Breast Augmentation

Breast augmentation, also known as augmentation mammoplasty, is a surgical procedure to enhance the size and shape of a woman’s breasts. Every year, it continues to be one of the most popular cosmetic procedures performed in the United States. Using saline or silicone breast implants, our board-certified plastic surgeon, Dr. Neil J. Zemmel, can tailor the breast augmentation procedure to create a fuller breast appearance with highly natural-looking results.

This page will give you a basic understanding of the procedure, including who the proper candidates are, how it’s performed, what results you can expect, and more. Each person has individual circumstances, which may affect their final outcome, and Dr. Zemmel can answer all of your specific questions at your complimentary consultation.

What Are the Benefits of Breast Augmentation?

Breast augmentation is among the plastic surgery procedures with the highest patient satisfaction ratings. Many women experience an immediate improvement in their self-esteem and discover a greater self-confidence. The breast augmentation procedure is often sought after for a number of reasons; some of the most common benefits include:

Am I a Good Candidate for Breast Augmentation?

Breast augmentation can enhance your appearance and self-confidence, but it won’t necessarily change the appearance of other parts of your body. Before you decide to have surgery, think carefully about the reasons you are considering breast augmentation and what your overall expectations are. Dr. Zemmel wants you to thoroughly consider and discuss your reasons for surgery.

The best candidates for breast augmentation are women who are looking for improvement, not perfection, in the way they look. If you’re physically healthy and realistic in your goals, you may be a good candidate.

Because of Dr. Zemmel’s extensive training and experience with breast surgeries like breast augmentation, he has developed a systematic approach to optimize your satisfaction and results. This reduces the need for “touch-up” procedures following breast augmentation. Dr. Zemmel’s approach includes a thorough pre-operative evaluation, accurate pre-operative breast implant sizing, and an emphasis on achieving a natural feel and appearance following augmentation.

What Can I Expect in My Breast Augmentation Consultation?

Breast augmentation requires careful pre-op consideration and decision-making. Dr. Zemmel begins this process with a careful initial consultation, assessing the history of any prior breast disease, prior pregnancies, breastfeeding, and breast surgeries. It is also important to assess any family history of breast disease or breast cancer. In addition, future mammography is an important consideration during the evaluation process.

During this consultation, Dr. Zemmel will evaluate your health and explain which surgical techniques are most appropriate for you. A careful physical examination is essential since the characteristics of each woman’s breast—such as size, shape, symmetry, skin quality and thickness—have a significant impact on the final result. The position of the breast on the chest wall and the position of the nipple on the breast also greatly influence the final result. Other factors include chest wall size, shape of the breast bone, patient height and weight, and any spinal scoliosis. If your breasts are sagging, Dr. Zemmel may also recommend a breast lift.

The cornerstone of Dr. Zemmel’s approach is to tailor treatment to your individual goals and circumstances. Dr. Zemmel will also ensure that you have a complete understanding of the issues involved so that you are able to make a fully informed decision. This will help you achieve the appearance you desire with the least invasive procedure available. Dr. Zemmel strives to have open, honest communication with you at all times. He believes this is the foundation of a solid doctor-patient relationship.

Be sure to discuss your expectations frankly with Dr. Zemmel, and he will be equally honest with you, describing the alternatives as well as the risks and limitations of each approach. Let Dr. Zemmel know if you smoke or take any medications, vitamins, or other drugs, as these may all affect your outcome. He will go over the details of your surgical plan, explaining the type of anesthesia to be used, the type of facility where the surgery will be performed, and the costs involved.

At the completion of your consultation, you will be given a written estimate of the cost of your procedure. At this time, you will also have the option to schedule your procedure if you so choose. The decision to undergo surgery is a very important one and should be given very careful consideration. Dr. Zemmel realizes the importance of this decision, and at no time will you be pressured to commit to the procedure. You are also encouraged to bring your spouse, significant other, family member, or a friend to your consultation.

What Are the Different Types of Breast Implants?

Saline vs. Silicone Breast Implants

All breasts implants consist of a silicone shell inflated with a filler material. The name of the implant designates the type of filler material. Saline implants are a silicone shell filled with salt-water solution. Saline is found throughout the body in all tissues and is harmless when absorbed.

