How Breast Augmentation Surgery Works and What to Expect

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the The Aesthetic Society.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

Useful Links

If you enjoyed this episode, you might also like:

• Learn about Breast Reduction
• Learn about Breast Lift
• Learn more about Breast Reconstruction
• Learn about Revision of Breast Surgery
• Meet Dr. Kerner and her staff
• Contact Us to schedule an appointment

Episode Transcript

Introduction

Welcome to Plain Talk About Plastic Surgery, a podcast that brings you down to Earth, honest and practical information about plastic surgery operations and procedures based on my 32 years of experience as a plastic surgeon.

I’m Dr. Elizabeth Kerner, and today we’re going to talk about breast augmentation. Most people will call this a breast aug. That’s just shorthand for augmentation mammaplasty, which means increasing the size of the breast.

The History of Breast Augmentation and Concepts of Breast Beauty

Augmentation mammoplasty is one of the most popular plastic surgery procedures, probably beat out only by liposuction and Botox® in the last couple of years’ statistics.  Augmentation of the female breast has been around reliably since the late 1960s.

Doctors Cronin and Gerow, plastic surgeons in Houston, developed the first breast implants and began successfully implanting them in women’s breasts in the late 1960s, early 1970s. Prior to that, women had tried all sorts of things to obtain a larger breast.

The most popular was injection of liquid silicone, which had horrible, unintended consequences.

In the 1900s to 1950s, surgeons would try moving tissue around from the upper abdomen into the breast, but most of these did not work very well and left significant scarring on the torso such that trying to get a cosmetic result was not at all possible with that.

I think it’s very interesting to contemplate why women want to have larger breasts. It certainly revolves significantly around self-image and societal expectations of femininity.

Many centuries ago, Paul Rubins, the famous painter, popularized the lush female breast, I would say. If you look at his paintings, women are large breasted and voluptuous.

Of course, that was part of the time. A wealthy woman would be well fed. And of course if she’s had many children, which was considered successful, typically she would have large breasts that would bulge out of her clothing, which is what he painted.

Then you fast forward to the time of the flapper women in the 20s, and everybody was really small breasted, and you wanted to look like a boy.

Go way back in time to Greek mythology, and oftentimes the Noble women would be also very small breasted. And then it varies by European, to Asian, to Indian, to African, what is considered to be a pleasing breast.

But the funny thing is, it’s really what’s considered to be a pleasing breast to the male.

It wasn’t really until the 1960s when women started becoming “woke”, as they say now, but developing their own feminism that women would say, “hey, we don’t want to wear bras and we don’t want big breasts.”

If you listen to my podcast on breast reduction, we talk about that a lot. And also with sizer bras — kind of the bra and breast revolution.

Now, I don’t think society dictates quite so specifically that large breasts are in shape or small breasts are in shape. Certainly not the way they do with big bottoms nowadays.

But individual women would say, “Boy, I think I look too flat. I feel like a boy” or “I used to be a C cup. Now I’ve had three children and I just have little sacks of skin, and I just don’t feel feminine.”

The flip side of that, of course, is a woman who’s very large breasted and feels like her breasts are so big that it makes her look fat; or they get in the way of activities; she can’t wear clothing; on and on like that.

For me as a plastic surgeon, of course this works out just great because everybody’s either wanting to increase the size of their breast, or decrease the size of their breasts, or lift them up. This keeps me quite busy in my world of operating.

What Makes a Good Candidate for Breast Augmentation Surgery?

So I’m going to talk about what we do with the breast augmentation. This is just going to be the technical operation of what is done and how it’s done and choices that are made. And then we’ll have a whole another podcast on implants because choosing an implant is the most difficult.

We, of course, have saline and silicone right now, and the choice is not as clear cut as you would like.

Everybody would like choice C, which is the safety of saline and the softness and the natural feel of silicone. And then, of course, a breast implant that never fails. But we don’t have that.

So when you come into the office for your breast augmentation, I will eventually take a look at you and look at your chest wall and say you would be a good candidate or a poor candidate.

And what would make you a good candidate?

Well, your breasts aren’t really terribly saggy, so you don’t need a lift. You do have a good functioning pectoral muscle, but it’s not hugely thick. So if you’re a body builder and you have a really thick pectoral muscle, it can make it very difficult to do an augmentation. It’s nice if you have normal amount of subcutaneous tissue. So when you squish the fat about an inch or two above your nipple, if you can squish up about one to two inches of fat — fatty subcutaneous tissue in your fingers — that’s like perfect.

If you have some actual breast gland, that’s kind of nice because that’s going to camouflage more and make you look more normal. If your torso is a little shorter, meaning that the length of your chest from your collarbone to the fold crease under your breast is not terribly long, I think your implants are going to look better, meaning that your postoperative result is going to look better because they sit a little bit higher on your chest.

