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1. I find it pretty amusing that most plastic surgery web sites give you the same information. Once you
have read one of them, it is very difficult to find useful additional information on the others. It almost
seems like most of the doctors' offices use the same templated script with minimal changes. We
decided to do something different.
The goal of this web page is provide you with enough information about breast augmentation, so that
you feel comfortable coming to either our office or any other plastic surgeons office and being ready to
speak about breast enhancement surgery almost as an expert. You should be able to better spot when
you are getting straightforward answers or being up sold on something you do not need.
We will tell you how to look at the online pictures as an expert, what to look for, how to select a proper
size, how to select between saline and silicone implants, how to decrease your chances of capsular
contracture, what to expect from surgery and even how to negotiate with your plastic surgery office
without offending them and much more.
We want you to be able to refer to this page before and after the surgery with questions and we ask you
to contribute your advices to other patients.
Let's start, we will start with the basics of breast augmentation.
What is Breast Augmentation, or Breast enhancement?
Breast augmentation, also known as mammoplasty, is a surgical procedure designed to accentuate the
size and shape of a woman's breasts. Breast augmentation, or BAM, is tremendous help to patients who
desire a fuller profile, who have lost breast volume due to pregnancy or nursing, or who have undergone
breast reconstruction and want to gain a more natural look again. Breast augmentation surgery will
make the breasts larger.
Can Breast Augmentation surgery alone lift up the breasts at the same time?
Most surgeons will tell you that breast augmentation surgery alone will not produce a significant
elevation of the breasts. It is true Fortunately, it is only partially true. Our chest wall (rib cage
underneath) is not vertical. It looks more like a cone, wider at the base and narrower at the top. When
plastic surgeon places an breast implant, the soft tissues of the breast stretch out forward and a little bit
up. The taller the implant, the more elevation of the breast the patient will get. So, the correct answer
is that the breast implant surgery always produces a little bit of breast tissue elevation. The larger the
implant is, (high profile implants), the more breast elevation the patient will get as the result of breast
enlargement surgery. However, breast elevation alone does not mean a breast lift yet. Confused? do
not be. Keep reading.
When most surgeons talk about breast elevation, they focus on position of the nipple and areola in
relation to the center of the breast. If the nipple is positioned above the fold before breast
augmentation surgery and the breasts are not saggy, the stretching of the skin and breast tissue by the
implant will move both breast tissue and the nipple up, creating a nice lift. This is perfect for patients
with small non-saggy breast. Most of these patients will need only breast implants to get great result.

2. On the other hand, if the nipple is at or below the fold, stretching of the breasts by the implant will
create an opposite result. The breast tissue will stretch by the implant but the nipple will actually turn
downward and point to the toes, making the breasts looking worse. Some patients call it snoopy breast.
These patients usually need a breast lift surgery. Some surgeons can perform these surgeries together.
The others prefer to separate them. There is no universally correct way, it all depends on complexity of
surgery, consistency of the breast, associated risk factors, patient preference and risk tolerance. We will
talk about details later.
What are the options for Breast enhancement, or breast augmentation surgery?
There are several options for breast augmentation. Some are medical, the others are surgical. Overall,
there are 4 options: medications, non surgical systems, minimally invasive techniques with fat grafting
and, most commonly, breast implant surgeries.
Medications. There are plenty of medications on the web claiming to provide natural breast
enhancement without surgery. The idea is great. However, the only way the natural medication can
produce breast enlargement is by stimulation estrogen receptors, just like it happens during pregnancy
in women or gynecomastia in older men with increased level of estrogen in the bloodstream. Most of
these natural medications are derived from yam, soy or other herbs. They create increased levels of
estrogen or estrogen like substances in the bloodstream. The breasts may actually increase in size but
these medications (even though most internet promoters call them harmless) can also affect menstrual
cycle, ovarian function, promote uterine problems, interfere with activity of birth control pills and so on.
Long term effect of these substances is not clear but it is far from benign. There are no FDA or any other
studies, there are no government regulations, the promoters have no liability for any problems these so
called natural and benign substances can cause you. My advice, stay away. You do not want to find out
the you have a higher risk of fibrocystic breast disease or even potentially breast cancer many years
from now because you were taking them.
Non-surgical systems. The best known system is called BRAVA. It looks like 2 plastic cups attached to a
suction device. The patients would place them on their breast overnight and the device with create a
negative pressure. This pressure stimulates formation of connective and breast tissue and overtime
increases the breast size. This is not a new technology. We have been skeptical about it for years.
Most doctors do not use it because the results are not predictable, it does not create elevation of the
breast, like implant and because the maximal increase is about 1/2 cup size. However, over the last 5
years or so, the advances in fat grafting brought this device back to life. Keep reading, you will see how
it works next.
Fat grafting. Fat grafting is not new. Surgeons have attempted fat grafting for facial rejuvenation, hand
rejuvenation for years and more recently for breast enlargement and breast reconstruction after
mastectomy (surgery to remove the breast because of cancer). Original efforts of fat grafting onto the
breasts were not very successful. The survival of the fat was unpredictable, the fat cells would die and
form cysts filled with liquified fat, causing pain and deformation. Another concern was that the fat
globules could calcify and on mammograms to radiologist they could look like cancer. The patients