Silicone gel implants are filled with gel silicone, and typically provide a more natural texture and feel. A more form-stable version of silicone implants is the “gummy bear” implant, which contains a highly cohesive silicone gel. These implants are designed to maintain their shape if a rupture occurs, decreasing the risk of a leak.

If you are interested in a specific type of implant, Dr. Zemmel will help you determine if they are right for you. He will explain the pros and cons of each in detail during your consultation.

Smooth vs. Textured Implant Surfaces

Breast implants may have a smooth surface or may have a rough, textured surface. The textured implants were designed with the goal of decreasing the rate of forming a scar around the implant, known as a capsular contracture. This does appear to be effective, but only when the implant is placed above the pectoralis muscle of the chest wall (see Submuscular Implant Placement, below). Textured implants have never been shown to provide any advantage over smooth implants when placed beneath the muscle of the chest wall.

Textured implants also have their own disadvantages. Textured implants are manufactured by taking a smooth implant shell and applying the texturing to the outer surface. This texturing process makes the shell slightly thicker and stiffer, which translates into an implant that is more visible through the skin and is more easily felt when the breast is touched. Because of these disadvantages and because most implants are placed beneath the muscle, the great majority of breast implants used today are of the smooth variety.

Dr. Zemmel believes that the smooth-surfaced implants provide a much more natural look and feel when compared to textured implants.

Round vs. Anatomically Shaped vs. High Profile

Most breast implants used today by Dr. Zemmel are round and smooth. These implants provide excellent shape, contour, and volume restoration. There are also implants that are teardrop shaped, called anatomic implants. These implants are designed to better simulate the shape of the natural breast. They provide more volume in the upper portion of the breast. In certain select cases these may be recommended, but all anatomical implants are textured and, therefore, are subject to some of the disadvantages of textured implants. Anatomic implants may also rotate position over time, changing the shape of the breast. This does not occur with a round implant, which is a symmetric disc.

Dr. Zemmel also uses a newer type of implant called a high-profile implant. These new implants allow a higher volume to be achieved with a smaller diameter implant. Women with smaller chest wall widths can therefore achieve the same breast volume as women with larger chest wall sizes. Depending on the shape of your chest, you may be a candidate for these new implants and may achieve an improved shape and more natural appearance. Some women who also need a breast lift may avoid this extra procedure with the use of a high-profile implant.

How Do I Choose the Right Size of Breast Implants?

This is one of the most important decisions you will make. Dr. Zemmel will use his experience to guide you through the process of choosing a size that can meet your goals. Dr. Zemmel uses several approaches to help you make the best decision based on your anatomy, personal preferences, and the appearance you desire. Most patients undergoing breast augmentation have the goal of achieving a “C”; a “D” cup tends to be the second most popular request.

Looking at Before-and-After Pictures

Dr. Zemmel will begin talking with you at length about your goals and desires. He will also show you examples of his patients’ breast augmentation before-and-after pictures. By finding someone who has a similar pre-operative appearance and evaluating their results, you will get an idea of whether or not you like the size they chose. You may wish to bring photographs from magazines or websites to better communicate to Dr. Zemmel the exact size, shape, and “look” you are trying to achieve.

Taking Measurements to Create a Natural Look

Several key measurements of your natural breast and chest shape will be taken. This gives Dr. Zemmel an idea of what size implant will help you meet your goals. As implant size increases, so does the diameter of the implant. There is an implant that will perfectly match the diameter of your natural breast, and that is a good starting point for discussion. Choosing an implant smaller than your natural breast shape will not provide the proper cleavage and shape following the procedure. Similarly, choosing an implant too large for your natural chest shape is more likely to give you an unnatural appearance.

CCs vs. Cup Size: How Breast Implants Are Measured

Unfortunately, implants do not come in cup sizes. Rather, they are categorized by the volume of saline (salt water) or silicone that they are designed to hold. There are several reasons for this. First, your final cup size will be partially determined by your pre-operative breast size, and everyone is different in this regard. Secondly, a “C” cup from one bra manufacturer is not necessarily the same as a “C” cup from another manufacturer. Everyone is built differently and bras are not manufactured to a set standard.

If you are of average height and build, you can expect that one cup size is approximately 200cc. If you are tall or have broad shoulders, you can expect that number to be slightly higher. Similarly, if you are more petite or have a narrower chest wall, you can expect that number to be slightly lower.

