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Techniques
Augmentation choices are the fill, the incision and the pocket. Lifts and reductions are named for the scar. Surgeons combine them.
By choice
Layer or pattern. Silicone shell filled with sterile salt water, pre-filled or filled during the operation
Inflatable saline implants have been in use since 1965. Some are pre-filled and others are filled during the operation. If the shell leaks, the implant collapses and the body absorbs the saline.[1][2][3]
Suits. Augmentation in women 18 and older.
Trade-offs. In 645 textured saline implants, deflation was 0.3% at 1 year, 2.2% by 3 years and 5.3% by 5 years.
Layer or pattern. Silicone shell filled with silicone gel
The first silicone gel implant was placed in 1962. The FDA approved the Allergan Natrelle and Mentor MemoryGel silicone implants in November 2006. The gel feels more like breast tissue, and a leaking gel implant does not collapse.[1][2][3]
Suits. Augmentation in women 22 and older.
Trade-offs. Most ruptures are silent; MRI is the most effective test and ultrasound an acceptable alternative. In the Mentor Core Study, 24.2% of primary augmentation patients had a rupture by 10 years.
Layer or pattern. Thicker, cross-linked gel that holds its shape
Form-stable implants, also called gummy bear implants, keep their shape even if the shell breaks. They entered US use under an investigational study in 2001, and three companies had FDA approval by 2014. Shaped versions have more projection at the bottom.[1][2]
Suits. Patients who want a fixed shape and accept a firmer feel.
Trade-offs. They are firmer than standard gel, need a slightly longer incision, and a shaped implant that rotates may need another operation.
Layer or pattern. Fat taken by liposuction and injected in small amounts at many levels of the breast
Fat is taken by liposuction from another part of the body and injected into the breast. Coleman reported 17 breast fat grafting procedures and argued against a 1987 position paper that had called for prohibiting it.[1][2][3]
Suits. A small increase in size without an implant.
Trade-offs. Across 35 studies and 3,757 women, average volume retention was 58% and the complication rate 27.8%; fat necrosis was 43.7% of complications.
Layer or pattern. Fold under the breast, edge of the areola, armpit or navel
Implants go in through the fold under the breast (inframammary), the edge of the areola (periareolar) or the armpit (axillary). Johnson and Christ placed 188 saline implants through the navel in 91 women.[1][2][3]
Suits. In a meta-analysis, the inframammary fold had less capsular contracture than the periareolar incision.
Trade-offs. The belly-button approach has a higher complication rate, and the FDA lists it as a non-approved incision site that can cause rupture.
Layer or pattern. Behind the gland, behind the pectoral fascia, or behind the pectoralis major
A subglandular implant sits behind the breast tissue over the muscle; a submuscular implant sits under the pectoralis major. Graf added the subfascial plane, between the muscle and its fascia, in 263 patients from 1998 to 2001.[1][2][3]
Suits. Submuscular placement had the lowest capsular contracture in a 91-study meta-analysis, 1.83%.
Trade-offs. Capsular contracture was 6.85% subglandular and 2.80% subfascial. In the Natrelle Core Study, contracture at 10 years was 15.7% submuscular and 26.3% subglandular.
Layer or pattern. Upper implant behind the muscle, lower implant behind the gland
Dual plane combines a retromammary and a partial retropectoral pocket in one patient. Tebbetts reported 468 patients treated from 1992 to 1998 as outpatients under general anesthesia.[1][2]
Suits. Sagging breasts and breasts with a constricted lower pole, where one pocket alone has limits.
Trade-offs. Capsular contracture was 1.99% across 15,480 dual plane patients, against 1.83% fully submuscular.
Layer or pattern. Scar around the areola, down to the fold and along the fold
Wise published a method for planning the mammaplasty in 1956, to make reduction outcomes safer and more predictable. The scar runs around the areola, down to the fold and along it. With very large breasts the nipple may be moved as a free graft and loses sensation.[1][2][3]
Suits. Large breasts and marked sagging with a lot of extra skin.
Trade-offs. In the BRAVO study of 179 reductions, 43% had a complication; each 10-fold increase in resection weight raised the risk 4.8 times.
Layer or pattern. Scar around the areola and straight down, none along the fold
Lassus began vertical mammaplasty in 1964 and reported 710 patients. Lejour added liposuction of the breast in 1994, removing 120 to 1,600 g per breast. Hall-Findlay used a medial pedicle in 400 reductions, averaging 525 g per breast.[1][2][3]
Suits. Small and large reductions and lifts, with a shorter scar.
Trade-offs. In BRAVO, vertical incisions were linked to more complications. Lejour excised extra skin at the bottom of the scar months later in 10% of patients.
Layer or pattern. Scar only around the areola, held with a circular nonabsorbable suture
Benelli confined the scar to the edge of the areola and held it with a circular nonabsorbable nylon suture. The same approach gives access to place an implant while correcting sagging.[1][2][3]
Suits. Mild sagging, small reductions and augmentation with a lift.
Trade-offs. In a meta-analysis of 4,856 single-stage augmentation-lift cases by all methods, complications were 13.1%, recurrent sagging 5.2% and reoperation 10.7%.
Layer or pattern. Implant alone, or implant with part or all of the scar capsule
The implant can be removed alone, leaving the capsule, or with a partial or total capsulectomy, sometimes called en bloc resection. In 87 patients with BIA-ALCL, total capsulectomy with implant removal gave better survival than partial capsulectomy, chemotherapy or radiation.[1][2][3]
Suits. Capsular contracture, rupture, BIA-ALCL, or a patient who no longer wants implants.
Trade-offs. Leaving the capsule needs less dissection and carries less risk of bleeding. Without replacement the breast may sag or dimple.