3. would potentially end up having biopsies to rule out cancer. However, more recently, some surgeons
demonstrated more success by perfecting fat processing techniques and adding BRAVA system to the
process. Newer methods of autologous breast augmentation is a two step process. First the patient
wears BRAVA system, stretching the breast tissue from outside and improving the blood supply. Then
the surgeon would take some fat from the abdomen, hips or thighs with micro-liposuction method
(using very small cannulas) and carefully inject them into the breast. According to some surgeons, the
results are much better, it does require a bit of experience, more than one session may be needed and
there is no implant. However, because of complexity of the surgery and multi-step process and
additional liposuction, the cost of autologous breast augmentation with fat is usually quite a bit higher
than the implant surgery. Because the surgeon is able to control where the fat is injected, some breast
elevation is possible. Most surgeons believe that this procedure is limited to 1 cup breast size increase.
The calcification concern had been also partially resolved. Apparently, the cancer related calcifications
are different on X ray to those coming from fat grafting. Overall, it is a great technique, it is gaining the
popularity in patients who are opposed to implants but it does have significant limitations and most
plastic surgeons are not actively doing it because of safety and longevity concerns.
Breast Implants. This is the most recognized and accepted method of breast augmentation. The
implants filled with either saline (salt water) or silicone are inserted above or below the muscle for
increasing the bust size. The surgery is most commonly performed on an outpatient basis at a hospital
or state-of-the-art surgical unit while the patient is under a general anesthesia and asleep.
There are several possible locations for the small incision that will be used for inserting the breast
implant. The most frequent technique utilizes an incision made in the lower portion of the breast.
Another technique, though less frequently used, involves making an incision in the armpit. A third
technique makes an incision around the areola (the darker skin surrounding the nipple). Another
technique uses an incision in the belly button, thus reducing the chance of scarring in the breast area.
The best technique is usually decided together between the patient and the surgeon during the
consultation.
During surgery, the breast tissue is raised to create an open pocket under the breast tissue or beneath
the chest wall muscle. Inserting an implant behind each breast can increase a woman's breast size by
one or more bra cup sizes.
We will discuss the differences, advantages, disadvantages and selection criteria later on.
Which Implants is better, saline or silicone?
This is a loaded question. These is no perfect implant. If there was one, every surgeon would use it.
Each implant has its own pros and cons.
Which brands of breast implants is better?
There are 3 main companies in US manufacturing FDA approved breast implants.

4. Mentor is one of the oldest and most reputable ones. The other one is Natrelle made by Allergan.
Allergan is the same company that makes Botox and Juvederm. Natrelle implants were previously
known as Inamed and McGhan. Natrelle brand is of the same quality as Mentor.
Both companies have superior product, similar size and shape selection, similar pricing and warrantee
structure. I honestly cannot tell you that one is better or worse than the other. Some surgeons are
faithful to one of these brands, the others use both. You cannot go wrong with any one of them. In the
car world, it is like comparing Mercedes and BMW, for example. It is a matter of personal choice.
The third company is Sientra. It had been approved by FDA in March of 2012. I do not have personal
experience with the company or their product, however, in casual conversations with my colleagues, the
product quality appears to be about the same. Let's hope that in the future we can say that we added a
Lexus to our car fleet of implants.
Where is the surgery usually performed?
Most breast augmentation, or breast implant, surgeries are performed by board certified plastic
surgeons in the hospital or accredited surgery centers. This is a very important question. You have to
make sure that your breast implant surgery is done at an accredited institution.
The hospitals are usually accredited by JCAHO. The outpatient surgery centers have to be accredited by
one of the 4 main agencies: Medicare, JCAHO, AAAHC, or AAAASF. If you do not see one of these 4
emblems on the surgery center, DO NOT DO IT THERE regardless of what you are told. No reputable
board certified plastic surgeon would perform breast augmentation surgery in a plain office, or plain
procedure room because of sterility concerns associated with breast implant surgery. This is true even if
the procedure is performed under local anesthesia only.
If you are traveling abroad for your surgery, consider looking for certification by JCI, Joint Commission
International.
Who can perform my breast augmentation surgery?
There is a significant difference between what is legal and what is appropriate.
By law any MD or DO can do your breast augmentation surgery as long as they have a medical license.
As a doctor, they do not have to have any surgical training at all. No reputable physician will perform
this surgery without proper training, however, it does not mean that all breast augmentation surgeries
are performed by trained surgeons. As a board certified plastic surgeon I can potentially do brain