If you have a long torso, then your implants are going to sit lower on your chest. They’re going to be just above the inframammary fold or that crease under your breast. And unfortunately, there’s absolutely nothing that can be done about that.

Implants are all round. They don’t make like hot dog or oblongly shaped implants, so your fullness is going to be really above wherever your existing fold is.

I also look for things like:

• Do you have scoliosis? Is your chest twisted a bit?
• Is the sternum very prominent, or does it dip in?
• Do you have ribs that stick out more on one side or the other?
• Is one side of the breast broader than the other side of the breast?
• Are the folds not at the same level?
• Are the nipples not at the same level?
• Is one side significantly larger than the other?

Although I mentioned these are all negatives, most of these occur in every woman to some degree or another. It’s just whether they’re going to be prominent enough that it’s going to make it difficult to get you a really nice, symmetrical result with a breast augmentation.

So I got off my planned discussion a little bit because I was going to talk about the operation first.

What Happens During Breast Augmentation Surgery

So I do a breast augmentation in the operating room. I do put you to sleep for it. I understand that some surgeons do not use general anesthesia and will do IV sedation and just local. I don’t feel like I can make you comfortable. If that is very important to you as a patient, then you’ll certainly need to seek out someone else.

I insert the breast implants through a small incision in your inframammary fold.

The length of that incision depends on what type of implant I’m putting in and how big. Some implants, especially saline, we put them in empty so they fold up and they can go in through a relatively small incision, a little bit over an inch and a half.

Other implants that are larger don’t fold very much and have to be put in through a larger incision. You just can’t physically put them into your body through a little one.

So let’s just say we’re doing an average incision. I would mark you before surgery. We’d go back to the operating room, you’d go off to sleep. I’ll make a small cut along your fold underneath of the breast, situated a little bit to the lateral aspect, and then go in through the skin. I’ll go right to the edge of the pectoral muscle.

We don’t normally do anything with the breast tissue. That way, we don’t create scars or problems or infections. And then at the edge of the pectoral muscle, I’m going to lift that up and separate the pec muscle from your underlying ribs. We’re creating a pocket or a space between the muscle and the ribs.

This is done with a long retractor, which it looks like a long spatula that has a light on the end of it. And I use a cautery. So as I go and I see little strips of muscle that go down to the ribs, I’m just going to cut them with a cautery. That way, there’s very little bleeding with this operation.

There are usually one or two blood vessels that come up from the rib to the muscle that will have to be cauterized. We don’t put clips on them, because if you think that through, you’d have a soft implant on top of a little piece of metal, and that would, of course, lead to rupture of the implant.

Where the blood vessels are it’s, very difficult to get a stitch around them. Occasionally, if there’s a big one, I may try and put a stitch around it. Usually we just cauterize them.

The Sizer Bra

Once that space has been created, then I like to use sizers. Sizers are just empty implants that are sterile, and we put them inside you and either fill them up with saline or air to mimic the volume that I think you want.

And then I sit you up and I look at your breasts and say, “do they look good? Do they look pretty? Are they like the picture that you’ve chosen?”

The sizer bra, which is another podcast, is sterile and I will take the sizer bra and put that over your breast and say, “Is your breast implant and breast filling your size of bra the way that you want it to?”

If it is not, then we either go up or down on the size of the sizer inside your breast. Once I know the volume, then the sizer is removed.

Also, when I have the sizer in it lets me look at my two spaces I’ve created to make sure that I’ve got them as symmetrical as I can — that the width and the height are about the same, or I’ve compensated for any underlying asymmetries that you’ve presented me that I need to put the implant in a specific spot to try and make it not so noticeable.

Then the next part of the operation is sort of like Part Two.

We know that putting an implant in we need to try and not touch the skin so that no bacteria travel inside. So we want to keep it as sterile as possible.

So gloves are changed, we use clean instruments that haven’t been touched. The implant is opened and covered with antibiotic solution, and then the pocket inside under the muscles irrigated with both Betadine solution and antibiotic, because we know that will kill the maximum number of bacteria.

And then to insert the implant, I’m going to put another sterile, sticky piece over top of your incision and cut a little hole in it and, then I will put the implant in. If it’s saline, I fold it up like a little cigar and insert it. So of course, it doesn’t touch your skin at all. If it’s silicone, I push it in through the incision, trying not to touch any bare skin at all.

Once it’s in, if it’s saline it will be inflated; if it’s silicone, we just position it in the pocket where it needs to be; and then sit you back up and look and say, “Looks good.” Hopefully it looks good, because if it doesn’t, I would have to go to a different size implant, and that means I’ve opened an implant that then has to get tossed away, which becomes an expensive proposition for me. That’s why I use sizers.

