One of the most popular and successful procedures that I do is the augmentation of the breast. This involves the placement of an implant, usually saline, under the patient’s own tissue. Different shapes, sizes and inflation amounts can be used to modify the breast. Unless a lifting procedure is done simultaneously, the breast will look exactly the same after surgery, but larger. Over 2 million women in this country have had breast augmentations. Surveys of patient satisfaction taken over many years have demonstrated that 90-95% of women are very pleased with the end result.

Incision Sites

There are three approaches. All three incisions yield wonderful results. The most popular incision is placed under the areola (the color change area between the dark skin and the lighter skin of the breast). Frequently the incision is placed under the breast in the fold. Since saline implants come deflated, this incision is usually only 1-1 /4″ long. The scar is invisible in most bathing suits.

Another incision used is under the arm in the folds of the skin (axilla). This approach may be better in people with a tendency towards keloids (thick raised scars). The axillary approach involves the use of an endoscope (telescope) and cameras and special instrumentation. These tools allow me to free up the lower inner portion of the pectoralis muscle. Post operative discomfort and problems after surgery are no more common with any of the incision sites.

Sutures are placed under the skin which dissolve after 90 days and subcutaneous sutures are placed and removed after 2-1/2 weeks to minimize the scarring. All incisions on the body go through a process of healing and are worst at 6-8 weeks after surgery. They flatten, soften and redness disappears over 6-12 months.

Implant Placement Position

There are two locations that breast implants can be placed: One is under the breast tissue only (submammary) and the other is under both the breast tissue and the pectoralis chest muscle (subpectoral). Of the two, many physicians feel that subpectoral position offers the most advantages. This is my approach.

Any implant placed in the body (pacemaker, artificial joint, etc.), has a light scar form around it. In some people, for not completely understood reasons, this scar thickens and contracts giving a hard, unrealistic shape to the breast (encapsulation). To avoid this, most doctors put the implants subpectorally. The hardness rate under the muscle with saline implants approaches 1-2% in many studies [1]. Factors such as infections or hematomas are very unusual but are thought to contribute to hardening of the breast. Subpectoral implants also make mammograms more easy to perform and interpret.

There are also two basic types of implant shells: smooth and textured. Some doctors feel that textured implants reduce encapsulation. However, in a recent study in Sweden, patients had a smooth implant placed on one side and a textured implant placed on the other with no difference in encapsulation rates [2]. Other studies concluded that if there is any difference between these implants, that it is very small [3]. In my hands, encapsulation with smooth implants in a subpectoral position runs 1-2% over 15 years.

Textured implants have their own set of problems. Most commonly, curtaining (a waviness of the breast implant visible and able to be felt through the skin) is very prevalent. To try to avoid this, some doctors use an “anatomic” implant that is flatter on the upper portion and then overinflate the implant. Even these textured implants are more likely to have curtaining. Also, one can feel the rough texture of the implant under the skin, especially in thin patients. Textured implants may have some advantage in special situations since they stick to the surrounding tissues like Velcro. Patients with breast cancer and with implant pocket positioning problems benefit from textured implants.

The Procedure

Using general anesthesia, the patient’s skin is sterilized as much as possible with an iodine gel. Sterile technique is used and an incision is placed in a pre-determined spot. Through this incision, electrocautery and blunt dissection are used to make a pocket underneath the pectoralis major muscle. This usually extends from the inframammary fold inferiorly to the second rib superiorly. Laterally, the space extends from the anterior axillary line (an imaginary line from the armpit) to the edge of the sternum. No muscle is cut but the inner inferior attachments of the pectoralis muscle are released to minimize movement of the implant with contraction of this muscle.

At this point, electrocautery is used to achieve hemostasis (stop bleeding). The pocket is washed with antibiotic solution and 12-hour pain medicine is infiltrated into the tissues to decrease post-op discomfort.

A smooth saline implant is partially inflated and placed through the incision. This is then inflated to the minimum amount and the patient is sat upright (while asleep). The position of the implant is adjusted and the implant further filled to obtain the best shape and size. The filler tube for the implant is then removed and the incision closed and dissolvable (90 day) sutures are placed beneath the skin and subcuticular skin sutures placed to further minimize scarring.

An ace wrap goes around the chest postoperatively. Drain tubes are frequently not used.

The patient awakens to a feeling of an elephant sitting on her chest. Further pain medicines usually take care of the tightness. The patient usually rests for an hour after surgery before going home with a friend or family member.

After 2 days, the patient returns and the ace wrap is removed. The patient can shower at this point. At 4-5 days, an important time comes, the moving and exercise of the implant. I make a pocket for the implant that is larger than the implant but this space closes down rapidly as the overlying muscle contracts. To keep this space larger than the implant and to keep the smooth implant soft, we begin exercises.

The implants are initially quite hard, ride too high and are swollen. They drop, soften and change shape over the first 2-1/2 months. Usually Vitamin E orally is recommended to decrease the tightness and thickness of the capsule that naturally forms around the implant. Sutures are removed at 2-1/2 weeks. No heavy exercising nor wearing underwire bra is recommended for 4-6 weeks

Saline vs. Silicone

Saline implants are used almost exclusively in this country. Silicone implants can be used only under a federal protocol. Women with breast cancer or who are having an implant replaced may have silicone implants.

