Breast Augmentation By Our Top US Board Accredited Plastic Surgeon

This is information as prepared for our clients, and designed to prepare you for your consultation and possible surgery. You can use it to explain to friends and family members what is involved in breast augmentation surgery. Please read it carefully and feel free to call my office if you have any questions.

Specifically, this is provided by Dr Piyapas, who is one of our top Plastic and Reconstructive Surgeons at Cosmetic Holidays International and is also a US Board Accredited Plastic Surgeon (

Breast augmentation with implants can be used alone or in combination with a breast uplift (mastopexy). Most patients are concerned mainly with improving size but when I see a patient I am looking at many different aspects of the breast apart from size. These include shape, chest and breast dimensions, skin quality, nipple position, level of the underwire fold and the amount of padding that is present to cover an implant. Many of these variables will be reviewed in this document.

There are more choices in implants now and the implants are better made with a more reliable envelope and better filler materials. Silicone gel implants are now allowed back on the market after a very frustrating period in the 1990’s where we were restricted to saline filled implants. It has been shown that silicone does not cause disease but there is no question that there are still some mechanical problems that can occur.

Implants can be inserted through different incisions and either above or below the muscle. The various reasons for the different choices will be outlined. The limits of size choices – at either end of the scale – will also be reviewed.


I have seen many changes in the quality and type of breast implants available. I am now very pleased with the newer silicone gel implants because the gel is more cohesive and the envelope is sturdier. I have found that these implants have a lower rate of capsular contracture (capsular contracture can result in hardening and distortion) and the implants feel more natural with fewer palpable (and sometimes visible) ripples.

  1. Health concerns:

Diseases: Silicone gel breast implants were taken off the market both in Canada and the United States in 1992 because there were concerns that silicone caused disease. Some patients felt that they developed rheumatologic diseases such as arthritis and lupus because they had breast implants. Numerous studies have been performed and finally the Institutes of Medicine reviewed all the information and made a definitive statement that there is no evidence that silicone causes any disease – either a known disease or one which had not been previously described. The studies were clear and both the FDA in the United States and the Health Protection Branch in Canada are convinced that silicone gel implants are safe and we are now allowed again to use them.

  1. Cancer: There has never been a concern that implants are related to the development of breast cancer. Although there are some studies that show that there are fewer breast cancers in women with breast implants, the accepted position is that there is no relation between the presence of breast implants and the development of breast cancer. There is, however, no question that the presence of breast implants can make mammograms somewhat more difficult to perform and interpret. Because the implant sits behind breast tissue or behind breast tissue and muscle, the performance of breast self-examination is not impaired.
  1. Mechanical problems:

Longevity: Breast implants are not natural. They are man-made and will not last a lifetime. How long they will last is not known but it is clear that the newer implants last longer. Patients are sometimes mistakenly under the impression that they need to be changed every 10 years but this is not true. We do know that the silicone gel implants used in the 1980’s often did rupture by 10 years and the advice for those implants is to at least have them re-evaluated. Even when the implant envelope has torn (usually just through wear and tear) the implant is still usually contained within the breast capsule that every patient forms. Unfortunately both mammograms and MRI’s are not good at diagnosing a ruptured implant.

  1. Rippling: All breast implants have ripples and folds that can sometimes be both felt and seen. The ripples are more common in thin patients with minimal natural breast tissue. They are also more common with saline implants. The newer silicone gel implants have fewer problems with rippling and are more natural feeling.
  1. Capsular contracture: Capsular contracture is both unpredictable and not preventable. All patients form a capsule from their own cells around every foreign body – from a sliver to a pacemaker. The capsule will form a complete covering around the implant but sometimes it will contract and tighten around the implant making it feel hard. This tends to make the breast appear rounder and sometimes distorts the breast shape. This capsular contracture occurs far less frequently with the newer silicone gel implants and far less frequently – in my experience – than with saline implants. Capsules can be surgically released but improvement only occurs about half the time.
  1. Leaking: When saline implants develop a leak the implant will empty quite quickly and the breast will get smaller within hours to days. When one of the older gel implants develop a leak, the gel oozes out but it usually stays within the capsule.

Occasionally the leaking gel can be forced out into the surrounding tissues. Silicone does not leak “all over the body” but it is quickly contained and forms what we call silicone granulomas or palpable lumps around the implant. The newer cohesive gel (or “gummy bear”) implants do not leak out in the same way. The gel is more solid and stays intact – much as a cut gummy bear or ju-jube candy.