Although a desire for a certain cup size is helpful to Dr. Zemmel in guiding you in the selection of the proper implants, it is more helpful to focus on the shape and appearance that you wish to achieve.

“Trying On” Breast Implants

Finally, Dr. Zemmel will have you “try on” various demo implants in a surgical bra. You may wish to bring a bathing suit, tank top or other clothing to see how you will look with different implant sizes. This helps confirm that you are making the right implant choice. Dr. Zemmel will have you perform the “trying on” during the pre-operative visit.

The initial consultation is very thorough, lasts approximately one hour, and tends to provide you with a tremendous amount of information to digest. Dr. Zemmel will see you again at least one more time before surgery and you will have the opportunity to try on the sizers again before making a final decision. Our goal and the measure of our success is your happiness.

How Will My Anatomy Affect My Breast Augmentation Results?

The shape of the breasts after augmentation is mostly determined by the breast shape before surgery. In general the post-operative results of the augmented breast will appear to be an enlarged, magnified version of the original. Apart from concerns about attainable shape, volume, and a natural versus fake appearance of augmented breasts, there are several unique anatomical considerations that may affect the potential outcome of your breast augmentation.

Certain patient characteristics cannot be altered by surgery but will have a significant impact on the final shape of the breast. These factors include width of the rib cage and chest, the shape and concavity of the breast bone, the volume of the existing breasts, and quality and elasticity of the skin. Some of these issues are discussed below. Since many of these anatomical factors cannot be changed by surgery, all patients must be aware of the influence these may have on their final outcome.

Breast Asymmetry

The position of the inframammary fold (the fold where the bottom of the breast meets the chest) and position of the nipples have a large impact on the shape of the final implant result. Most women have some degree of asymmetry of the breasts, which is normal. Surgery may correct certain types of asymmetry such as difference in the height of the nipple and inframammary fold. However, volume and size differences of the breasts can be corrected by adjusting the size of the implant.

Determining Cleavage

The depth and width of cleavage achieved in breast augmentation is not equal for every patient, and is dependent on several factors. Chest wall contour and breastbone prominence, the amount of body fat, and the thickness of tissue over the breastbone all influence the smoothness of the contour transition from sternum to the breasts. The starting separation between the breasts and the position of the nipple on the breasts also influence the final result. These anatomical factors vary greatly from patient to patient.

Prominence of the Upper Chest Wall & the Breast Bone

The shape of the bones in the chest wall (breast bone and ribs) will have a noticeable impact on the final shape of the augmented breast. Women who have a prominent breast bone may have a larger intramammary space (the space between the breasts). This limits the amount of cleavage that can be produced and will also affect the position of the breasts on the chest wall. In order to compensate for these anatomic differences, Dr. Zemmel may choose to use a high profile implant in situations where the breastbone is excessively prominent. This will give a large breast volume and projection for a given width of implant. This will allow the breasts to face a more forward direction.

Tuberous (Tubular or Constricted) Breast Shape

The original breast shape, proportion, and form will impact the final result after breast augmentation. In certain women the starting point shape of the breasts will completely prevent the desired augmented shape unless action is taken to reshape the breast tissue and skin distribution. The tubular or tuberous breast is one such situation where the original breast shape requires modification in addition to a normal augmentation.

The “typical” candidate for breast augmentation will have a relatively pyramidal shape to the breast. The nipple level will be well above the level of the inframammary fold (the crease below the breast where it meets the chest wall), and the skin and breast tissue will be evenly distributed over the chest wall. When an implant is placed beneath the muscle, this results in a proportional enlargement of the original breast. The original proportions and slight variances of the breasts will be magnified. Small asymmetries present before surgery will also remain after surgery.

Larger differences in size, width and position of the breast can be corrected with additional maneuvers during surgery, and Dr. Zemmel will discuss this with you in detail at your consultation.

The tubular breast has many variations, but all share certain common features:

Augmentation alone will result in the appearance of the native breast remaining well-defined atop the new implant mound. It will appear as if the small constricted breast is sitting on top of the implant. If the original narrow breast base diameter and constricted breast tissue are not treated, a natural, well-contoured breast will not result. Several maneuvers must therefore be performed in order to correct the tuberous breast.