There is a large controversy about whether silicone implants cause systemic diseases. Most studies (notably the Mayo Clinic [7] and Harvard studies [8]) have not demonstrated a relationship between silicone implants and disease processes. This does not mean that it doesn’t happen. The silicone may cause a rare allergic reaction but more studies are necessary. Recently, two scientific studies found that women with silicone implants have less breast cancer than women without implants [4]. Also, rheumatoid disorders seem to not be related to silicone implants [5]. In any event, saline implants are a good substitution for silicone. New studies are looking at different and more viscous fillers for inflatable implants. Vegetable triglycerides, hyaluronic acid, hydrogel and polyethylene glycol are all being considered [6].

Symmetry and Breast Droop

All women have asymmetric chest walls and breasts. The heart is on the left and pushes the ribs anteriorly. Sometimes if the asymmetry is very extreme, a different size of implant or different inflation rate can be used.

When seen from the side, if the nipple is at or above the inframammary fold, a breast augmentation may provide enough lift for a good result. lf the areola is very large and the breast is droopy, a periareolar reduction lift (donut mastopexy) may be performed. This involves removing a circle of skin around the areola to reduce the size and slightly tighten the skin of the breast. A variation of this is the excision of a crescent of skin above the nipple to slightly raise it. In extreme situations, a full lift is necessary.

If the nipple is below the fold of the breast, a keyhole shaped portion of skin is removed from the breast and the nipple raised (Mastopexy). This tightens the breast and gives it a further lift. This can be done with or without an implant.

In conclusion, using smooth implants in a subpectoral position gives a wonderful result. On occasion, further skin/nipple lifts and reductions may be necessary.

Almost all patients are very pleased with augmentation and quality of life studies frequently show increased self-esteem after these surgical procedures.

Questions and Answers About Breast Augmentation

  1. Am I a candidate for breast augmentation?
    Any woman between 18 and 80 years old is a candidate for breast augmentation
    as long as they are in good health.
  2. Where are the incisions?
    A choice of three locations:
  1. under the breast
  2. around the areola (the dark skin surrounding the nipple)
  3. armpit
  • Where are the implants placed?
    The implants are placed beneath the chest wall muscle.
  • What type of anesthesia is used?
    General anesthesia- you will sleep through the surgery.
  • How much recovery time is necessary?
    There will be discomfort for 24 to 48 hours. Pain medicine is used to keep the patient as comfortable as possible.
    Dr. Benvenuti injects 12-hour pain medication at the time of surgery to decrease the discomfort.
  • How long do the stitches stay in?
    The stitches remain in for 2 1/2 weeks. They are under the skin and do not leave suture marks.
    At this time, you may not go in the ocean, pool or jacuzzi.
  • How long before I can return to exercise?
    Light exercise may resume within 2 weeks. Strenuous lifting or running may be resumed 4-6 weeks after surgery.
  • What size breasts will I have?
    The breast size depends on amount of skin, tightness of chest muscle, and anatomy of the chest.
    It is difficult to promise a bra cup size since bras vary greatly.
  • Are there any permanent physical limitations after breast augmentation? No.
  • Does having breast augmentation mean I will be unable to breast feed when I have children?
    The mammary ducts are left in place so breast feeding should be possible.
  • Do implants cause breasts to droop?
    If the patient has a lot of skin and sagging prior to the augment, the breast will continue to sag as the years pass.
    An eventual lift may be necessary.
  • Does breast augmentation make mammography more difficult?
    Mammography is still successfully performed on breast augment patients. Make sure the mammography lab
    works on augment patients regularly. A four view mammogram is necessary.


1. pLevine, David M. Saline inflatable prosthesis: Fourteen years’ experience, Aesthetic Plastic Surgery, 17:325-330, 1993.

2. Tarpita, Erkki, et al. Capsular contracture with textured vs. smooth saline-filled implants for breast augmentation, Plastic and Reconstructive Surgery, 99: 1934,1997.

3. Asplund, aile, et al. Textured or smooth implants for submuscular augmentation: A controlled study, Plastic and Reconstructive Surgery, 97: 1200,1996.

4. Keron, Kenneth, et al. Carcinogenic potential of silicone breast implants, a Connecticut statewide study, Plastic and Reconstructive Surgery, 100:737, 1997.

5. Blackbrew, Warren, et al. Lack of evidence of systemic Inflammatory Rheumatic Disorders in women with breast implants, Plastic and Reconstructive Surgery, 99:1054, 1997.

6. Rohrich, Rod, et al. Development of alternative breast implant filler material. Plastic and Reconstructive Surgery, 98:559, 1996.

7. Gabriel. Sherine E. et al. Risk of Connective-Tissue Diseases and Other Disorders After Breast Implantation, NEJM, 330(24): 1697-1702, 1994.

8. Guerrero, Jorge Sanchez et al. Silicone Breast Implants and The Risk of Connective-Tissue Diseases and Symptoms, NEJM, 332(25): 1666-1670, 1995.