5. surgery on my office and it is still legal. I do not have training to do brain surgery, and my malpractice
would not cover it, but it is legal.
So, what do you need to look for?
First is training. Your surgeon needs to be trained as a plastic surgeon. Not radiologist, pathologist, or
ear nose and throat doctor, not family physician or cosmetic gynecologist. You are looking for a plastic
surgeon. It is important not only because they are trained to do the breast augmentation surgery and
deal with complications. If you have a complications, like infection, for example, and need to be
admitted to the hospital, a cosmetic gynecologist will have to look for a plastic surgeon to admit you.
The hospital will not allow them to admit you because the hospital does not recognize their training as
being appropriate for this surgery. The simple question to ask your doctor is this: Are you trained as a
plastic surgeon?
Second, board certification. Look for a board certified plastic surgeon. You may verify it on the internet.
Make sure that the doctor is certified by American Board for Plastic Surgery. There are plenty of other
boards, like Cosmetic Surgery, Breast surgery, Esthetic Surgery and so on. Make sure you are asking
about the correct board. The question to ask is: Are you certified by American Board for Plastic Surgery?
Some non plastic surgeons may try to confuse the public. Some will have ads like that: Cosmetic
Surgeon, 20 years of experience, Board Certified. Sounds ok, right? Wrong! The doctor is not a plastic
surgeon. Cosmetic surgeon is not a trained specialty but a self designation. Board certification may be in
Pathology or Emergency Medicine, so is the experience. For all you know, this may be a board
pathologist, who for 20 years was doing autopsies, then took a weekend course on how to do breast
implants and opened a cosmetic surgery office. The states are becoming more aware of these tactics
and introducing more stringent regulations. I have nothing against family docs or pathologists I was
using in this example, but as an educated consumer you have to make sure that the surgeon you are
about to pay thousants of dollars for your surgery is actually properly trained to do it. A weekend
course is not enough from my standpoint.
Third, having active and unrestricted hospital privileges. Especially if your surgeon is offering to do your
surgery at the accredited office facility, make sure that he or she has privileges at local hospital in case
of unforseen problems. The question to ask is: What hospital do you have your privileges at? Another
term that I just used was "unrestricted". If the doctor had demonstrated to the hospital administration
and colleagies that his training and expertise are below standart, some hospitals could introduce
"restricted status". It means that the doctor cannot operate at the hospital without supervision by
another physician.
Fourth, experience. Some board certified plastic surgeons had been doing wound care surgeries, burns,
and skin grafts for 20 years. Unfortunately, it does not mean that they have enough experience to
perform breast augmentation surgery, especially if you have a complex case, tuberous breast deformity,
significant asymmetry, of trying to combine breast aumentation with a breast lift and or fat grafting. Ask
them how many of these surgeries they performed over last year, or last 6 month. There is no magic

6. number, but if the answer is 1 or 2, you have your answer. They may be well trained in plastic surgery
and have proper theoretical knowledge, but may be lacking practical experience in this specific surgery.
What is a typical consent for Breast augmentation surgery? Why is it so long?
Most plastic surgeons will use similar consents for plastic surgery procedures that had been developed
by our professional society. The reason they are so lengthy is because they explain in writing everything
that you might or might not have been informed of during your visit with your doctor in greater detail.
It is not designed to confuse you or release the doctor from responsibility for negligence. It is designed
to inform you about the procedure you selected, its alternative treatments, risks and complications as
well as it describes the financial and other agreements to avoid misunderstanding later on. We actually
ask our patients to read it in advance at home and write down any questions they might have about it.
This way our office visit is far more productive.