Breast Augmentation with Implants

In modern surgery, two methods for breast augmentation have become established, both of which have their own advantages. The use of implants made of silicone is considered to be a classic, which enables a safe and ecologically harmless enlargement of the bust. If a woman rejects the insertion of a foreign body into the breast and has sufficient own fat in other parts of the body, the transplantation of the fatty tissue offers a modern and interesting alternative. In principle, it is not possible to give a general advice on one of the two methods. In addition to the presentation of the two variants, the individual discussion with the cosmetic surgeon should be the most important basis for the decision.

Breast surgery with implants is the most common surgical method in plastic and aesthetic surgery for breast augmentation. The aesthetic surgeon uses breast implants that consist of a silicone shell and are filled with either silicone gel or table salt to achieve this. We recommend breast augmentation with silicone implants as a low-risk method with a very high satisfaction rate, as the quality of modern silicone implants is particularly high. Thanks to the continuous improvements in the production of silicone implants in recent years, these breast implants can now ideally remain in place for a lifetime. So, there’s no need for post-operative treatment. For this reason, you should choose the right implant for you very carefully, especially with regard to shape and size. It is a life-changing decision, even though measures do exist to replace or remove the implants later on. We would be happy to provide you with our expert knowledge for an intensive consultation and decide together with you which implant is most suitable for your breast and body shape.

In the 1990s, silicone implants for use in breast augmentation in aesthetic surgery were withdrawn from the market in the USA. The reason for this was the suspicion, which could not be refuted by the FDA (U.S. Food and Drug Administration), that a continuous leakage of silicone from the silicone implants cause deposits in the body of patients who have undergone breast augmentation. As a result, more saline implants have been used in the USA in the previous decades than in other countries of the world where breast augmentation is widely performed as an aesthetic procedure (e.g. Brazil, Europe, etc.). Meanwhile it has been proven that patients who wear silicone implants after breast augmentation do not have higher silicone levels in blood, urine or even breast milk than women who do not have silicone implants. In addition, the silicone implants used for breast augmentation today are designed in such a way that a gel is created due to a high cross-linking of the silicone polymers, which would not lead to any leakage of the silicone, even if the shell were damaged. This has led to the FDA in the USA also reconsidering and revising its position on the use of silicone implants for breast augmentation. The use of silicone implants for breast augmentation was approved again in the USA in 2006. In the meantime, a considerable amount of silicone implants have been used for breast augmentation without negative case reports being published. There is a general opinion in science that the use of silicone implants is basically harmless. This is why about 90 percent of breast augmentations in the USA are now performed with silicone implants. In Germany and in the other countries of the European Union, this has never been formally discussed. Therefore, a considerable part of the development of modern silicone implants has taken place through the free availability and permanent clinical application for breast augmentation in the past decades here in the domestic market or in other countries of the European Union.

A frequently discussed aspect of breast augmentation over the years has been the question of the position of the implants. The correct positioning of the implant is of great importance for the long-term success and a lasting aesthetic appearance of the breast after breast augmentation. In principle, the inserted silicone implants can be placed on different levels of the breast. A distinction is made between submuscular position (below the muscle) and subglandular position (above the muscle), with regard to the large pectoral muscle.

When positioning the implant under the muscle, a distinction is made between complete placement of the implant under the pectoral muscle on the one hand and partial coverage by the pectoral muscle on the other (‘dual-plane’ technique). In this process, part of the muscle is detached and mobilized, whereby the lower implant pole is covered exclusively by mammary gland tissue. There is no resultant loss of muscle function. Especially in the case of very large implants used for breast augmentation, it can be useful to sink at least part of the implant under the pectoral muscle. In this way, the advantages of the submuscular position (i.e. under the muscle) are used for at least half of the implant, so that breast augmentation can be performed with a reduction in the risk of developing capsular fibrosis.

