Breast augmentation is perhaps the most frequently performed cosmetic procedure worldwide. Small breast tissue can result from insufficient breast development or a decrease in volume over time. Breast reduction due to reasons other than developmental factors often occurs after pregnancy, particularly after breastfeeding or significant weight loss. Insufficient breast volume compared to normal can lead to negative body image, feelings of inadequacy, and decreased self-esteem. These issues can negatively impact a person’s social relationships, sexual activity, and quality of life. With the increasing importance of body image, changing societal expectations, and rising acceptance of cosmetic surgery, there has been a rapid increase in breast augmentation surgeries both in Turkey and worldwide.

Breast augmentation surgery first began in the 1950s with the direct injection of various solid and semi-solid substances into the breast tissue. Epoxy resin, beeswax, paraffin, petrolatum (vaseline), and liquid silicone are some of the substances used. Liquid silicone was originally developed in the aviation industry during World War II. This material was first used for breast augmentation in 1961, but it was abandoned due to adverse effects such as recurrent infections, long-term inflammation, discharge, swelling, and tissue loss. Finally, in 1962, the first modern breast implant was produced, consisting of an impermeable silicone elastomer shell on the outside and sterile saline or silicone gel inside.

Since that date, implants filled with both silicone gel and saline have undergone various technical changes and improvements; eventually, fourth-generation silicone implants emerged and were approved by the FDA in 2006. With the production of 5th-generation implants, which have a flatter, wider, and more curved top and a more protruding, domed, and rounded bottom, the aim was to achieve more natural-looking results in both breast augmentation and breast reconstruction surgeries after breast cancer. These are also called teardrop-shaped (anatomical) implants. Currently, the most widely used FDA-approved 4th and 5th generation implants in the US and in our country are produced by Mentor and Allergan. Worldwide, implants produced by these two major brands are used by plastic surgeons as the safest products.

Surprisingly, silicone-based materials are actually a part of our daily lives. Society has been encountering these materials for over 50 years through hairsprays, tanning lotions, and moisturizing creams. Due to its water-repellent nature, silicone is resistant to the activity of biological enzymes when placed inside living tissue. This makes silicone-based materials stable and inert. Because they are biologically inactive, they do not affect the immune system. Extensive research has shown that silicone gel implants are not associated with connective tissue diseases or diseases affecting the immune system.

The initial assessment of a woman seeking breast augmentation at a cosmetic surgery clinic is crucial. As with all aesthetic procedures, we believe it’s essential to patiently listen to the patient’s concerns before proceeding with the examination and detailed evaluation. Even if we know the problem they’re experiencing, we should avoid interrupting or asking questions. This is important because it provides valuable insights into the patient’s approach to their problem, whether their social and family life is affected, and their mental health. It also allows for a more relaxed and sincere communication, helping the patient overcome initial anxiety and shyness, and fostering a closer connection with us, rather than the traditional doctor-patient relationship of complaint-examination-diagnosis-treatment. We know that many patients today often spend time gathering information about this procedure through friends or the internet. Even when this isn’t the case, providing detailed information about the procedure can fill in any gaps in knowledge and correct any misconceptions. A well-informed patient with balanced mental health and realistic expectations is a suitable candidate for this procedure. A detailed medical history and physical examination reveal risk factors, and knowing about these is important for taking the necessary precautions during the treatment process. We generally recommend pre-operative mammography for women over 35 or at any age if we know they are in a high-risk group for breast cancer.

The ideal size and shape of a woman’s breast is a relative concept and varies according to both personal preference and cultural norms. However, there is a common consensus on some characteristics that represent the ideal form of a woman’s breast. These include a sloping or full upper pole and a slightly curved lower pole where the nipple is located at the most prominent point of the breast. The resulting breast shape after breast augmentation surgery depends on the dynamic interaction of the breast implant, the breast tissue, and the surrounding skin and soft tissue covering.

During the examination, the soft tissue pinch test is important for understanding the thickness of the soft tissue covering and planning the placement of the implant. The amount, volume, and distribution of breast tissue are also important, as shaping of the breast tissue may be necessary to achieve the desired breast shape. Preoperative planning is of paramount importance. The choice of entry point, whether the implant will be placed under the muscle, submuscularly, under the breast tissue, or in a dual-plane configuration, the type, volume, width, length, fullness, and degree of protrusion of the implant, and whether a breast lift is needed, are all determined based on detailed preoperative examination, measurements, and analyses. We can show the patient the probable outcome based on these analyses. After performing a body scan with a three-dimensional sensor, we virtually apply the desired volume and type of implants, essentially performing a virtual surgery. This allows the patient to instantly see the result on their own three-dimensional image and even understand how it will look when wearing clothes. Based on our observations and experience, we believe this increases patient confidence. We’ve seen that some patients express hesitation about undergoing surgery without knowing what to expect.