  1. Saline implants:

I rarely now use saline implants for several reasons. They feel less natural because the saline moves around and because the implants are more prone to rippling. I personally believe that they can be more prone to problems in some patients because of the “water hammer” effect of the saline putting pressure on the walls of the implant with movement. There is no confusion, however, about knowing when a leak has occurred. Loss of saline and reduction in breast size is quite rapid and can sometimes only take a few hours for complete “deflation”.

  1. Silicone gel implants:
  1. Cohesive: All silicone gel implants now are “cohesive” to varying degrees. Some are very cohesive but the implants can also feel too firm. Implants that resemble a soft gummy bear are probably the best. The gel in these implants stays in place when the implant is cut with scissors or a knife.
  1. Textured versus Smooth envelopes: Some implants have a textured surface and some have a smooth surface. When I started using the newer cohesive gel implants I thought that it was the textured surface that was giving a lower capsular contracture rate. I have now used both the textured and smooth surface implants with equally good results.
  1. Profile: Some implants have a low profile and some have a higher profile. Patients cannot tell the difference (and neither can surgeons when reviewing patient photos). The choice of profile gives the surgeon some more flexibility in size choices when trying to fit the ideal base diameter to a particular patient. I fit the shape, profile and size to the desires of the patient but the actual choice of type of implant is something that the patient needs to leave to me.
  1. Shape: Some implants are round and some have a tear drop type of shape. Although a tear drop shape may initially sound ideal, it is not appropriate to most patients. Again it is a choice that I need to make depending on a review of an individual patient’s shape, size and desires.


There are many different aspects of a patient’s breasts that are important for me to consider. The position of the breasts on the chest wall (the “footprint”) needs to be analyzed. Most patients are not aware of these variables and are not aware of what can and cannot be changed. I will review each of these in turn.

  1. Underwire level:

Some patients are “high breasted” and some are “low breasted”. The position of the breasts on the chest wall can be quite different from patient to patient. When a patient’s breasts are low on the chest wall they can be disappointed with the result. The underwire level of the breast will not change – and in some cases it is purposely lowered. Lowering is considered only in some types of breasts and ideally only in those patients where the breasts sit high on the chest wall.

  1. Distance from the collarbone:

Just as important as the underwire level is the level of the upper breast border. Patients will often push their breasts up to show me how they want them changed. An implant can raise the upper breast border – and shorten the distance from the collarbone only a couple of centimeters. A breast lift alone without an implant cannot change this position at all.

  1. Cleavage:

The distance between the breasts on the chest wall can only be changed slightly. Some patients are quite wide and they often hope that we can narrow this distance. Although we can be successful in some cases, improvement is unpredictable. Some patients will actually get wider. This is one reason why it is important for me to assess the desired size but to tailor the actual implant size to the desired breast base dimensions.

  1. Chest wall:

The implant base diameter needs to fit the chest wall horizontally – both to fit (or improve) cleavage but also to fit (or improve) how the breast meets the sides of the chest wall. In some patients the breasts are not only small in size but also too small to properly fit the horizontal dimensions of the chest wall. This may mean that a patient needs to choose an implant which is somewhat larger than they initially thought. On the other hand, an overly large implant will hang over the sides of the chest wall and get in the way with arm movement.

Most patients have some asymmetry in both breast size but also in breast shape. In some patients I will try to keep the same implant size but in some patients I will purposely choose a different size so that I can match up the desired base diameters so that the patient looks more symmetrical after surgery. Patients are aware of a significant difference in implant sizes but the ultimate goal is to make them look as even as possible. Many of these choices cannot be made by the patient and are best left to me. I see things that patients are often not aware of and it is important that patients trust my experience to give them the best result possible.


The position of the breast on the chest wall is an important consideration, but the actual breast itself needs to be analyzed.

Size and padding:

The main issue for me to assess is not just the size – and differences between the breasts – but also the amount of breast tissue and fat present for padding. It is important that there be enough tissue to pad the implant otherwise the implant edges will be visible. If there is not enough padding present the implant may be better placed under the muscle (see section on implant positioning). Even with good padding the implants can often be palpated underneath and on the outside of the breasts. It is important for the patients to have enough padding in the areas where patients expose their breasts in bras or bathing suits. Adequate padding is important in the upper part of the breast and around the cleavage area.


Patients often say that their breasts sag if they are “empty” especially after pregnancy. But plastic surgeons define sagging as the position of the nipple relative to the underwire fold. If the nipples are in a good position then an implant alone will give a good result. If the nipples are low then a breast uplift may be indicated. A breast uplift will have more scarring (around the nipple and down to the fold instead of just an incision in the fold itself). Although most patients recover normal to near-normal sensation breast augmentation alone is less likely to interfere with sensation than a breast uplift (mastopexy).

