CME
Breast Augmentation
Scott L. Spear, M.D., Erwin J. Bulan, M.D., and Mark L. Venturi, M.D.
Washington, D.C.
Learning Objectives: After studying this article, the participant should be able to: 1. Understand the different variables
that are inherent to breast augmentation. 2. Identify certain breast shape characteristics that make one approach more
advantageous than others. 3. Take into account certain patient characteristics to develop a logical surgical plan for breast
augmentation.
The optimal technique for breast augmentation has
always been debated, and numerous variables fit the needs
of the variously shaped patients in our population. The
purpose of this article is to present the advantages and
disadvantages of the various techniques available in breast
augmentation so that, in conjunction with the patients
physical examination, a sound surgical plan can be de-
veloped for aesthetic augmentation of the breast. (Plast.
Reconstr. Surg. 114: 73e, 2004.)
According to the American Society of Plastic
Surgeons, more than 206,000 breast augmen-
tations were performed in the United States in
2001, a 533 percent increase over 10 years ago
and a 56 percent increase when compared with
1998 statistics. 1 Breast augmentation has
sparked considerable debate in the political
realm with regard to the safety of breast im-
plants, as well as collegial disagreement over
the technical aspects used to create an aes-
thetic breast. When broken down into its parts,
the procedure of breast augmentation con-
fronts the surgeon with three distinct variables
requiring decisions in the preoperative pro-
cess: (1) implant selection, (2) incision loca-
tion, and (3) pocket plane.
The purpose of this article is to provide the
surgeon with the advantages and disadvantages
of the various techniques available to make a
sound clinical plan. The beauty in plastic sur-
gery is that there is no one implant, incision, or
pocket plane that is appropriate to treat every
patient. It is this notion that makes breast aug-
mentation both an art and a science.
From the Division of Plastic Surgery, Georgetown University Medical Center. Received for publication October 25, 2002; revised June 6, 2003.
DOI: 10.1097/01.PRS.0000135945.02642.8B
73e
IMPLANT SELECTION
Silicone versus Saline
The decision made by the U.S. Food and
Drug Administration more than 10 years ago
that resulted in the moratorium on silicone
implants has narrowed the implant choices. At
present, there has been no evidence to show a
link between silicone gelfilled implants and
any systemic medical illnesses including auto-
immune disease, connective tissue disorder, or
cancer.27 Nevertheless, for cosmetic augmen-
tation, saline implants remain the only choice
available to plastic surgeons in the United
States. Silicone gelfilled devices are reserved
only for specific secondary and reconstructive
augmentation applications in Food and Drug
Administrationsponsored adjunct studies.
Like a pendulum that has reached its terminal
apex, we expect that silicone implants will once
again return to favor and be approved by the
Food and Drug Administration by the time this
article appears in print, some time in the year
2004. During the last 10 years, there have been
improvements in manufacturing standards and
quality and improvements in implant design,
notably low-bleed silicone elastomer shells,
more cohesive silicone gels, and implant shell
surface texturing. As a result of intense scru-
tiny, the net effect during the last 10 years has
been an improvement in the quality and safety
of these devices.
74e
Although at this writing saline remains the
only option available in the United States, the
next generation of silicone implants merits dis-
cussion. In the absence of capsular contrac-
ture, saline implants exhibit several problems,
such as palpability and firmer consistency,
compared with silicone implants. Much of the
earlier literature involving silicone implants
dealt with their potential for capsular contrac-
ture and silicone bleed leading to granulomas.
Although we have noted that there is no cred-
ible evidence linking silicone gel implants to
any systemic illness, the fear of escaping sili-
cone gel is present. The next generation of
silicone implants, already in use outside the
United States, contains a soft cohesive gel that
is slightly firmer than earlier silicone gel im-
plants. This cohesive gel implant is a form-
stable device that retains its anatomic shape
even with some degree of capsular contracture
or loss of integrity of the shell envelope. When
cut or ruptured, the shape of the implant re-
mains intact and the silicone does not run out.
