According to The Aesthetic Society, the number of breast augmentations performed in the U.S. has increased by 89 percent since 2020, with 375,000 performed in 2021 [2022 stats were not yet released at time of press]. Though trends have shifted over the years, demand for more fullness with the help of implants is greater than ever. Need more proof? More than 1.3 million people liked TikTok “it girl” Alix Earle’s video detailing her breast surgery, which she shared after being flooded with questions from followers. Here’s what the experts want you to know about the procedure.
What happens before breast augmentation
There is a lot of information to cover during a consultation for breast augmentation, and the surgeon should take their time with the patient, says New York plastic surgeon B. Aviva Preminger, MD. “I ask what bothers the patient about the appearance of their breasts, what expectations they have, and what look they are trying to achieve. I perform a breast exam and take precise measurements, photos and a 3-D image. We talk about options, and the patients touch and feel different types of implants and learn about the risk and benefits of each. They also try on different sizes of implants with a sizing bra.”
Glen Carbon, IL plastic surgeon Ryan Diederich, MD says many top surgeons have significant wait times, so it’s best to plan your procedure timeline backward from your goal date to ensure you can meet it. “At my practice, we often plan a tentative procedure date during the first phone call, even prior to consultation, to make the process as seamless for the patient as possible.” Depending on the patient’s goals and schedule (and the surgeon’s), the surgery may take place a few weeks post-consult, or a few months.
“Prior to breast augmentation, it’s important for patients to optimize their health to make sure they are positioned for the best possible outcome while limiting the procedural risks,” Dr. Diederich says. “This includes a healthy lifestyle with a well-balanced diet, avoidance of all nicotine exposure, and maintaining a stable weight.” San Diego plastic surgeon Larry H. Pollack, MD advises patients to avoid ibuprofen, which can thin the blood, for two weeks prior to the procedure, and to increase their intake of vitamin C to boost their immunity.
Saline vs. Silicone
According to Houston plastic surgeon Henry Mentz, MD, silicone implants are pre-filled with a silicone gel that is similar in texture to natural breast tissue, while saline implants are filled with sterile saltwater after they have been placed in the breast. “Many patients prefer silicone because they think the gel, which is contained within a solid silicone outer shell, provides a more natural feel and look,” he says. “However, if a silicone implant ruptures, it can go easily unnoticed because the silicone tends to remain inside the capsule (intracapsular rupture) and the breast changes little in appearance. If leaking should occur with a saline implant, it is usually quickly apparent because the implant deflates.”
Shape + Profile
Implants come in either round (the more traditional and popular option) or teardrop-shape. “My preference is to use round, smooth implants, which come in various profiles,” says Dr. Mentz. “For instance, a low-profile implant is a bit wider with less projection than a ‘high-profile’ implant that will project outward more. There are also several options in between.” Breast implant manufacturer Natrelle offers smooth silicone implants in five profiles, ranging from low to extra-full projection. For those who want more cleavage, doctors typically recommend low- profile implants.
Breast implant sizes are measured in ccs (cubic centimeters), which describes how much space an implant fills. “Ten years ago, the average volume was much larger,” says Dr. Pollack. “Today, the trend is a smaller, perkier look or a more athletic one. We are also seeing a trend in ‘downsizing’ for women reaching their 50s. After having large implants for many years, they are choosing to go smaller to avoid feeling top-heavy as they age.” Dr. Mentz agrees, noting that the average implant size in the ‘90s and 2000s was 375 to 400-ccs (a full C or D cup), but now patients tend to lean more toward the 250 to 275-cc range (a small C/full B cup).
Incisions + Scarring
Three unique incisions, or entry points, can be used to insert implants. Dr. Diederich says the inframammary fold (the crease below the breast) is the most common approach based on safety data; however, this can vary depending on the patient’s needs. “The inframammary fold incision allows the scar to be covered by the breast in most cases,” adds Dr. Preminger. The periareolar incision involves cutting around part of the nipple, which lets the scar blend into the surrounding tissue. Lastly, the transaxillary approach involves placing the implants through the armpit to help avoid scars on the breasts. This does result in a small scar in the armpits, however. Regardless of the entry point, the scars are usually fully healed within six to 12 months.
