The best breast augmentation candidate comes from one of two groups: the first are women whose breasts never developed proportionately, are limited in the clothing they can buy, and who would like more confidence in their appearance. The second group is women who lost breast volume after nursing and want to restore what was lost and fill up what may have become an empty breast. Women who want to be large and disproportionate, the “Baywatch look,” in fact make up a small percentage of women who get breast augmentation. Less commonly, women whose breast are not just small, but are misshapen, get breast augmentation. All women who get this operation should be doing it for themselves, not for a boyfriend or a husband. They must be healthy enough to undergo an elective operation and must be mature enough to weigh the risks and benefits of the surgery.

Like most life decisions, it is weighing the risks v. the benefits. Each woman will perceive the risks and benefits for herself differently. On the positive side, breast augmentation patients studied after surgery report higher self-esteem and confidence, enjoying their appearance more both in and out of clothing. But that must be weighed with the recognition that in all likelihood this is not a “once-in-a-lifetime” procedure – at some point a breast revision may be necessary. Complications such as infection after breast augmentation surgery can occur. Scar tissue can form around breast implants; implants can break; implants can get out of the right position; there are additional costs in the future; there can be changes with mammograms, and much more that each woman considering breast augmentation should consider. Despite all of these tradeoffs, when women come in to have these problems treated, they are usually so happy with their implants they rarely are willing to give them up.

There is an ideal shoe size for your foot. Too small and your foot will be crammed and too large and your foot will not fill the shoe. The same thing is true with breasts: too large and it will look round and fake; too small and it will be loose and empty on the top. If you are reading this, it is probably because you thought the photos of my patients looked beautiful. The common denominator to the most beautiful breasts is that they were sized objectively on the basis of measurements. Dr. Manuel Gutierrez measure five things, and from that he uses a formula to determine the ideal size. This formula has been published and thoroughly vetted by top plastic surgeons. Dr. Manuel Gutierrez even has a patent for an implant-sizing device based upon these principles, so he is thoroughly versed in making this determination.

This remains one of the biggest concerns of every augmentation patient, so it will bears repeating: there is an ideal implant size for you. You can go smaller, but you won’t be filled up. You can go bigger, but you will look round. Think of a soft-sided purse: if you put only a couple of things, it will collapse and lose its shape. If you shove a lot of stuff into your purse, it will always look round. With a breast, the shape changes as the volume changes meaning you cannot have the same shape with any volume. If you want to look relatively natural, there is a limit to how large you can go. If you want to look relatively filled, there is a limit to how small you can go.

Sometimes Dr. Manuel Gutierrez measures a patient and they want to look smaller than what anatomically is the ideal size for their breasts. That is okay, so long as they understand their breasts may not be totally filled up, and that they may be empty on the top.

At other times he measures a patient and they want to be larger than that ideal size. If they do go larger, they face two tradeoffs. The first is that they will look rounder and less natural. The second is that the size and weight of an implant that is too large for their tissues will more rapidly stretch their skin over time and compress their own breast tissue, leading to rippling, an implant that can be felt, and perhaps the need for a lift in the future.

The best incision is under the breast, and I will explain why. I base this suggestion not on unsubstantiated anecdote, but upon objective scientific evidence.

Most patients decide on incision based upon where they want the scar. But each incision sets up an entirely different operation. Risks and complications are different, and those issues are more profound than the scar. The armpit incision tends to be more painful and less accurate than the other approaches. If a revision is necessary, another incision usually must be made.

The nipple incision yields a scar that is barely visible on most but not all Caucasians, but on patients of other races it very frequently gets pigmented and thick. It often results in a reduction of muscle coverage over implants due to technical issues, which means the implant can be more seen and felt. By cutting through the breast tissue, there is more pain, swelling, and changes in nipple sensation. Most important of all, is the fact that this incision requires pushing the implant through the breast. Though we do not really think about it, the ducts within the breast have bacteria within them. When the implant goes through the ducts, those bacteria get on the implant. And it is exactly those bacteria that cause the inflammation that causes capsular contracture. This remains the leading cause of revision surgery after breast augmentation, and it should be a priority to do everything possible to reduce this possibility. Significant experimental data demonstrate this to be true.

The best published results are with the under the breast – the inframammary – incision. The incision is hidden in the crease under the breast; there is less contamination with bacteria in the breast; more nerves are avoided; the breast tissue itself is not cut so there is less pain; the same incision is the ideal incision for any kind of future revision; and the list goes on. Most important of all is that the very best published data is with this incision. Plastic surgeons and plastic surgery patients too often make decisions based upon undocumented personal experience, and this is inaccurate. If we just look at the facts, the results are best with this incision, which is why I encourage all patients to select it.