First a breast augmentation is performed through a periareolar approach. The implant will be placed below the muscle. A Benelli-type mastopexy (breast lift) can be performed to reposition the tight breast tissue over the new breast mound. Areola diameter is also reduced with this type of breast lift. The breast tissue itself is also radially cut (scored) to allow it to flatten and redrape over the implant (similar to the opening of an umbrella). The incisions are then closed with absorbable sutures placed under the skin of the areola.

Placing Breast Implants Over vs. Under the Muscle

Breast augmentation involves surgical placement of the breast implants either over the pectoralis muscle (subglandular) or underneath (submuscular). Dr. Zemmel typically prefers to place implants beneath the pectoralis muscles to enhance breast size and shape, as this limits implant edge visibility. In addition, he finds this technique reduces the tendency to show visible wrinkling of the breast implant and gives a much more natural look and feel.

The left figure shows a subglandular placement of the implant. The right figure shows a submuscular implant placement.

Subglandular Implant Placement

Implant placement over the muscle in the subglandular position puts the implant in complete contact with the breast tissue. This typically results in a more rounded augmented look, which some women prefer. The advantages of this technique include ease of the surgery, which can be accomplished by almost any surgeon; avoidance of a breast lift, although one is usually needed later; and less post-operative discomfort, since only skin and breast tissue are operated on.

This approach allows for the insertion of oversized implants, which is what some women desire. Disadvantages are marked interference with mammograms, clear visibility and feel of implant edges, visible and palpable rippling of the skin over the implants (especially with any textured implants), higher rate of capsular contracture, high rate of downward migration or “bottoming-out,” and difficulty correcting later sagging problems when they occur. Dr. Zemmel rarely recommends placing the implants over the muscle.

Submuscular Implant Placement

Submuscular implant placement is when the implant is mostly covered with the pectoralis muscle. This can be accomplished through an areola (nipple) incision, an inframammary, or transaxillary incision. This allows the implant to be covered at its uppermost aspect by muscle, while only the lower part of the implant is covered by breast tissue.

This has many advantages including separating the implant from the breast tissue, allowing for minimal interference with future mammography and breast diagnostics. The breast is recontoured at the upper pole, which hides the edge of the implant. Submuscular placement also allows the breast to form a natural “tear-drop” configuration and reduces the rate of capsular contractures. Dr. Zemmel performs nearly all breast augmentation procedures via this technique.

Where Are Breast Augmentation Incisions Made?

Dr. Zemmel usually accomplishes submuscular placement of breast implants via a periareolar, inframammary, or transaxillary (armpit) approach. While all three approaches can provide excellent enlargement of the breast with enhancement in contour, each technique has its unique benefits.

Inframammary Technique

The inframammary technique is the oldest and most traditional technique. It uses a small 2.5 cm (approximately one inch) incision placed in the lower breast fold. This is the crease where the breast meets the chest wall. The approach provides the most direct access for placing the implant in the submuscular pocket. The breast tissue itself is not operated on, and therefore the chance of altering nipple sensation is significantly less. It allows easy access to the pectoralis muscle for release. This approach also has an extremely low complication rate.

The scars typically heal very well, and at 6 to 12 months after surgery becomes a fine line well hidden in the breast fold from the frontal view. Most women can hide the faded scar when in a normal bikini. The scars, however, may be slightly visible when lying down nude as the breast moves higher on the chest wall. This approach can be used in most women who desire a primary breast augmentation without a breast lift.

Periareolar Technique

The periareolar technique uses a small 3 cm incision located around the bottom of the areola (the dark skin around the nipple). The incision is placed at the juncture between the areolar and chest wall skin to hide it. The scars from this incision heal very well. The main benefit of this approach is that the incision is located in a very inconspicuous location and can be covered even with the most revealing clothing. It also provides excellent access to the submuscular pocket.

Because the breast tissue itself is operated on, the risks of alterations in nipple sensation are greater. This approach can also be used in women desiring primary breast augmentation or women who require a breast lift. Women must have a large enough diameter nipple/areola in order to benefit from this technique.

