Breast Augmentation Surgery

Breast augmentation surgery, a “boob job,” or “breast implant surgery,” is a common operation intended to make one’s breasts larger. The breasts can be augmented with breast implants or with fat transfer (fat grafting). Breast augmentation is often done at the same time as a breast lift (mastopexy). A breast lift (mastopexy) is an operation for women with sagging or drooping that lifts and reshapes the breast. Breast augmentation with implants or fat transfer are the only two ways to get fullness in the upper breast that many women want. Breast implants can be placed above, or below your pectoralis major muscle. There are many types of breast implants, and each type has advantages and disadvantages.

Breast augmentation is one of the most common cosmetic procedures performed, especially in the Treasure Valley. Many surgeons in and around Boise, Meridian, Eagle, and Canyon County offer breast augmentation; it is important that you choose a surgeon certified by the American Board of Plastic Surgery, like Dr. Poppler with extensive training in breast augmentation, mastopexy, and other surgeries to reshape the breast. This ensures your surgeon has all the skills and experience necessary to help you choose the best procedure for you. It is common for Dr. Poppler to see women for second opinions and revision surgeries who had surgery with an inexperienced, and/or non-board-certified surgeon. These patients have often had breast augmentation with very large implants, when the patient should have had a breast lift, or other breast surgery. At your consultation, Dr. Poppler will take a thorough history including your hobbies, activities, sports, previous surgeries, and medical conditions. He will also discuss your wishes in detail. Dr. Poppler will then talk you through your options and give you his recommendations on how to best achieve your goals. Your questions will be answered and ultimately, you will choose which operation is right for you.

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Where Are the Scars?

During breast augmentation with breast implants, Dr. Poppler makes a cut (called an incision) in the fold underneath your breast so that it will be well hidden by your breast tissue. Dr. Poppler uses his experience to predict how the scar will move as your skin heals and stretches so that it remains at this fold and is not visible to others. If your breasts sag, are droopy, or have “ptosis,” Dr. Poppler may recommend you have a breast lift (mastopexy) at the same time as augmentation. In this case, you may need an incision at the edge of your areola (the round darker area around your nipple) or running vertically down your lower breast below the nipple. If you choose breast augmentation with fat transfer (fat grafting), you will have small (less than 1cm) incisions near where we remove fat (usually on your abdomen, sides, or back), in the fold under your breasts, and/or at the edge of the areola. All incisions are carefully planned by Dr. Poppler to minimize visible scarring.

What is fat transfer or fat grafting?

Fat transfer, or fat grafting is a procedure that involves removing fat from an area of the body where you don’t want it with liposuction, processing that fat to remove injured fat cells that won’t live and non-fat tissues, then injecting that fat in areas where you want more fullness. This is a very common and safe operation, especially for patients undergoing breast reconstruction. Dr. Poppler has extensive experience performing this operation for breast reconstruction and cometic breast enhancement. In general, about 70-80% of the fat transferred to the breast will survive and will permanently add volume. Fat transfer usually increases the breast size by up to one full cup size. This is a very good option for women who have fat they would like to get rid of on their abdomen and flanks, who want to go up in size a cup size or less, and who would prefer not to have a breast implant. This is not a good operation for very thin women who do not have fat that can be removed. However, new “alloplastic” fat options (fat donated by human organ donors) are available at Treasure Valley Plastic Surgery for thin women who strongly prefer to avoid breast implants. Fat transfer with your own fat or donated fat tends to be more expensive than an augmentation with an implant and the recovery from liposuction with fat transfer takes longer than from breast implant placement alone.

What is a breast implant?

A breast implant is a medical device, thoroughly studied for safety in large clinical trials that are reviewed and approved by the Food & Drug Administration (FDA). Breast implants are among the most thoroughly studied devices you can have placed in your body and have been around since the early 1960s. Technology has improved dramatically in the past 20 years and implants placed today have fewer problems than in prior decades. There are two main types of breast implants: silicone implants, and saline implants. Both types of breast implants are made from a soft, medical grade silicone elastomer sack (the implant shell) and the material your body touches is very similar for both types of implants. The implant shell IS NOT made of plastic and does not break down in the same way as plastics over time. For silicone breast implants, the inside of the implant is filled with silicone gel. For saline breast implants, the inside of the implant is filled with salt water.