One aspect of these devices is that their use
requires a careful evaluation of the patients
chest dimensions to determine the appropriate
style of implant. The devices are available in a
wide variety of dimensions that vary in height
and projection. There has been a large expe-
rience with these implants in Europe,8 where
they have proven to be very popular.
Smooth versus Textured
Surface texturing is one option available today
for breast implants. Historically, textured im-
plants have been found to lower the capsular
contracture rate.9,10 A review of several different
studies suggests that subglandular breast aug-
mentation with smooth, saline-filled implants
may yield a capsular contracture incidence per
implant as high as 23 percent to 40 percent
compared with textured surfacing, which has
the potential to reduce that contracture inci-
dence to between 2 percent and 29 percent.11
This is at the cost of more visible rippling and
greater palpability, as well as greater cost for
the implant. The differences between textured
and nontextured implants seem to decrease
when both are placed in the subpectoral posi-
tion. The incidence of capsular contracture
with saline-filled implants may decrease to
nearly 1 percent when the implant is placed in
the subpectoral position.12 Therefore, surface
texturing does not appear to offer a clear ad-
vantage in avoiding capsular contracture when
PLASTIC AND RECONSTRUCTIVE SURGERY, October 2004
the implants are placed submuscularly. Tex-
tured implants are recommended in patients
with adequate soft tissue for whom subglandu-
lar positioning of the implant is desired.
Round versus Anatomic
The terms anatomic, shaped, or teardrop are
all used to describe devices with a vertical axis
that is different in dimension than the horizontal
axis. Tall teardrop shapes are best suited for pa-
tients with a long chest or low breast position. A
reduced-heightshaped device creates a rela-
tively exaggerated width with abbreviated height
to decrease upper-pole fullness.13 Overall, with
an anatomically shaped implant, there is a dimin-
ished tendency toward upper-pole bulges, round-
ness, or distortion and greater volume support
for the lower breast.14
Lately, there has been controversy about
whether anatomic implants are really anatomic
and whether round implants behave anatomi-
cally in vivo.15 From our experience, anatomic
implants retain their basic shape, whether re-
cumbent or upright, because of the shape built
into the device. Round implants can appear
somewhat anatomic given a loose peripros-
thetic space in the setting of an underfilled
device. This situation, however, carries an in-
creased risk of shell folds, visible rippling, and
possibly early device failure.16 A caveat unique
to using these shaped devices is implant rota-
tion.12 Meticulous attention must be made not
to overdissect the implant pocket, which would
make rotation more likely. We recommend
postoperative use of a support brassiere with a
binder strip placed across the superior pole of
the breasts for 10 to 14 days to minimize the
risk of rotation.
Round implants can be considered to be
more forgiving, enabling the creation of an
aesthetically pleasing breast with a variety of
patient shapes. In general, if there is an aes-
thetically shaped breast as well as relative vol-
ume to the existing breast, a round or shaped
implant device is an appropriate choice. Cer-
tain body types, when augmented with round
implants, have a greater risk of excessive up-
per-pole fullness and distortion. These body
types include thin patients, patients with a high
inframammary crease, patients with a vertically
or horizontally deficient chest, and ptotic pa-
tients. In these instances, the anatomic implant
provides valuable additional options to alter
the shape of the breast.
Vol. 114, No. 5 / BREAST AUGMENTATION
INCISION SITE
Because of the ever-present patient concerns
with scars, various techniques have been de-
vised to minimize or hide the incision. Current
choices include periareolar, inframammary,
transaxillary, and periumbilical incisions. Pa-
tients present with certain anatomic variables,
constraints, and desires that may make one
approach more advantageous than another.
Therefore, surgeons should be adept at several
of these techniques. Figure 1 presents an algo-
rithm to guide the selection of the incision site
based on the characteristics of the breast. It is
meant to serve as a relative guide, and the
examples given below demonstrate how nipple
size, fold position, and the need for additional
procedures can be used to select an appropri-
ate incision site.
Periareolar
The periareolar incision in many ways is the
most versatile approach. It gives central access
to all quadrants of the breast and is compatible
with all the various breast implants and planes
of dissection (Fig. 2). It is the most versatile
incision when the inframammary fold is being
lowered significantly, as well as the logical
choice when considering or planning a simul-
FIG. 1. Breast augmentation algorithm.