Transaxillary Technique

The transaxillary approach uses a small 2 cm incision located in the deep fold of the armpit. The most important benefit of this technique is that the breast is left without any incisions. The armpit scar, however, may be visible when in a tank top or in a bikini as the arms are raised. Dr. Zemmel will consider performing this technique if requested by a patient.

How Should I Prepare for My Breast Augmentation?

Dr. Zemmel will give you instructions to help you prepare for surgery, including guidelines on eating and drinking, when to stop smoking, and taking or avoiding certain vitamins and medications. While making the necessary preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days, if needed.

What Does the Breast Augmentation Procedure Involve?

Breast augmentation can be performed with general anesthesia, so you’ll sleep through the entire operation. Some surgeons may use a local anesthesia, combined with a sedative to make you drowsy, so you’ll be relaxed but awake, and may feel some discomfort. Please consult with Dr. Zemmel on which type of anesthesia you prefer.

The method of inserting and positioning your implant will depend on your anatomy and Dr. Zemmel’s recommendation. The incision can be made either in the crease where the breast meets the chest, around the areola (the dark skin surrounding the nipple), or in the armpit. Every effort will be made to assure that the incision is placed so resulting scars will be as inconspicuous as possible.

Working through the incision, Dr. Zemmel will lift your breast tissue and skin to create a pocket, either directly behind the breast tissue or underneath your chest wall muscle (the pectoral muscle). The implants are then centered beneath your nipples. Dr. Zemmel will discuss the pros and cons of each surgical approach with you, and together you will decide which method is best.

The surgery usually takes one to two hours to complete. Stitches are used to close the incisions, which may also be taped for greater support. A gauze bandage may be applied over your breasts to help with healing. You will be placed in a soft surgical bra for additional support.

What Can I Expect After Breast Augmentation?

You’re likely to feel tired and sore for a few days following your surgery, but you’ll be up and around in 24 to 48 hours. Dr. Zemmel will prescribe pain medication and antibiotics after surgery. Within several days, the gauze dressings, if you have them, will be removed, and you will continue to wear the surgical bra. The mild swelling and bruising should subside in 10 to 14 days. The sutures used to close the two small incisions will be absorbable and underneath the skin, so they will not need to be removed.

You may be able to return to work within a few days, depending on the level of activity required for your job. Dr. Zemmel will instruct you on when to begin exercises and normal activities. Your breasts will probably be sensitive to direct stimulation for two to three weeks, so you should avoid much physical contact. After that, breast contact is fine once your breasts are no longer sore, usually three to four weeks after surgery.

Routine mammograms should be continued after breast augmentation for women who are in the appropriate age group, although the mammographic technician should use a special technique to assure that you get a reliable reading, as discussed earlier.

What Are the Risks of Breast Augmentation?

Breast augmentation is a common and relatively straightforward operation to perform. But with any operation, there are inherent risks associated.

The most common problem is called capsular contracture. This occurs if the thin layer of scar around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or “scoring” of the scar tissue, or perhaps removal or replacement of the implant.

As with any surgical procedure, excessive bleeding following the operation may cause some swelling and pain, and in rare cases another operation may be necessary to remove the accumulated blood.

A small percentage of women develop an infection around an implant. While this may occur at any time, it is most often seen within one week after surgery. In rare cases, the implant may need to be removed for several months until the infection clears. A new implant can then be inserted.

Some women report that the sensation in the nipples becomes oversensitive, under-sensitive, or even numb. You may also notice small patches of numbness near your incisions. These symptoms usually disappear within time, but may be permanent in some patients.

There is no evidence that breast implants will affect fertility, pregnancy, or your ability to nurse. If, however, you have nursed a baby within the year before augmentation, you may produce milk for a few days after surgery. This may cause some discomfort, but can be treated with medication prescribed by Dr. Zemmel.

Occasionally, breast implants may break or leak. Rupture can occur as a result of injury or even from the normal compression and movement of your breast and implant, causing the man-made shell to leak. If a saline-filled implant breaks, the implant will deflate in a few hours and the salt water will be harmlessly absorbed by the body. The implant will then need to be replaced.

A few women with breast implants have reported symptoms similar to diseases of the immune system, such as scleroderma and other arthritis-like conditions. These symptoms may include joint pain or swelling, fever, fatigue, or breast pain. Research has found no clear link between silicone breast implants and the symptoms of what doctors refer to as “connective-tissue disorders,” but the FDA has requested further study.

