RX Muscle
Winter 2004

Plastic Surgery – Breast Implants

by Dr. Mordcai Blau, M.D.

Breast Augmentation is the most frequently performed plastic surgery on women in the U.S. today. Over 300,000 women undergo breast augmentation every year, with the popularity of the procedure ever increasing, especially amongst female body-builders.

Breast implants are most commonly used as aesthetic enhancement on an individual who is lacking in natural breast tissue due to genetically predisposed or environmentally induced factors. Because breast tissue is primarily composed of fat cells, in the past, physicians attempted to inject fat (obtained through liposuction) into the breast. However, today, this is completely unacceptable due to calcification (complete hardening of the breast). Hormonal therapy may increase the natural breast size, slightly, but not enough for the majority of women.

Currently, the most common way to increase breast size is via breast implants. A breast implant is a sac of silicone elastomer that is either filled with saline or silicone, and is surgically implanted under the breast tissue. The proportion of the breast to body height and weight is taken into consideration, as is the chest width, location of nipple/areola complex, and cleavage. Because the concepts of aesthetics are constantly changing, there are many factors such as implant type, size, and site that should be tailored to the individuals’ specificity.

TYPE OF IMPLANT: Silicone vs. saline?

This discussion is going to remain for many years. Until 12 Years ago silicone was the dominant implant in the U.S.A. However, due to possible autoimmune mediated health problems associated with leakage, saline is now used in 90% of surgeries. Legal, psychological, and technical factors will eventually determine which is preferable. Silicone implants are now gaining momentum and the FDA is going to rule on weather or not to legalize them (which will probably happen). Although the silicone might have some side effects, it doesn’t seem as awful as thought to be a decade ago. The advantage of silicone implants is that it is softer and appears more natural. However, leaks may be found in secondary tissue. Generally, saline is a bit firmer, but it is without the supposed health risks because a leak is simply absorbed by the body. The decision should be made after consultation with an experienced surgeon.


The breast implant can be placed either under the pectoralis major muscle (sub muscular) or on top of the muscle and under the breast glands (sub glandular). Sub muscular implants are more popular because they are less palpable, have lower risk of capsular contracture, and don’t inhibit mammography. However, it requires more invasive surgery and longer healing time. Bodybuilders prefer sub-glandular insertion because the heavily developed pectoralis muscle might flatten the implant and there will be less projection of the breast. Women with sagging or drooping breasts may opt for sub glandular placement for the better projection as well. Disadvantages of sub glandular implants include impairment of proper mammography and increased risk of capsular contraction.


There are four areas of incision:

  1. Periareola (lower part of areola 1 – ½ inches)
  2. Sub-mammary (on the lower breast crease)
  3. Axillary (arm pits)
  4. Trans umbilical (from the belly button)

Each has advantages and disadvantages but the preferred incision is periareola because it is less noticeable. Arguments against periareola are that it is harder to perform, that there is interference with sensation of the areola and violation of the breast tissue. Physicians who are experienced in this method find it easy to do. Personally, I did not see a difference in nipple sensation compared to other methods. Instead of inserting the implant through breast tissue it can be turned under the skin to further preserve the tissue.


Most surgeons have experience with teardrop (natural implants) and with the round implants. Preference is toward the round implant because it appears more natural. Previously, there were high profile implants (which projected more) and low profile implants (less projection). Recently, medium profile implants were introduced.


There is no expiration date for implants. One should be checked by a physician if there are any symptoms or changes that are not expected including deflation, infection, change of location, etc. Mammography, ultrasound, or MRI should follow onset of any of these symptoms. Older patients have to be checked more regularly by themselves, a physician, or radiologist. Once someone has implants for over ten years they should consider replacing them.

RISKS: (not common but possible)

  • Capsular contraction: Scar tissue forms around the implant to form a hardshell. There are several steps to prevent it, such as, size and location of the implant, as well as medications like Singular and Acculent.
  • Infection or rejection from non-sterile techniques.
  • Shifting (moving) of the implant. The pocket for the implant should be adjusted for the patient (this will usually, prevent shifting).
  • Scars: Less conspicuous in the periareola compared to sub-mammary incision.
  • Sensation: May be initially decreased. Usually 90% of sensation will return within 1-2 years of surgery.
  • Violation of breast tissue.
  • Breast Feeding: About 50% of women won’t be able to successfully breast feed, particularly those with periareola incision.
  • Synechia: Adhesions (also known as “kissing Breast”), sometimes related to techniques.

In general complications occur less when using experienced and certified surgeons.


Plastic Surgery is an art form in combination with science. Each patient and physician has a different sense of what is aesthetically pleasing (although the basics are common). During a consultation with a physician, the goals of both the patient and physician should coincide and be realistic. The results are not entirely depending on the physician. It is important to understand that everybody starts with differing anatomical breasts (some patients are better candidates than others) and there are always unforeseen factors (also very rare).


  • Make sure you feel comfortable and trusting.
  • See more than one physician.
  • Check for credentials.
  • Make sure the facility is accredited by a respectable organization and that they belong to a reputable hospital in the area.
  • Use the internet to view before and after pictures.
  • It is a big plus if a trusted person refers him.
  • Ask for references and phone numbers of pervious patients and actually speak to them.
  • Do you like the atmosphere of the plastic surgeons office?
  • Is the staff accommodating and polite?
  • Is the plastic surgeon also an artist in other fields like painting, drawing, sculpting?