75e
taneous mastopexy. In addition, it is in the most
appropriate location when breast parenchyma
alteration is needed, as is the case with tuberous
breast deformity. Although the diameter of the
areola is a limiting factor when contemplating
this approach, areolas as small as 25 mm in di-
ameter (approximately the size of a quarter) will
allow for the creation of a 4-cm incision along
one half of the areolar circumference.17 Caution
must be used in areolas that are lightly colored
with indistinct margins, because the scars will not
hide as well in those circumstances. Also, there
have been preliminary reports suggesting an in-
creased risk of changes to nipple sensation and
lactation ability with the periareolar approach.
Although these studies are small, retrospective,
and not definitive, these issues warrant closer
inspection.18,19
Inframammary
The inframammary incision represents the
simplest and most straightforward approach to
breast augmentation. Direct access to both the
subglandular and subpectoral planes can be
achieved without violating the breast paren-
chyma, and visualization of the breast pocket is
unsurpassed by the other incision options. The
scar is frequently inconspicuously hidden in
76e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2004

FIG. 2. (Above) Preoperative views of a 26-year-old woman with hypoplastic asymmetric breasts with poorly defined infra-
mammary fold and large nipples. (Below) Postoperative views approximately 12 months after periareolar dual plane augmentation
with 390-cc (filled: right, 430 cc; left, 400 cc) McGhan style 68 saline-filled implants.

the well-developed inframammary fold and can
often be seen only in the recumbent position
(Fig. 3). In addition, the length of the incision
can be of generous size to fit various implants.
Certain circumstances, however, require
thought as to where to make the incision. In
patients with significant hypoplasia that causes
an ill-defined inframammary fold or with a
constricted breast and a breast fold too close to
the areola, placement of the incision is less
obvious. In these cases, once the implant is
placed, the incision may lie above the new
inframammary crease and be visible on the
breast, or it may be too low and be visible
beneath the breast. Special caution should be
used in such instances, and the incision should
therefore be at or just above the site of the
anticipated new fold, as governed by the verti-
cal diameter of the implant.20 Thus, the infra-
mammary incision works best when the preop-
erative natural fold closely approximates the
fold after augmentation.
Transaxillary
The transaxillary incisions obvious appeal is
that it avoids a scar on the breast. The scar is
well concealed, and like the inframammary in-
cision, it does not violate the breast paren-
chyma (Fig. 4). This incision is particularly
advantageous in patients with small, minimally
ptotic breasts with an ill-defined inframam-
mary fold or small areola. An endoscope can
be used in either the subpectoral or subglan-
dular plane. It allows sharp dissection, accurate
hemostasis, and precise release of muscular
and soft-tissue attachments. Despite such ad-
vantages, there are definite trade-offs to such a
remote approach. When compared with the
other, more direct incision options, the
transaxillary incision lacks the same degree of
Vol. 114, No. 5 / BREAST AUGMENTATION
FIG. 3. (Above) Preoperative views of a 24-year-old woman with hypoplastic symmetrical breasts, slight ptosis, and a well-defined
fold. (Below) Postoperative views approximately 8 months after inframammary dual plane augmentation with 280-g McGhan style
410 anatomical silicone gelfilled implants.
control and accuracy and theoretically has a
higher risk of asymmetry and implant malposi-
tion. Because of this, it may have a higher
revision rate. Furthermore, subsequent sec-
ondary procedures may be difficult or impossi-
ble with an axillary incision, and this may re-
quire a new incision that is located more
directly on the breast. Because it would be
difficult to adequately manipulate the breast
parenchyma in complex cases such as the tu-
berous breast deformity, the transaxillary inci-
sion is also not recommended when substantial
parenchymal rearrangement is required. Fi-
nally, the transaxillary approach is at a signifi-
cant disadvantage when using shaped implants
or large silicone gel implants, particularly
those containing cohesive gel.