Some patients would prefer to accept some sagging and therefore avoid extra scarring. It is important for me to review with each patient what they would look like with augmentation alone. An implant alone will not raise the breast – in spite of some advertising to the contrary.

If a patient’s breasts are very saggy (ptotic) then an implant alone is not an option. There is a narrow group of patients where a choice of having or not having a breast uplift can be considered. If the nipples are positioned below the underwire level then an uplift must be considered – otherwise the breasts will have a “double bubble” appearance with the breasts dropping off the bulge of the implant.

I have less control over breast shape than patients think. The shape a patient presents with determines the shape that results after surgery. If a patient is a bit “saggy” before surgery then they will still be a bit “saggy” after surgery. If the patient has some “skin on skin” and can hold up a pencil with their breasts then that shape will remain after surgery. Patients often request a breast where the nipple is well above the underwire fold but they have to start that way – we cannot even achieve this ideal with a breast uplift (unfortunately).

An ideal breast has the nipple positioned about one-third to one-half up the breast mound. If the nipple is too low the breast shape is unattractive and the nipple needs to be elevated by performing a breast lift. In a “high breasted” patient with low nipples sometimes the underwire fold can be slightly lowered with a good result. These patients may be able to avoid having an uplift because the nipple appears to be in a better position on the breast itself.

  1. Skin quality:

Some patients will have very tight skin with good elasticity. These patients sometimes are limited to smaller implants because the skin will not stretch. The good news is that the skin will also not sag very easily in these patients.

Some patients have very poor quality skin and even an uplift might result in repeat sagging. These patients may need an uplift as the years pass and in some patients it is difficult to achieve a good result. It may seem counterintuitive but in these difficult cases sometimes breast tissue needs to be removed from the lower part of the breast and a larger implant used to give a better shape.

  1. Areola shape and size:

The areola may stretch with breast augmentation. The amount of stretching is not in the surgeon’s control. The areola size can be reduced when a breast uplift is performed but stretching can still occur when an implant is used at the same time as an uplift.

When there is significant asymmetry in nipple position or areolar size, I may suggest making an incision around the areola to change the size but also to reposition the nipple into a more symmetrical position. The usual incision for breast augmentation is in the underwire fold under the breast but occasionally I will suggest using an incision around the areola for asymmetry reasons.

  1. Nipple shape and size:

Rarely will patients ask for the nipples to be reduced at the same time as the augmentation. This can be done but the risk of losing sensation is somewhat higher.


Implants can be placed either above or below the pectoralis muscle. They are always placed completely behind breast tissue so that breast examination can be properly performed. I sometimes recommend that the implant be placed above the muscle and sometimes I recommend that the implant be placed below the muscle. There are different reasons for different advice in different patients. Patients will often come in to the consultation convinced that they want one or the other position based on what their friends have said. I recommend that patients ignore this “street advice”.

  1. Below the muscle:

The main reason for placing implants below the muscle is for padding. It is important that the edges of the implant not be visible – and sometimes in the very thin patient even placing the implant below the muscle is not adequate. I will assess the amount of padding in each patient and make my recommendation.

The other reason for placing implants below the muscle is for mammography. The presence of implants in either position can make mammograms harder to perform and harder to interpret. As long as the implant stays soft mammograms can be done with the implant either above or below the muscle. However, when capsular contracture occurs with hardening of the breast, mammograms are easier to perform when the implant is below the muscle.

But there are problems with the implant when it is placed below the muscle. The cleavage is widened and there can be movement of the breasts with muscle movement. Patients cannot lift weights without the breasts moving. This can be very obvious to others but many patients learn how to keep from contracting the muscle. This muscle movement is often called the “dancing breast syndrome”.

Implants can also tend to stay in too high a position on the chest wall when they are placed under the muscle. This is because the muscle goes into some spasm after the surgery and the muscle spasm can distort the surgically created pocket for the implant. If the implant heals in this position it may need to be corrected. Some people think that the muscle “holds” the implant higher than when it is placed above the muscle but this is false. The implant only stays high when it has healed in an incorrect position.

  1. Above the muscle

When a patient has enough padding, the implant placed above the muscle can result in the most natural breast appearance. There is no point in placing an implant below the muscle in a patient with adequate padding. Placing the implant below the muscle will only widen the cleavage and result in muscle movement with exercise.


  1. Inframammary incision:

Incisions are usually placed in the underwire fold under the breast. The incision needs to be about 2 inches long (5 centimeters) with the cohesive or “gummy bear” implants so that the gel is not fractured on insertion (think of squishing a gummy bear with your thumb). The incision with saline implants could be shorter because the implant was filled after the envelope was put in place.