Whenever the skin is cut there will be a scar. If you cannot tolerate a scar, you should not have the surgery. While some patient like the idea of the armpit incision since there is no scar on the breast, they end up with the only scar that is visible with a sleeveless blouse or dress. Some patients like the idea of a scar around the areola, and unless that heals very well, there is a very conspicuous “smiley face” in the area of the breast that is the focus of the most attention. The underneath scar usually is very faint. But even if it is not it is at least hidden in the crease underneath the breast.

The most critical measurement is the distance from the nipple to the bottom of the breast, and even if the nipples are at unequal height, these distances must be the same. If it is short on one side, that nipple will point down; if it is long on one side the nipple will point up. Once that distance from the nipple to the bottom is determined, Dr. Teitelbaum precisely make a pocket that will fit the implant. This is yet another reason to favor the under the breast incision, as it affords the surgeon the most direct, well-lighted visualization of the operation, so that everything is done on good vision and nothing must be done blindly with a finger through a dark tunnel.

You must accept a risk of some loss of sensation. The most common area to lose sensation is on the skin of the lower outer quarter of the breast. Whether this happens is related to the course of the nerve to this patch of skin. Less common, but more important, is whether sensation is lost in the nipple. The nipple incision is more apt to create this problem, but with all incisions this is a risk because the major nerve to the nipple comes from the very side of the breast, and any dissection puts this nerve at risk. The larger the implant, the wider the pocket has to be, and the greater the chance of this damage. The less accurate the dissection, the greater the risk of this problem. But even when everything is done perfectly, some women can permanently lose sensation and all patients must be able to accept that risk before proceeding.

Yes, but you usually need to get extra views, called displacement views. So you will get a complete set the usual way, and then another set with the breast tissue pulled forward, away from the implants. Sometimes the implants shadow a part of the breast tissue. Depending upon how significant this area is and your risk factors, the radiologist may order you to get an ultrasound or an MRI in addition to the mammogram. While insurance companies pay for a standard mammogram, some do not pay for the extra views or extra studies needed because of the breast implants.

No. The risk of breast cancer does not change if you have an implant. And the cancers are not detected later, larger, or with a worse prognosis. In fact, by having the uniform implant behind the breast tissue rather than the irregular rib cage, it is easier to feel the breast tissue and more breast cancers are picked up by the patient with implants than those without.

They will only look fake if you want them to look fake. If your implants are properly sized for you, then they will not look fake. The only exception to that is patients who are literally skin and bones, upon whom you can see their ribs. The implant goes in front of the ribs, so if you can see the ribs, you will have to see the implant. But even in those cases, the lack of breast tissue is so profound that a small implant will usually look much more attractive.

The thicker the tissue and the smaller the implant, the more natural they will look. The thinner the tissue and the larger the implant, the more fake they will look. So the answer is to have your tissue measured, and to get an implant that fits your body.

How long implants last and how long it will be until you have your next surgery are two different issues that are often confused. A broken implant is not even in the top five reasons for having a revision. The most common reasons patients have another surgery is the build up of scar tissue, drooping, implant getting out of position, wanting a change in size, etc. Implants only break at a rate more or less of 1% per year. Sometimes those breaks can be noticed as a change in the breast. At other times the patient cannot detect a difference and the break can only be detected by an MRI.

We warn all patients that they may lose the ability to breastfeed, but in the scores of patients of my own who have had implants I cannot recall one who was unable to nurse.

Occasionally after nursing the skins stretches and the breast looks empty. Sometimes capsular contracture develops. Sometimes the breasts droop. For these problems, a revision may be necessary. But most of the time augmented breasts still look beautiful after pregnancy and do not require a revision.

You can drive when you are off of all narcotic pain medication and feel totally unrestricted by your discomfort such that you could make any movement you might need to safely drive your car. That is ultimately a decision that I cannot make for you.

When you will feel ready to do your job is highly individualized. So long as your work doesn’t involve straining and heavy lifting, you can expect to be back to work after three or four days. Some people go back even sooner, and many work from home the next day.

Dr. Manuel Gutierrez suggests you wait 3 weeks. He wants to be sure that everything is healed. There is always a chance of causing bleeding if you start much before that time. When you start, listen to your body. You will be a little out of condition and a bit sore. But you will get back to where you were before surgery very quickly.

A small amount of alcohol will not interfere with your recovery.

We would like to say never, since they are bad for you. Smoking does slow down healing, and it would be best to avoid them for three weeks.

You should shower the evening of your surgery. Your incision can get wet, but don’t rub it. Soap your breasts and let warm water hit them.