Depending on the amount of breast tissue the patient has and how active they are in their lifestyle, implants can be placed in three different pockets: above the muscle, under the muscle, or more of a hybrid known as subfascial. “Subfascial means placing the implant between the covering ‘fascia’ of the pectoralis muscle and the muscle,” says Dr. Diederich. “Like scar location, many surgeons are passionate about the pocket choice, but it depends on the patient.”
Eugene, OR plastic surgeon Mark Jewell, MD says the subfascial approach provides excellent outcomes. “It avoids breast movement that leads to implant malposition when the pectoralis muscle contracts.”
THE BREAST IMPLANT REGISTRY
In collaboration with the FDA, the Plastic Surgery Foundation created the National Breast Implant Registry (NBIR) in 2018. “It’s an important quality improvement initiative and safety surveillance registry that collects clinical, procedural and outcomes data at the time of operation, as well as any subsequent reoperations for all patients who receive breast implants in the United States,” Dr. Mentz explains. “To date, more than 1,500 physicians have registered to participate, and more than 78,000 breast implant cases have been entered.”
The Aesthetic Society’s free Aesthetic One app, a HIPAA-compliant platform, allows doctors to share breast implant ID cards, operative summaries, photos, and more with their patients in a quick, easy-to-use format.
What happens after breast surgery
“For the first few days, your chest will feel tight and you will feel pressure until the pocket starts to stretch,” Dr. Pollack says, noting that swelling also occurs, and pain medication can be prescribed to help with any discomfort. Arnica and bromelain supplements can also help minimize swelling. “During this period, lots of rest and little movement of the upper body, other than range of motion, is recommended,” he adds. “I also emphasize sleeping on your back slightly elevated and not on your side, as this could cause swelling or bleeding.”
Expect to take at least one week off work for desk-jobs and longer for more physically demanding roles. A one-month hiatus from exercise is also standard for most patients.
The pros and cons of fat transfer
Though implants are still the most popular choice for adding fullness to the breasts, fat transfer (the fat is usually taken from the patient’s thighs or stomach via liposuction; donor fat can also be used) can increase their size as well. One key advantage of fat transfer, as Dr. Diederich points out, is that “it utilizes your own tissue—no foreign body—and once the fat has survived, it is yours forever. This is assuming you don’t experience a major weight fluctuation that could change the breast volume.”
Dr. Preminger loves using fat to augment the breasts, but says it often isn’t enough alone to achieve patients’ larger size goals, particularly if they are thin. “In this case, I will recommend a composite augmentation using a small implant and fat together for a natural result,” she explains. “It is also important to remember that not all of the fat that is transferred to the breasts lasts long-term, and that overfilling the breasts with fat may actually cause less of the fat to survive and last.”
Dr. Diederich adds that “other disadvantages are if you desire a significant volume increase, it may take multiple fat transfer procedures, and fat typically does not resist gravity over time in the same way a breast implant does.”
The explant equation
Some patients begin to have what Dr. Diederich calls “implant fatigue,” which is when they’ve had their implants for decades and are just ready to live life without them. “As a result, we are seeing an increased number of implant removals, with or without complementary procedures such as a breast lift or fat transfer,” he says.
In other cases, “explants” are performed to relieve patients of symptoms associated with Breast Implant Illness (BII), such as joint pain, fatigue and hair loss. Last year, a study on BII conducted by The Aesthetic Society and The Aesthetic Surgery Education and Research Foundation (ASERF) revealed that 94 percent of subjects showed improvement of at least some of their symptoms within the six months after their implants were removed. However, multiple studies reveal that more than 90 percent of patients who have had breast augmentation with implants are happy with their results.