancer screening. Furthermore, patients may develop capsular contracture over time and should consult with a plastic surgeon if they have any concerns or questions about this.

Contraindications of Breast augmentation

Breast augmentation is not contraindicated in the majority of individuals. However, they include active breast infection, active malignancy, pregnancy, a history of autoimmune illness, current radiation therapy, unstable medical conditions, or known silicone sensitivity. This procedure should not be performed on individuals who are psychologically unstable or who have unreasonable expectations.

Outcomes

Breast augmentation produces the best outcomes of any cosmetic surgery. The majority of patients are not only satisfied with the outcome, but they also gain self-esteem and confidence as a result. Complications following breast augmentation are uncommon and vary according on surgeon expertise. According to surveys, around 70-80 percent of patients are happy and believe the outcome was excellent.

Breast augmentation surgery cost

Breast implant surgery ranges in price from £3,500 to £8,000. This generally does not include the cost of consultations or follow-up treatment.

Is breast augmentation safe?

Breast augmentation and reconstruction with both saline and silicone implants are deemed safe. Both types of implants are still being studied for their safety and efficacy.

To ensure that you get a comprehensive picture and understand everything related to breast augmentation, we invited Dr. Choi who is a renowned cosmetic surgeon from Seoul, Korea to address any questions you may have from an experienced point of view.

Interview

1. How many types of breast surgery are there in Korea?

There are many types of breast surgery. Depends on what the patient wants. If the person has small breasts, we can enlarge them. If the breasts sag, we can lift. And, if the breasts are too large we can do reduce them. And for cancer patients who lost their breasts, we also do reconstruction.

2. What is a breast lift?

Breast can sag for a variety of reasons. Breast feeding or change in weight due to sudden weight loss or gain. If breasts enlarge then subside, they tend to sag. Lift surgery addresses that type of issue. Breast lift surgery can be divided into several types.

3. In what cases does breast lift be done?

We cannot exactly say a breast lift is needed. If lifting will improve one’s psychological well-being, sure. But if one wishes to enlarge without the lift, we must examine if the ducts are level with the nipples. If the mammary ducts are below the nipples, then we cannot simply do enlargement. It must be done together with a lift. We do try to avoid lift surgery, as it can leave a visible scar. However, if the ducts are below the nipples, then a lift is the recommended course.

4. How long does an implant usually last?

When clients come for a consultation and ask if they can change the implant every ten years. Todays’ breast implants are in their sixth generation. The first ones came out in the 1960’s. However, do patients who had second and third generation implants change to new ones? No, they don’t. If they don’t burst, they can keep using. But since it is not obvious sometimes whether the implant burst, it is imperative that one gets regular exams. However, there were implants that were problematic. For example, Allergan’s implants. Since they are not healthy, it is recommended to change to a new one if one has the Allergan implant currently.

5. Is it possible to have an operation while breast lumps or mastitis?

At our hospital, we always perform ultrasound exams before surgery. Usually, we implant below the muscle layer. Above the muscle, there is the mammary duct, which is prone to lumps or even cancer. If upon exam, presence of cancer is detected, then we cannot perform implants until the cancer is first addressed at the hospital. But most people do not have cancer. If the growths are benign, we can do the surgery after removing them. Or if the size is small, it is better to leave it alone and perform surgery. So, even if there is a lump, we can do the surgery without big issues.

6. OK, for example, how to choose the best implant that suits me? What are your recommendations?

We perform breast surgery for over a thousand patients each year. We constantly watch for the best implants, those that have low side effects. We keep statistics every year. We found out that microtextured implants have the lowest occurrence of side effects. We know by material type and manufacturer. The shapes are different, and we can discuss which one may best fit your needs. Whether one wants a larger set of breasts is an individual choice. The doctor can help choose the type of implant would best fit the client’s goals. So, a consultation is very important.

7. When can a client return to do sports after the surgery?

Two to three days after surgery you can start working at an office. In jobs that require the use of arms a lot, it takes about a week of recovery. For intensive sports, it is best to recover for a month prior to doing so. For simple sports like jogging, it only takes a week of rest. So, even if you visit from abroad, since it only takes a week’s rest mostly, it is a manageable procedure for visitors.

8. Is it possible to breast feed after implantation?

Yes, definitely possible. The implants go under the muscle tissue. Breastfeeding is no problem since the tissue is above the muscle layer. Breastfeeding and breast implant surgery poses no issues.

9. What are the limitations for breast lift surgery?

What cosmetics surgeons abhor are scars. But it is impossible to perform a lift without slicing off some excess tissue. The aim of lift surgery is to limit as much as possible the visible scarring. But if we limit the scarring, then the lift is modest. It is key to have a thorough consultation to best match the expectations with the appropriate procedure. This way, we can limit the potential regrets. Since scars do not completely disappear, even with laser treatments, we must consult prior to surgery.

10. Is there any age limit for breast surgery?

Breast surgery can be done to anyone who is fully grown, about two to three years past full growth. Today, many college students have them done. But also, many around age sixty, also have them done. All age groups of adults have them done. Younger ones tend to want to enlarge, while the older tend to want a lift. Breast surgery covers all those needs.

11. What are the most common side effects after breast surgery?

Side effects of breast surgery are of course, worrisome. The fact that a large foreign matter is inside coexisting with the body is a big deal. Whether the implant can safely coexist with the body is the big question. So, we use our knowledge to choose the best implants. But even with that dedication, there are times when implants trigger side effects such as leaking, bleeding, infection, etc. In order to limit such problems, the hospital should be well equipped, clean. Also, the skill and experience of the surgeon is important. And the maintenance after the surgery. Whether a high-quality implant is being used. All these matter and influences the results. I began doing implants about twenty years ago. Even back then, the issues were low occurrences but today, they are even lower. This is a procedure that can be done without too many worries.

Conclusion

There are many types of breast surgery. Depends on why the patient wants one. If the person has small breasts, we can enlarge them. If the breasts sag, we can lift. And, if the breasts are too large, we can reduce them. And for cancer patients who lost their breasts, we also do reconstruction.

Breasts can sag for a variety of reasons. Breastfeeding or change in weight due to sudden weight loss or gain. If breasts enlarge then subside, they tend to sag. Lift surgery addresses that type of issue.

Implants are now in their sixth generation as the first ones came to market in the 1960’s. If old implants have no issues, there is no reason to have them removed and changed. However, there are issues that require attention, including leaking, bleeding or infections. Also, some are known to be problematic, such as Allergan’s implants. If a patient has an Allergan, she is recommended to have them removed and replaced with a safer one.

As to the concerns for being able to breastfeed after augmentation, yes, it is no problem as the implant lies below the muscle layer while the breast milk is generated above the muscle layer.

Hospitals such as View PS perform over a thousand surgeries a year, rendering a unique experience and knowhow. Their experience allows them to suggest the best implants and perform the surgery with precision.

Breast surgery can be done by anyone who is fully grown, about two to three years past full growth. Today, many college students have them done. But also, many around age sixty, also have them done. All age groups of adults have them done. Younger ones tend to want to enlarge, while the older tend to want a lift. Breast surgery covers all those needs.