Silicone breast implants are more popular than saline implants because they tend to feel softer and last longer. Silicone implants also have more personalized options as the silicone gel inside can be modified to be runny like syrup (low cohesivity) or not runny and hold its shape (highly cohesive gel, or “gummy bear” implants), and everything in between. Both saline and silicone implants have similar safety profiles, and one is not necessarily better than the other.

Both saline and silicone breast implants can have a shell that is either smooth, or textured. Highly textured implants were previously very popular because they helped prevent a complication called capsular contracture and allowed placement of “shaped” (not round) implants that wouldn’t rotate. However, highly textured implants were later discovered to be associated with a rare type of cancer called BIA-ALCL. For this reason, Dr. Poppler does not use highly textured implants. Modern textured implants have a texture that matches the texture of your cell walls and are a very good option for patients who prefer there breast augmentation be over their pectoralis major muscle, or for patients who have previously had capsular contracture. Smooth implants and less textured implants (known as “smooth silk” implants) are not associated with any cancers.

There are four companies that make FDA approved breast implants:

Allergan – makes both saline and silicone breast implants – all Allergan implants have a smooth surface.
Motiva – makes only silicone breast implants – all Motiva implants have “smooth silk” texture.
Sientra – makes only silicone breast implants – implants may be smooth or textured.
Mentor – makes silicone and saline breast implants – implants may be smooth or textured – offers the largest implants available in the United States.

Dr. Poppler most commonly uses Allergan and Motiva breast implants but offers all implant types and honors warranties for patients with all brands of previously placed implants. As you can see, the choice of breast implants is complicated. For this reason, Dr. Poppler will take time assessing your priorities and preferences and help you decide which implant is best for you.

Why would I want an augmentation above, or below my pectoralis major muscle?

Augmentation above or below the pectoralis major muscle is a personal choice and there is not one right, or wrong way to do breast augmentation. Dr. Poppler will talk you through the reasons you may want to go above, or below the muscle and give you his advice based on your lifestyle, hobbies, and body characteristics at your consultation. Breast augmentation below the pectoralis major muscle is the most common way to do breast augmentation because the risk of capsular contracture, a complication where the body forms a thick, and tight sack around your breast implant that can distort the breast or be uncomfortable, is less likely when augmentation is performed under the muscle. Very thin women should also consider augmentation below the muscle to minimize the chance of seeing the implant edges or ripples (waves on the implant surface). Augmentation under the muscle can also mildly weaken the strength of the pectoralis major muscle and cause forward rotation (or slouching) of the shoulders. For this reason, women who lift heavy weights or for whom posture or shoulder mobility is very important may want to consider breast augmentation above the pectoralis major muscle. Implants with a textured surface are designed to minimize that risk. For this reason, Dr. Poppler usually uses Motiva implants with a “smooth silk” textured surface if he is going to perform augmentation above the muscle.

How long do breast implants last?

Modern silicone breast implants typically last longer than 20 years and most are warrantied for 20 years. The FDA (Food and Drug Administration) recommends checking for leakage of silicone breast implants with a breast implant specific MRI scan or a high resolution ultrasound five years after they are placed, and every three years after that. Saline breast implants typically last for 10-15 years and are typically warrantied for 10 years. No special monitoring is required for saline breast implants because your body will absorb the salt water they emit and they will get smaller when they begin to leak.

What is the “internal bra?”

“Internal bra” surgery is a modification to breast augmentation with implants or breast lift (mastopexy) in which, your surgeon places a piece of absorbable mesh to support your breast tissues from the inside. This mesh slowly dissolves over about 1-1.5 years, leaving behind scar tissue that supports the breast tissues permanently. This technique is helpful for women who want very large breasts prone to droop caused by gravity over time. It is also a useful adjunct for women that choose breast augmentation with implants above the pectoralis major muscle as there are less tissues to support the weight of an implant. Internal bra placement is more technically complicated than breast augmentation or breast lift without mesh and slightly increases the risk of complications. The mesh used for this procedure is also expensive. For these reasons, the internal bra is not right for everyone and if you want or need it, you want an experienced, well trained plastic surgeon certified by the American Board of Plastic Surgery like Dr. Poppler to perform this operation.