Transumbilical
The transumbilical incision is the newest ap-
proach to breast augmentation. Through an
77e
inconspicuous scar, a subcutaneous tunnel just
above the rectus fascia is created to the breast
whereby the implant pocket is created hydrau-
lically with the use of expanders. Although it is
described for use in the subglandular and sub-
pectoral pockets,21 in our experience, the sub-
pectoral plane is significantly more difficult. As
with the transaxillary incision, the transumbili-
cal incision is outside the aesthetic unit of the
breast and thus poses less risk of implant ex-
trusion. Unfortunately, both share the draw-
backs of remote access. Its potential for inac-
curacy increases the risk for implant
malposition, particularly for textured or
shaped implants. It would not seem possible to
place a silicone gel implant of any significant
size through the umbilicus. This method has
not been approved by the Food and Drug Ad-
ministration and is thus officially off-label.
This does not prohibit its use, but it could place
78e
FIG. 4. (Above) Preoperative views of a 25-year-old woman with hypoplastic symmetrical breasts, well-defined fold, and small
nipples. (Below) Postoperative views approximately 16 months after transaxillary augmentation with 240- to 270-cc (filled: 250
cc) McGhan style 68 saline-filled implants.
the surgeon in a weakened position in defending
an unsatisfactory result. Furthermore, problems
with hemostasis and secondary procedures al-
most certainly would require a more direct inci-
sion. Because of the need for the upper abdom-
inal tunnel, this technique should be used with
caution in the very thin patient with minimal
subcutaneous tissue or the obese patient where
tunneling would be difficult. Overall, its advan-
tages are greatest and most dramatic in selected
patients who do not have a well-defined infra-
mammary fold or an areola that would be suit-
able for a periareolar incision (Fig. 5).
IMPLANT PLACEMENT SITES
Subglandular
In the history of breast augmentation, the
development of various techniques for creating
implant pocket planes is generally an evolution
to better methods rather than a development of
PLASTIC AND RECONSTRUCTIVE SURGERY, October 2004
equally acceptable options, as is the case with
various implant and incision choices. Early aug-
mentation procedures involved placement of the
implant in the subglandular plane. This was gen-
erally effective in patients with some amount of
breast tissue and subcutaneous fat and the
obvious place to start. It worked best when
there was adequate soft-tissue coverage of the
implant. In patients with less soft tissue,
there is a higher risk of implant visibility, and
a sharp transition can often be seen in the
upper pole. In addition, there is substantial
evidence that this position is associated with
a higher incidence of capsular contracture.22
It is also clear that the subglandular plane is
less satisfactory for mammography.23
Submuscular
Total muscle coverage was developed as an
option to reduce implant visibility and palpa-
Vol. 114, No. 5 / BREAST AUGMENTATION
FIG. 5. (Above) Preoperative views of a 28-year-old woman with hypoplastic asymmetrical breasts, poorly defined fold, and small
nipples. (Below) Postoperative views approximately 12 months after transumbilical augmentation with 300-cc (filled: 330 cc)
McGhan style 68 saline-filled implants.
bility and, ideally, to decrease the incidence of
capsular contracture. This was, however, at the
expense of adequate lower-pole shape and in-
framammary fold definition. In addition, late
superior migration of the implants or pseudo-
ptosis of the breast was seen in a significant
number of women. This was a result of the
gravitational effects on the breast against an
implant still supported by the lower muscle
panel. Since newer devices were developed
that seemed to reduce the risk of capsular con-
tracture, there became less need for total mus-
cle coverage.24
Subpectoral
Subpectoral placement generally refers to
partial muscle coverage of the implant in its
upper pole by the pectoralis major, with the
lower portion of the implant being subglan-
dular. This plane seems to achieve about as
79e
low a rate of capsular contracture as total
submuscular positioning while also facilitat-
ing mammography. There is improved upper-
pole breast contour because the muscle blunts
the transition between the upper breast and the
implant superiorly. The pocket dissection is eas-
ier overall in the subpectoral loose areolar plane,
and the breast parenchyma is less devascularized,
which is optimal for any planned breast shaping
or mastopexy. Subpectoral implantation should
be used with caution in patients with significant
postpartum atrophy, glandular ptosis, and signif-
icant native tissue volume. These clinical situa-
tions are at a higher risk for developing a double-
bubble deformity.25
Dual Plane
The dual plane augmentation has devel-
oped as a variation of the subpectoral plane
augmentation to minimize the risk of a double
80e
breast contour deformity. This variation, re-
cently described by Tebbetts,26 helps to create a
desirable breast shape utilizing the subpectoral
plane in conjunction with the subglandular
plane, which is adjustable for the less ptotic
nulliparous breast to the more ptotic or loose
breast. The key difference between dual plane
and subpectoral implant sites is the use of a
subglandular dissection that may extend above
the level of the inferior border of the pectoralis
major superiorly. For patients with minimal
breast tissue, dissection only proceeds for a few
centimeters. For patients with more breast soft
tissue leading to ptosis, the subglandular dis-
section may continue up as far as
the level of the superior border of the areola.