While there is no evidence that breast implants cause breast cancer, they may change the way mammography is done to detect cancer. When requesting a routine mammogram, be sure to go to a radiology center where the physicians are experienced in the special techniques required in patients who have breast implants. Additional views will be required. Ultrasound examinations may be of benefit in some women with implants to detect breast lumps or to evaluate the implant.

While the majority of women experience no complications, Dr. Zemmel will discuss each one of these in detail so you have a clear understanding of the risks of breast augmentation.

What Will My Breast Augmentation Scars Look Like?

You can expect your scars to be firm and pink for at least six weeks. Then they may remain the same size for several months, or even appear to widen. After several months, your scars should begin to fade, although they will never disappear completely.

A common concern for some patients, such as African American women, is the fear of heavy scarring (also known as hypertrophic scarring) or keloid scarring (pathologic scarring). These terms are used interchangeably, but they represent separate physiologic processes.

What Can I Expect in My Final Breast Augmentation Results?

For many women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance. Your decision to have breast augmentation is a highly personal one that not everyone will understand. The important thing is how you feel about it. If you’ve met your goals, then your surgery is a success.

Regular examination by Dr. Zemmel and routine mammograms for those in the appropriate age groups at prescribed intervals will help assure that any complications, if they occur, can be detected early and treated.

How Can I Prevent Capsular Contracture?

One of the most common complications of breast augmentation is the development of a foreign body reaction called capsular contracture. Any foreign material placed within the body will cause a reaction. All materials including suture, silicone, metals, and plastics cause a thin scar to form around the implant separating it from the rest of the body. The scar attempts to place the implant in the smallest volume possible by contracting. In most patients (greater than 98%) the scar remains thin and soft and undetectable. In a small minority of patients, the foreign body reaction is more robust and the capsular scar is thicker. Dr. Zemmel uses several ways to limit the amount of scar production before, during, and after surgery.

Refrain from Smoking

First, it is essential to maximize the potential for wound healing by providing optimal amounts of oxygen and nutrients to the wound. Smoking impairs wound healing and should be stopped at least 4 weeks prior to surgery to ensure the best results.

Limit Germs and Bacteria

It is also important to limit the amount of bacterial contamination around the implant. Dr. Zemmel observes the strictest sterile technique in the operating room to reduce the amount of bacteria around the implant. It is important to limit potential germ contamination at the time of surgery by adequate pre-op hygiene. Dr. Zemmel will instruct you to take a thorough shower the morning of surgery (using regular soap), and avoid shaving the armpits for a transaxillary approach for one week prior to surgery. This prevents ingrown hairs in the surgical field. A strong antibacterial prep is done at surgery with strict avoidance of germ contamination during the operation.

Special Surgical Technique

Dr. Zemmel creates an oversized submuscular pocket that is significantly larger than the implant, which allows the implant more room to form a capsule. This helps reduce the chance of a tight scar forming directly around the implant causing a visible or palpable scar.

Massage Your Breast Implants

Finally, Dr. Zemmel instructs all patients to begin early, vigorous post-operative massage of the implants, fully displacing them throughout the entire oversized submuscular pocket. This is used to keep the implant pockets wide open, soft, and freely moveable. This will eventually give a natural feel and appearance to the breast.

How Are Mammograms Performed with Breast Implants?

Prospective candidates over age 40 should receive yearly mammograms in accordance with the guidelines of the American Cancer Society. How breast augmentation may interfere with future mammography must be considered throughout treatment.

For this reason, Dr. Zemmel prefers submuscular placement of breast implants, which has no significant impact on breast self-examination or mammograms. After breast augmentation, women must obtain mammograms at centers experienced in using specialized Eklund displacement views.

How Much Does Breast Augmentation Cost?

Breast augmentation costs an average of $7,700 to $8,200 at Richmond Aesthetic Surgery. Since every patient receives a surgical plan tailored to their unique needs and aesthetic goals, this cost will vary for each individual.

Our team will provide you with a quote by the end of your consultation based on your treatment plan, helping you budget for your procedure. Insurance companies do not consider breast augmentation to be medically necessary, and carriers generally do not cover the cost of this procedure.