The most common incision site for breast augmentation is the inframammary fold. Silicone gel implants typically leave a 5 cm scar. This approach provides the best visualization of the surgical area and allows for precise placement of all implant types. Nipple incision, made at the junction of the nipple and skin, leaves a scar that is generally inconspicuous in individuals with fair skin. This method allows for easier adjustment of the inframammary fold and provides a direct entry point to free up the area in patients with stenosis in the inframammary fold. Disadvantages include limited visibility of the surgical area during the procedure, increased risk of infection due to cutting of breast tissue ducts, increased risk of changes in nipple sensitivity, and the possibility of a visible scar on the breast. It is not suitable for every patient. It is not preferred for individuals with nipple diameters under 40 mm or those who will receive large implants. The axillary incision method uses an endoscope, allowing for precise tissue separation and clear visualization of the surgical area via monitor. Both silicone gel and saline-filled implants can be placed under the muscle or under the breast tissue. Disadvantages include the inability to modify the breast tissue if necessary, and the need for an incision through the breast for secondary surgeries requiring correction. Furthermore, precise implant placement can be somewhat challenging with this method, and round implants are preferable to teardrop-shaped (anatomical) implants. The advantage of breast augmentation through the navel is that it leaves a well-hidden, distant, and inconspicuous scar. However, due to the narrow incision site, silicone gel implants cannot be used; only implants inflated with saline after placement can be used. Similar to the armpit approach, a second incision through the breast is necessary for corrective surgeries. The choice of incision site depends on the condition of the breast, the patient’s wishes, and the surgeon’s experience. For example, for patients who do not want any scarring on their breasts, have no problems other than a volume deficiency in the breast tissue, and do not require any intervention on the breast tissue, an armpit endoscopic approach may be a good choice.

Theoretically, the most accurate position for implants to achieve a natural-looking appearance is under the breast tissue, as normal breast tissue is located above the pectoral muscle. However, placing implants in this area increases their visibility and palpability. The submuscular placement should always be preferred, especially when the breast fascia is thin and has limited elasticity, meaning the pinch test is less than 2 cm. The submuscular placement may be slightly more advantageous than the submammary fold placement because it creates an additional layer between the implant and the fascia, but it should be remembered that this fascia is very thin. Submuscular implant placement eliminates problems such as the implant being palpable, but its disadvantage is that it does not provide sufficient protrusion at the lower pole, thus failing to provide a natural breast appearance. Due to this disadvantage, a two-plan method has been described, and this is the method we use most frequently. In this technique, the upper part of the implant is placed under the muscle, while the lower part, which makes the breast protrude more, is located directly under the breast tissue and fascia. This reduces palpability and provides a natural breast appearance. There are also three different subtypes that can be applied depending on the condition of the breast skin and sagging. With this method, we can even achieve a certain degree of lifting in breasts with mild sagging using only implants, without the need for a full breast lift.

Patient factors should be considered when choosing the implant shape. Typical round implants have their most prominent point at the center, and the remaining volume is evenly distributed across the base of the implant. In contrast, anatomically shaped implants have flatter and thinner upper poles; most of the volume and protrusion are concentrated at the lower pole. Therefore, an anatomically shaped implant with a certain base width and volume will provide less upper pole fullness than a round implant of the same volume and width. This feature of anatomically shaped implants is particularly beneficial for individuals who desire significant breast enlargement but have a relatively narrow breast width.

We generally use implants with a textured surface to reduce the risk of a postoperative side effect called “capsule contraction.” This side effect is observed more frequently in implants with smooth surfaces. Normally, a capsule forms around a placed implant due to the body’s reaction to a foreign object. However, if a surrounding and tense connective tissue, or scarring, forms around this capsule, causing hardening, deformation, and displacement of the implant, this is called capsule contraction (tension). The risk of such a complication is reduced if implants of appropriate volume, type, and size are placed in pockets of appropriate width created during breast augmentation. The only disadvantage of these implants is the risk of rotation within the body; because, unlike round implants, the silicone gel is not evenly distributed throughout, the area with the greatest volume should remain at the bottom. In case of rotation, this situation changes, and deformities and asymmetries may be observed in the breast. To prevent this, the implant pocket is opened just enough to accommodate the implant; wider separation is not performed. Even with round implants, when the patient is standing, the silicone gel tends to accumulate towards the lower pole due to the effect of gravity. This creates a shape similar to anatomical implants, but this wrinkling in the implant shell can damage the outer edge of the implant over time.

As you can see, breast augmentation is not as simple as filling an empty space. It is based on a certain logic and requires experience. Every woman has a different breast structure, different desires, a different body type, a different perception, and a different breast coverage characteristic. All of these must be taken into consideration when deciding on the technique, implant type, size, and volume to be used. The width and protrusion ratio of breast implants are more important than the volume, or size, of the implant. For example, placing an implant with a width of 12.5 cm in a patient with a breast width of 12 cm will not only fail to give a good result but will also bring with it the possibility of postoperative problems. Manufacturers offer dozens of different sizes, shapes, and types of implant options with the same volume. An implant that gives a perfect result for one patient may not even provide a moderately good appearance for another patient, even if they have similar breast characteristics. Implants of the same volume, size, weight, and type do not provide the same breast size in different patients. Therefore, thinking, “My friend got a 350cc implant, it looks great, I want the same,” is not a realistic approach.

Deciding on the type and size of implant through trial and error during surgery is incorrect practice. The implant to be placed and the technique to be applied should be determined before the surgery. This decision is made after a detailed analysis, a meticulous preoperative evaluation, measurements, and the patient’s wishes are revealed. Generally, after showing the patient the changes the implant provides in the breast using three-dimensional simulation programs and obtaining their approval, we perform trials of implants of a higher and lower volume during the surgery. We place the implant that gives the desired result among the three implants.

We usually discharge patients after a one-night hospital stay. We recommend chest and arm stretching exercises after surgery. The time it takes for patients to return to work generally ranges from 3 to 5 days; however, we do not recommend strenuous exercise for 2-3 weeks. We provide our patients with a post-surgical bra to wear for 3-4 weeks. Bleeding is an early complication and may require further surgery. To prevent this, we recommend that patients discontinue all blood-thinning medications and herbal remedies and teas one week prior to surgery. In addition, infection can occur, although rarely. Late-stage capsule constriction may occur; if it is bothersome, further surgery may be necessary to re-examine the capsule.