  1. Periareolar incision:

Occasionally a patient will request an incision around the areola but this can only be considered in patients with relatively large areolas. The scars around the areola can be better than the scars under the breast but they are more visible because of their location. The incisions around the areola are also more likely to interfere with nipple sensation.

  1. Armpit (axillary) incision:

I used to use the axillary incision in some patients when I used saline implants. It is harder to get a good pocket shape and any revision meant a second scar in the fold under the breast because access to correct capsules etc was not adequate through the armpit. I don’t use the axillary incision for the cohesive gel implants because the incision needs to be larger and there is more risk of implant displacement.


The choice of implant size is more complicated than just the size alone. As I outlined above, I need to take the breast and chest wall dimensions into account as well as skin quality and elasticity. I also need to look at nipple position and breast asymmetry.

  1. Bra size:

Bra sizes are confusing and it depends on which clip setting is used and what style and brand of bra a patient likes. It is important to understand that cup sizes are different with different band sizes. A 34D has the same cup size as a 36C which has the same cup size as a 38B. A discussion with the patient about cup size is only the beginning.

  1. Rice test:

It is difficult to place an implant in a bra because it doesn’t sit properly. I suggest to patients to try the “rice test”. This involves trying on a bra (without padding) that has the

correct band size and placing rice loosely inside a soft plastic bag or an old nylon stocking. A bra cup is about 150 to 180 cc and a kitchen cup is about 250cc. Most implant choices will start about 200 cc (a minimum to fit the breast dimensions) and go up to about 400cc. Beyond that (for most average sized patients) the implant will be too big for the skin envelope and will stretch the skin and cause sagging and the breast will extend out under the armpit. What I recommend for a patient who is 5’1” will be quite different for a patient who is 5’10” tall.

  1. Photos:

I find that a review of photos gives me the best idea of what to aim for. These can be either photos of other patients or photos from magazines. We can talk about breast shape but I have little control over shape. The shape that a person has initially will determine the shape they have after surgery (eg cleavage, sagging etc). But a review of photos gives me the best idea of what size to aim for. I often refuse to focus on actual implant size because patients are often mislead by photos from the internet. The actual implant size will depend on how tall the patient is, how wide their chest wall is, and how much breast tissue they started with.

I will do my best to give a patient a size that is close to what they request. Patients need to remember that size is not the only variable and my goal is to give each patient the best result possible – not an exact size.


  1. Size:

It is important for patients to have as good an idea as possible of what size they would like. In spite of the limitations listed above, it is important for patients to look for photographs on the internet ( and are good sites. I personally do not put before and after photos on the internet because I think it is important to review photos with the patients existing size and shape in mind. Having the patients try the rice test at home is also a useful guideline (but not exact).

  1. Mammograms:

For patients who are over 40 years old, we will be asking to see a copy of a mammogram performed within the last year. Patients should always try to go to the same place so that mammograms can be compared to previous ones. The best time to go is after your period when the pressure of the exam will be less uncomfortable.

  1. Instructions:

Make sure that you read through your instructions. It is important to read the section on medications to avoid. We want you to get the best result possible and it is important that

we reduce all tendencies to bleed excessively. Although aspirin and anti-inflammatories, such as ibuprofen, are great drugs we don’t want you to take them (or any herbals) for two weeks before surgery because they can cause you to bleed too much during and after surgery. Tylenol and codeine are both fine, but even one aspirin ten days before surgery can cause excessive bleeding.


There is usually very little pain with the surgery. When the implant is placed under the muscle it can be a bit more uncomfortable. Most patients describe the discomfort as being similar to the pressure that results when the milk comes in after delivery.

There are very few restrictions after surgery. It is important to avoid excessive exercise for a few weeks such as swimming or weight lifting. Jogging may be uncomfortable without a very supportive sports bra. Most patients can go back to work within a few days to a couple of weeks.


I normally like to see patients a week after surgery , then and because they are international patients I am more than happy to keep in touch with them directly or through agents on a regular basis to make sure there are no problems.


Revision surgery is fortunately rare but occasionally necessary. If there are any complications such as capsular contracture it may be indicated to undergo another operation. Patients also need to realize that breast implants will not last a lifetime and any repeat surgery as the years pass is likely to involve costs.

If both the patient and I are not satisfied with the result I am prepared to do what I can to make improvements. Sometimes there is nothing that can be done. I need to remind patients that exact size determination is not possible – the size of implant that I choose will be what I feel fits best with the patient’s desires and their breast shape, skin quality and breast dimensions. I rarely will agree to a size change.

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Everything you will every need to know about breast augmentation by our top US Board Accredited Plastic Surgeon!