Why Women Choose Breast Augmentation with Implants

Can go up several cup sizes
Less expensive than augmentation with fat
Less recovery than augmentation with your own fat
More predictable than augmentation with fat
No risk of lumpiness caused by fat transfer

Why Women Choose Breast Augmentation with Fat

Can go up about one cup size
No future risk of implant leak and need for replacement
Good for women who want liposuction in another area simultaneously
Feels more natural than an implant to the patient and their partner

Possible Complications

Like all surgeries, breast augmentation has risks. The risks are small but are higher in people with certain medical conditions such as smoking, poor nutrition, auto-immune diseases, or diseases that require the use of blood thinning medications. Dr. Poppler will carefully review your risk factors with you at your consultation and help you modify these where possible to make your surgery as safe as possible. At Treasure Valley Plastic Surgery, your safety is our number one priority, and all surgical prices include an insurance plan to help pay for care related to any complications.

Possible complications of breast augmentation with breast implants include (listed from most to least common):

All implants will eventually need to be replaced – usually not for 20 or more years but it is important to financially plan for future surgeries.
All implants should be monitored for signs of leak or rupture – most implants are warrantied against leak for 20 years. When a silicone implant leaks, the silicone is contained by your capsule (the scar sack your body forms around your implant) and does not freely float around your body.
Capsular contracture – the scar sack your body forms around the implant gets tight or painful, usually a complication that occurs after more than a decade but can happen earlier.
Mild breast asymmetry or malposition of your implant (implant is too high, too low, too far out towards your armpit).
Scars that may be thick or uneven – rare
Changes in skin feeling (numbness) – rare
Breast implant illness (BII) – rare – this is a multi-factorial, poorly defined condition that leaves women feeling unwell. Symptoms are vague and can be caused by many conditions including peri-menopause, menopause, hormonal disorders like thyroid imbalance, poor sleep, poor diet, chronic stress, anxiety, allergies or sensitivities, and other medical disorders. Some women diagnosed with this condition improve after removing their implants, others do not. There is considerable debate in the medical community about if this is a real condition, or not. For a full discussion of this topic, please see Dr. Poppler’s blog article or video discussing breast implant illness (BII).
Poor wound healing – very rare
Bleeding or hematoma (a blood collection around the implant that can cause bruising, inflammation, or capsular contracture) – very rare
Infection – extremely rare

Possible complications of breast augmentation with fat transfer or fat grafting are all rare but include (listed from most to least common):

Uneven contour where that fat is removed
Uneven results with one breast retaining more fat than the other
Need for additional fat transfer to achieve your goals
Change in appearance of the breast if you gain, or lose weight
Firm lumps in the breast called fat necrosis or oil cysts – these are benign and do not cause problems but can be scary when first discovered as you may worry that it is a breast cancer. It is important to check out all breast lumps to ensure they are not cancer and therefore you may end up having additional procedures (mammogram, ultrasound, or biopsy) to ensure it is nothing serious.

Should I lose weight before surgery?

If you are significantly overweight, you may not be a good candidate for breast augmentation and Dr. Poppler may recommend you lose weight prior to surgery so that he can give you a better result and decrease your risks with surgery. Best results are achieved when you are at the weight you intend to stay at. Losing weight before surgery is not helpful if you think you will gain it right back. Similarly, doing surgery before losing weight produces a sub-optimal result because your skin will loosen again and your breast size and shape will change as you lose weight. For this reason, it is best to lose weight before breast augmentation surgery if you intend to lose weight or if you are significantly overweight, but otherwise you should have surgery when you are at a stable weight you are happy with.

How long is recovery after breast augmentation?

Recovery from breast augmentation surgery usually takes about 6 weeks. Most patients return to light activities within 1 week, and work in 2 weeks. Return to most exercise is possible about 3 weeks after surgery. You will need to wear a supportive bra at all times for 1.5-3 months. Swelling is typically mostly gone in 4 weeks but will come and go for about 3 months. If you have liposuction and fat transfer, swelling will be more severe and persistent than if you have an augmentation with implants.

Is breast augmentation safe?

Breast augmentation surgery is generally safe when performed on appropriate patients by a board-certified plastic surgeon. Like all surgeries, there are risks such as asymmetry, poor breast shape, capsular contracture, implant rupture, lumps, pain or scarring. Choosing an experienced surgeon like Dr. Poppler, following his advice to modify any risk factors before surgery, and following aftercare instructions lowers these risks and improves results.

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