Once we have the final implant and sit you up and look at everything, make sure that you’re all symmetrical, then you lay back down and I will sew you up with just a couple of layers of stitches, and then a little butterfly bandaid and a piece of tape.

Prior to putting the implant in and prior to doing the irrigation, I’ll also inject lots of long-acting numbing medicine in along the muscle where I cut it to provide, hopefully, good post-operative numbness for at least 8 to 12 hours.

Post-Op Recovery, Pain Management, and Final Results

When you’re sitting up, you look very good because you’re asleep and your muscle’s relaxed and, I know exactly what you’re going to look like. As soon as you wake up and that muscle goes, “oh, dear, what have you done to me?” it’s going to spasm down. And so it’s going to push hard against your implants and you’re going to look flat, and a little too high, not very close, and somewhat misshapen.

So the next morning, when I see you in the office, I’ll be kind of all happy, like, “don’t you look great” and you’re going to be looking at your breasts going, “I think you need your glasses because they don’t look so good to me.”

Over time that muscle will relax. The implants will settle a little bit, and usually within two to three weeks, you’re back to what I saw you looking like in the operating room when your muscle was relaxed.

After surgery, you’ll go to the recovery room for 30 to 45 minutes to an hour as you wake up. We hope very much that you don’t have nausea. We do have pain medicine for you. And I am doing a new protocol now called an ERAS, which is Extended Recovery After Surgery, where we use differing medications to help with nerve pain and muscle pain, with hopes that you won’t need as much of the narcotics.

As everybody knows, the opioid crisis is a real deal, and so we’re doing our part to try and cut down on how many narcotics we prescribe you. I’ve been doing this about nine or ten months now with this new protocol, and I think it is making a significant improvement in patients’ postoperative pain.

The way everybody looks when they come in the morning, how much pain and discomfort they’re in, is just hugely, hugely improved. Now, of course, it’s not going to work on everyone, but it’s something we’re going to continue to do.

After surgery it will take you, as I said, two to three weeks for the muscle to begin to stretch and accommodate. Usually by six weeks, you’re starting to look pretty good, although the breasts are a little stiff and by three to four months, pretty much that’s what you’ve got.

Over time, implants do settle. It’s mostly because of gravity, and the pocket — remember the pocket is a space inside under your muscle — will stretch a bit, and it almost always stretches towards the outside part of your ribs, because that’s where there’s no muscle and there’s very little breast.

Women will come in and say, “Well, my implants are sitting too far over.” It’s been ten years, and I will nod and say, “yes, you’re right. That’s just gravity and the weight of your implant.”

If you go with a very large implant, that progression of drooping to the side will only be magnified. So the smallest implant you can go into that will give you the size that you want is certainly the best for you long term. And of course, implants don’t last forever. So eventually you’ll need to have them replaced, or removed if you decide that you don’t want them anymore.

I would say breast augmentation is highly successful. It is not successful in women that are very droopy because they need to have a lift done and a lift creates scars on your breast. You can see our podcast about mastopexy.

So if you’re asking me to put an implant in and take up a large amount of skin that really ought to be cut out, it’s not possible. Some surgeons will say, “Well, we’ll just put a really big implant in and it’ll take all that skin up,” and it does… of course, you look really, really large and you’re going to droop really, really a lot because there’s a lot of weight for gravity to work on.

So those are things to think about and ponder before you make your decision.

Why I Don’t Perform an Armpit Incision or an Areolar Incision

I don’t ever use an armpit incision. I was never trained on it. I don’t use an incision around the areola.

Actually, both of the armpit and the areolar incisions have been shown to have a higher infection rate, so I don’t do that. I don’t like the aerola, also, because you have to cut through the breast tissue and that creates more numbness. I don’t generally put implants under the breasts because they’re going to sag more. They can interfere with mammography and your potential for numbness of breast skin and/or nipple in areola is higher.

If you have specific abnormalities of the breast, you may be a candidate for going underneath of the breast, because that’s the only way to correct those. And then, of course, that’s a whole another discussion.

Conclusion

So that’s what you’ve got for breast augmentation. Pretty straight and simple. And next podcast, we’re going to talk about the implants.

Thank you very much for listening to this. And for more information, please check out my Facebook page or my website, which is www.DrKerner.com. That’s D-R-K-E-R-N-E-R.com.

I have lots of before and after augmentation pictures. We also have lots in the office that we can show you.

I also send out regular newsletters with updates about important information on ongoing skincare specials or specials for CoolSculpting, or important information, such as when advisories come out about breast implants and the lymphoma. That will also be another podcast because that is definitely about a 30 minute discussion.

Thank you very much for listening, and I hope to see you as a patient soon. Have a great day. And don’t forget to use your sunblock.

More Episodes You’ll Love