Breast augmentations with implants under the muscle offer a number of advantages, which we would like to make available to patients. The most important aspect here is good blood circulation under the muscle, which protects the inserted silicone implant and has demonstrably lower capsule fibrosis rates than with the position above the muscle. The so-called capsule fibrosis is a hardened connective tissue capsule around the implant, which occasionally occurs after breast augmentation. Since this phenomenon causes pain as well as breast deformations, the therapy is usually carried out by a renewed operation in which the implant is replaced. This is prevented by the position of the implant under the muscle. Furthermore, the muscular cover prevents the implant from deforming in the sense of wrinkles or furrows (also called ‘rippling’) visible from the outside during movements of the upper extremities. By covering the upper breast pole, a more natural breast shape can usually be achieved. In addition, the implant is felt less after breast augmentation, so that the palpation produces a softer and more natural breast than if the implant were placed directly under the skin. However, breast augmentation with implants placed under the muscle also has some disadvantages. Due to the muscle’s relative strength, the maximum projection of the implant is often limited. Furthermore, with this positioning it is possible that a visible (temporary) displacement or deformation of the implant may occur during physical activity, especially in the area of the upper extremities. Although very few patients complain about such difficulties after breast augmentation, it’s necessary to discuss this with patients, especially active ones.

Breast augmentations with implants placed over the pectoral muscle offer a significantly larger projection per implant volume and thus a more attractive breast shape for patients who wish to have large implants. Women with weak connective tissue and a sufficient surrounding soft tissue mantle, which provides an optimal embedding for the implant, can benefit cosmetically. Some surgeons prefer this implant position for breast augmentation, especially for athletic women or bodybuilders who want to avoid implant deformations due to muscle contraction. The disadvantage of implants for breast augmentation located above the muscle is that deformations tend to be more visible from the outside. The wrinkles and furrows already mentioned cannot be concealed by muscle tissue. However, if sufficiently covered with soft tissue, a change in the shape of the implant can also be sufficiently concealed. The same applies to the natural feeling of the breast after breast augmentation. Implants located above the muscle are usually felt more depending on the surrounding soft tissue coverage.

We carry out a special maneuver in order to utilise the advantages of a good blood circulation situation and to keep the capsule fibrosis rates low for breast augmentation with implants located above the muscle. The muscle skin (muscle fascia) of the large pectoral muscle is also lifted on the surface to the skin. This allows the breast augmentation to be performed over the muscle – i.e. subglandular. However, the silicone implant is covered with the muscle skin (subfascial layer). This procedure also leads to a significant reduction in the number of capsules formed.

As with the choice of implants, the plastic surgeon also has various options, i.e. the skin incision for breast augmentation. As a matter of principle, aesthetic plastic surgery always aims to keep the incision small and inconspicuous in order to make the result of breast augmentation as natural as possible. This makes it possible to make the incision directly through the nipple and areola, to avoid scarring. Similar to the incision made at the border between the areola and the skin, the main problem here is that large implants (anything over 300 ml) are difficult to insert through the resulting small opening. In addition, the gland is manipulated and cut, which can have an effect on the ability to breastfeed after breast augmentation. Alternatively, access via the navel is available, which is, however, disadvantageous in that only saline implants can be inserted through it. This is because the desired volume for breast augmentation can only be filled from the outside with a syringe after the empty saline implant has been inserted. Silicone implants are too large to be inserted via the navel for breast augmentation. Incisions through the underbust crease or the armpits are alternatives for inserting silicone implants. While the armpit offers more risk of injury to nerves and vessels, access in the underbust crease provides better visibility of the surgical area. In this way, surgery can be performed safely and without scarring.

The technology and expertise in the field of breast implant production is continuously developing, which leads to a constant improvement in the quality of the implants. In the meantime, silicone implants can be produced to such a high quality that the durability of these silicone implants is almost unlimited. The long life span of these breast implants ensures that ideally they are not replaced, but can remain in place for a lifetime.

High-quality breast implants produced today usually meet such high quality standards that the question “When do I have to change my breast implants?” can be answered with “Never”. The durability of today’s generation of silicone implants means that post-operative surgery is no longer necessary. From a medical point of view, whether or not breast implants have to be changed only rarely depends on if complications occur that could make it necessary to replace the implants. In addition, some patients decide to change the implant after some time for purely aesthetic reasons, as they wish to have a different shape or size. However, we recommend that the choice of breast implant is made with care so that you are satisfied with for life with the impants and they do not need to be reoperated on.

The result of a breast augmentation depends largely on the individual body shape as well as the choice of the breast implant. Anatomical breast implants are normally very noticeable when comparing the before and after images. However, due to their shape, they appear more natural than round breast implants, which can be more easily guessed by a direct before and after comparison. In order to give you an impression of your expected result before the operation, we create a 3D simulation of the breast in a personal consultation using a special camera on a tablet PC. This 3D simulation also supports us in the selection of the right implant and helps us to communicate this to the patient.