A great deal of discussion occurs before breast augmentation since there are several choices to be made and concepts to understand.

       Modern breast implants are made of a silicone shell that contains either saline (salt water) or silicone gel. Silicone gel implants are available as part of a study in select patients. Implant shells can be smooth or textured. Textured shells were developed to help control the problem of capsular contracture. Contracture is a scar which forms around the implant and balls it up into a hard and undesirable shape. Contracture has been more common with silicone gel filled implants and may play less of a role in modern saline implants. Two basic implant shapes exist: round and anatomic (teardrop). The vast majority of patients will do well with a round implant. If additional lower breast projection is needed an anatomic implant can be used.

       The implants can be inserted though several incisions. The most common route is an inframamary incision placed at the bottom of the breast. This provides a straightforward route for implant insertion and its scar usually fades well. Another method places the incision along the areola. This is a good incision to use when the areola is darker than the surrounding skin so that the scar is well hidden. A third incision is in the armpit area. This technique requires the use on an endoscopic camera to properly place the implant. Silicone implants cannot be placed through this incision. A fourth technique, which I do not currently perform for several reasons, place the implants through a belly button incision. All of these techniques can provide an excellent result and, once properly performed, their main difference lies in the location of the scar.

       Another choice to be made is the implant location relative to the pectoralis muscle - above or below. Placement of the implant below the muscle further decreases the contracture rate. It also blunts the upper aspect of the implant to allow for a more natural appearance in small-breasted and thin-skinned patients. Placing the implant under the muscle usually entails cutting the muscle and causes more post-operative pain and possible implant motion when the pectoralis muscle is exercised. Placing the implant above the muscle (below the breast gland) is the best way to fill a sagging breast and the preferred method in cases of moderate and severe breast droop (ptosis).

       Once the decisions have been made, routine laboratory testing to rule out anemia or unknown pregnancy is often performed and photographs are taken to assess post-operative effectiveness. Mammograms are ordered in all patients over 30 years of age in order to detect any possible abnormalities and to serve as a baseline for postoperative comparison.

       No aspirin, ibuprofen, or similar drugs should be taken within two weeks of surgery. These medications can cause serious excess bleeding during, and after, the operation. If you have any questions about drugs you are taking, including over the counter preparations and natural herbs, please call the office.

       You should be at the office surgicenter or hospital at least 90 minutes prior to your scheduled surgical start time. Bring all paperwork from the office with you, as many of these papers will save time on the day of surgery.

       You will be seen pre-operatively and a few marks will be drawn on your chest to help guide the surgery. You will then be brought into the operating room and given anesthesia. The operation will proceed as discussed pre-operatively in most cases, though some intra-operative changes in plan are sometimes required to give the best result possible.

       Incisions will be made and pockets opened into which the implants are placed. In most cases saline implants are used and they are filled and adjusted to provide an even result. In some cases (mastopexy, prior implants) silicone filled implants can be used.

       Once the implants are in place, the wounds are closed and a dressing applied. The dressing will stay in place for 1-2 days until changed in the office.

• Most patients will go home several hours after the surgery.

       Keep the dressing on until your office visit. Take the pain medication and antibiotics as prescribed. Your pain should steadily decrease with time. If the pain increases significantly there may be bleeding around the implant and you should call the office immediately.

       At the first office visit you will be placed into a new dressing. In many below-the-muscle cases an upper breast bandage is placed to help push the implant down against the action of the pectoralis muscle. In above-the-muscle cases, a sport bra is usually fitted for support.

       Upper body exercise should be minimized and no reaching type motions should be performed for 2-3 weeks. Massage of the implants may help decrease capsular contracture.

• Patients can return to non-strenuous work in 3-7 days in most cases.