The dual plane pocket should allow for im-
plant placement and soft-tissue redraping,
creating a more aesthetic lower-pole contour
and avoiding a double-bubble deformity.
NONSURGICAL BREAST AUGMENTATION
Recent technology has been developed us-
ing external negative pressure devices to create
enlargement in breast mound volume.27 Simi-
lar to the distraction theories that are well
defined in osteosynthesis and found in ortho-
pedic and craniofacial surgery, this negative
distraction force induces breast tissue growth.
To obtain such results, a stringent regimen is
required: a brassiere-like system applying 20
mmHg of vacuum pressure to each breast is
worn for 10 to 12 hours per day over a 10-week
period to obtain an average increase of 98
percent over starting size. The stable long-term
increase in breast size, however, is 55 percent.
In addition, temporarily halting treatment can
cause a recoil effect to occur. This system is
touted as a means for breast enlargement with-
out the pain and risk of surgery. One must be
aware that these are preliminary studies and
that long-term studies are needed to prove the
validity of this technique. In addition, the vol-
ume added to the breast in the typical surgi-
cally augmented patient is significantly more
than the 100-cc to 110-cc gain found with this
system. More importantly, the patient compli-
ance that is needed to achieve the suggested
results leaves a huge variable that cannot be
controlled by the plastic surgeon.
CONCLUSIONS
There has been and always will be continued
debate regarding the optimal technique for
breast augmentation. Numerous variables cur-
PLASTIC AND RECONSTRUCTIVE SURGERY, October 2004
rently fit the needs of the variously shaped
patients in our population. Although there is
no one single technique that is considered the
best, one must take the options that are avail-
able in conjunction with the physical examina-
tion of the patient to create a sound surgical
plan for achieving an aesthetic-looking aug-
mented breast.
Scott L. Spear, M.D.
Division of Plastic Surgery
Georgetown University Medical Center
1st Floor, PHC Building
3800 Reservoir Road N.W.
Washington, D.C. 20007
spears@gunet.georgetown.edu
REFERENCES
1. American Society of Plastic Surgeons National Clearing-
house of Plastic Surgery Statistics. Cosmetic Surgery
Trends, 1992 to 2001: Published Results. Arlington Heights,
Ill.: American Society of Plastic Surgeons, 2002.
2. Muzaffer, A. R., and Rohrich, R. J. The silicone gel-filled
breast implant controversy: An update. Plast. Reconstr.
Surg. 109: 742, 2001.
3. Angell, M. Shattuck lecture: Evaluating the health risks
of breast implants: The interplay of medical science,
the law, and public opinion. N. Engl. J. Med. 334: 1513,
1996.
4. Barnard, J. J., Todd, E. L., Wilson, W. G., et al. Distri-
bution of organosilicon polymers in augmentation
mammaplasties at autopsy. Plast. Reconstr. Surg. 100:
197, 1997.
5. Deapen, D. M., Pike, M. C., Casagrande, J. T., et al. The
relationship between breast cancer and augmentation
mammaplasty: An epidemiologic study. Plast. Reconstr.
Surg. 77: 361, 1986.
6. Rohrich, R. J., Hollier, L. H., and Robinson, J. B. De-
termining the safety of the silicone envelope: In search
of a silicone antibody. Plast. Reconstr. Surg. 98: 455,
1996.
