Breast augmentation techniques vary widely from office to office. The aesthetic sense of the surgeon is critical. The surgeon has to integrate breast shape, form, and volume into a harmonious body contour and silhouette. Enhancing the breast shape and volume will improve your overall visual appearance, balance your figure,and allow clothing to fit better.

There are numerous choices that must be discussed and decided upon between the patient and the doctor. This includes the choice of implant. In general implants are either round or anatomic shape. The anatomic implant is narrower, taller (vertically oriented) and projects away from the body more than round implants, which are wider and less projecting. The choice of implant is determined by the patient's anatomy, i.e. breast base diameter (width of breast), nipple position relative to the clavicle (collarbone), nipple position relative to the inframammary fold (crease under the breast), and chest wall width and symmetry.

There is also a choice of saline-filled or silicone-filled implants. On November 17, 2006 the FDA lifted its restriction on silicone gel-filled breast implants in women 22 years of age and older. After almost a decade of scientific research the FDA has concluded that these products are safe and effective and no conclusive evidence has been found to link them to any connective tissue disorders or cancer. Due to the silicones natural look and feel they are often the preferred implant of choice and most closely imitate a woman's natural breast tissue.

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I believe all implants should be placed submuscularly for three important reasons: (1) mammography is much more accurate; (2) capsular contracture rates (implant hardening and distortion) are much lower. This is especially important for silicone implants which tend to harden more than saline; (3) palpability of implant folds and edges are diminished. This is especially important for very thin and athletic women. Because of easy muscle release procedure that I routinely employ, athletic women are not hindered, and the implants do not move with muscle (pectoralis) contraction. It also tremendously reduces post-operative pain.

I do not use the umbilical (belly button) approach because of problems with submuscular placement and shaping the inframammary fold (crease under the breast which influences cleavage shape and position). I also do not use the inframammary fold approach because the incision may be exposed when lying down, or if the bathing suit or bra rides up. In addition, if the patient wants larger implants in the future, the inframammary fold must be lowered, and the scar will be on the breast itself! The periareolar incision is easily concealed at the conjunction of the breast and the nipple skin in women of all color. Concerns over additional risk of nipple sensory loss are unfounded.

Finally, choice of size is best judged by the review of pre- and post-operative photos of similar patients and the use of magazine photos that the patient brings to the office. "A picture is worth a thousand words!" It also helps to align the doctor's and patient's expectations for the surgery. Sometimes a breast lift (mastopexy) may also be indicated, requiring an incision around the areola (circumareolar), or around the areola and down to the inframammary crease (lollipop). This is most commonly required after significant weight loss and/or postpartum, when the amount of skin is disproportionately large relative to the amount of breast tissue.

Dr. Kornstein is a member of Allergan's Breast Implant Advisory Panel and will discuss the latest options with you at your consultation.