7. Su, C. W., Dreyfuss, D. A., Krizek, T. J., et al. Silicone
implants and the inhibition of cancer. Plast. Reconstr.
Surg. 96: 513, 1995.
8. Heden, P., Jernbeck, J., and Hober, M. Breast augmen-
tation with anatomical cohesive gel implants. Clin.
Plast. Surg. 28: 531, 2001.
9. Hakelius, L., and Ohlsen, L. A clinical comparison of
the tendency to capsular contracture between smooth
and textured gel-filled silicone mammary implants.
Plast. Reconstr. Surg. 90: 247, 1992.
10. Pollack, H. Breast capsular contracture: A retrospective
study of textured versus smooth silicone implants.
Plast. Reconstr. Surg. 91: 404, 1993.
11. Spear, S. L., Elmaraghy, M., and Hess, C. Textured-
surface saline-filled silicone breast implants for aug-
mentation mammaplasty. Plast. Reconstr. Surg. 105:
1542, 2000.
12. Mladick, R. A. No-touch submuscular saline breast
augmentation technique. Aesthetic Plast. Surg. 17: 183,
1993.
13. Spear, S. L. Breast augmentation with reduced-height
anatomic implants: The pros and cons. Clin. Plast.
Surg. 28: 561, 2001.
Vol. 114, No. 5 / BREAST AUGMENTATION
14. Hammond, D. C. Breast augmentation using anatomic
implants. Oper. Tech. Plast. Reconstr. Surg. 7: 125, 2000.
15. Hamas, R. S. The postoperative shape of round and tear
drop saline-filled breast implants. Aesthetic Surg. J. 19:
369, 1999.
16. Spear, S. L., and Mardini, S. Alternative filler materials
and new implant designs: Whats available and whats
on the horizon? Clin. Plast. Surg. 28: 435, 2001.
17. Spear, S. L., and Beckenstein, M. The periareolar ap-
proach to augmentation mammaplasty. In S. L. Spear
(Ed.), Surgery of the Breast: Principles and Art. Philadel-
phia, Pa.: Lippincott-Raven, 1998.
18. Neifert, M., DeMarzo, S., Seacat, J., Young, D., Leff, M.,
and Orleans, M. The influence of breast surgery,
breast appearance, and pregnancy-induced breast
changes on lactation sufficiency as measured by infant
weight gain. Birth 17: 31, 1990.
19. Hurst, N. M. Lactation after augmentation mamma-
plasty. Obstet. Gynecol. 87: 30, 1996.
20. Spear, S. L., and Beckenstein, M. The inframammary
approach to augmentation mammaplasty. In S. L.
Spear (Ed.), Surgery of the Breast: Principles and Art.
Philadelphia, Pa.: Lippincott-Raven, 1998.
81e
21. Pound, E. C., III, and Pound, E. C., Jr. Transumbilical breast
augmentation (TUBA): Patient selection, technique, and
clinical experience. Clin. Plast. Surg. 28: 597, 2001.
22. Biggs, T. M., and Yarish, R. S. Augmentation mamma-
plasty: A comparative analysis. Plast. Reconstr. Surg. 85:
368, 1990.
23. Silverstein, M. J., Handel, N., and Gamagami, P. The
effect of silicone gel-filled implants on mammogra-
phy. Cancer 68: 1159, 1991.
24. Spear, S. L., and Bulan, E. J. The medial periareolar
approach to submuscular augmentation mamma-
plasty under local anesthesia: A 10-year follow-up.
Plast. Reconstr. Surg. 108: 771, 2001.
25. Hidalgo, D. A. Breast augmentation: Choosing the op-
timal incision, implant, and pocket plane. Plast. Re-
constr. Surg. 105: 2202, 2000.
26. Tebbetts, J. B. Dual plane breast augmentation: Opti-
mizing implantsoft-tissue relationships in a wide
range of breast types. Plast. Reconstr. Surg. 107: 1255,
2001.
27. Khouri, R. K., Schlenz, I., Murphy, B. J., and Baker, T. J.
Nonsurgical breast enlargement using an external
soft-tissue expansion system. Plast. Reconstr. Surg. 105:
2500, 2000.