All those mathematical descriptions refer to the quantitative values obtained by evaluating a large number of breasts. However, “beauty and attractiveness” are electro-chemical perceptions that contain senses far beyond these values. “Beauty” can not be achieved within certain mathematical patterns. Breast should be examined in correlation of many factors such as the age of the person carrying it, the contour of body, spine, hip and chest, the condition of mammary glands and skin, status and expectation. The evaluation of the physician and patient together determine the suitable breast contour, size and structure.

The person who applies for a breast augmentation surgery should always keep in mind that: Breast implant is a foreign material to be placed in your body. Techniques and procedures to be used in the placement process are very important for this foreign object to stay with you in a healthy way for a long time (lifetime). Thus, the long-term permanence of the operation results and possible problems if something is ignored must be questioned unconditionally.

What is breast augmentation? How is it performed?

Breast augmentation is an operation to enlarge the breasts of small breasted women by implant (implant) or fat injection in order to achieve proportionate body contour.

Which methods are used for breast augmentation?

• Today, the most preferred method for breast augmentation is silicone prostheses. Water(serum) filled prostheses, augmentation by using a person's own fat or hyaluronic acid injection are the alternative methods.

• Together with the physician, it is determined which of these methods will be most suitable for the person.

Breast augmentation surgery can be preferred in situations as follows:

• For women who think their breasts are small, breast augmentation surgery may be recommended to have proportionate body contours, especially to correct the hip-waist-breast ratio.

• Loss of breast volume may occur after pregnancy. Breast augmentation can be a solution for the ones whose breasts are not much sagged.

• Two breasts are never exactly the same. However, in women with evident asymmetry, more symmetrical breasts can be obtained with prostheses.

• Breast reconstruction can be performed with implant in appropriate cases after breast cancer treatment.

• New prosthetics may be replaced with the older (generation) ones from previous surgeries.

• It is also possible to perform breast augmentation surgery since the desired image cannot be obtained after failed breast aesthetic operations.

• For patients who have lost excess weight after obesity, the need is mostly lifting+prosthetics. However, in some patients with small breasts during obesity, only prosthetics may be sufficient since breasts do not sag after weight loss.

Where is the implant placed in breast augmentation surgery?

Breast prostheses are conventionally placed in subglandular or submuscular planes.

In recent years, variations such as full or partial submuscular plane, dual plane, subfascial plane have formed.

Each plane has its advantages and disadvantages over others.

Subglanduler plane

The normal anatomical location of the breast is under the mammary gland and above the chest muscle. Therefore, this is actually the most natural and anatomical plane.

During this procedure, the implant is placed on top of the chest muscle. The muscle and the mammary gland are not damaged.

Since the muscle is not cut, the pain and movement limitation after the procedure is much less.

In order to use this plane, breast skin and subcutaneous tissue thickness should be at least 2 cm. This plan cannot be used for people with thinner tissues and very little breast tissue. Because there will not be enough tissue to cover and hide the implant, the implant will not look natural and it will be noticeable.

It gives very good results for people who have enough tissue to cover the implant.

Subfascial plane

There is a very thin layer of fascia just above the chest muscle. This membrane covers the breast chest muscle and separates the mammary gland and chest muscle.

It is thought that for patients with no submuscular perform need, the implant is better concealed when placed under this fascia layer rather than under the mammary gland. However, the separation of this fascia layer from the muscle requires patience, delicacy and thoroughness. Besides, this layer should be removed using a narrow 3 cm incision made usually under the breast. Most surgeons consider this procedure troublesome and unnecessary.

I think it is useful to remove the fascia layer and place the implant under this layer, this is a better way to hide the implant. For this reason, I am enlarging with subfascial plane in all the cases that I will not use a submuscular/dual plane.

In this plan, the pain is less than the submuscular plan because the chest muscle is not cut.

Submuscular plane

Especially for people who are very weak, have very little breast tissue and whose skin structure is insufficient to cover/hide the implant, mostly submuscular plane is chosen. In this procedure, the chest muscle is cut and removed from where it attaches to the ribs, a pocket is created underneath and the implant is placed here.

With this plane, the upper part of the implant is covered by the muscle, while the lower part remains under the mammary gland. In this way, the implant is covered by muscle on the upper part which is the thinnest region of the rib cage. In other words; the implant is not completely covered with muscle but only its upper part.

Dual plane

It has become popular in recent years and is actually a variation of the submuscular plane. Here too, the breast muscle is cut and the implant is placed under it. However, in the dual plane, according to the sagging condition of the breast, the mammary gland and the chest muscle are separated from each other to obtain a more beautiful appearance.

Dual plane 1 is used in cases without sagging, dual plane 2 in slight sagging and dual plane 3 in cases with more sagging.

I have been using dual planes 1-2 and 3 frequently, too.

Where will the incision be?

Breast implant can be performed with 4 different surgical approaches:

• Nipple circumference (periareolar)

• Inframammary fold (submammarian, IMF incision)

• Armpit (transaxillary)

• Navel (trans-umbilical)

Periareolar incision

In previous years, periareolar (nipple circumference) incisions were frequently used. In this method, a semicircular incision is entered through the transition area between the brown area around the nipple and the skin. The mammary gland is reached directly. It's quick and easy.

Disadvantages of periareolar incision

• This method has a higher risk of loss of sensation in the nipple.

• In some cases, a light scar remains in the suture area and is noticeable.

• In this method, the milk channels can be cut while creating a pocket for the implant.

• When placing the implant, it contacts the nipple, milk ducts and the mammary gland. Bacteria are inevitable in milk ducts and nipples. Although not in the early period, these bacteria cause capsule formation with slow and latent infections in the long term. In the studies, capsule contracture formation was found to be high in the prostheses placed with this incision.

Submammarian incision

It is the most popular method nowadays. With good planning before the procedure, the incision scar fits on the inframammary fold and is not visible after recovery.

The capsule contracture is less because the nipple and milk channels are not touched. A complete control of the breast is provided and it allows access to every point by seeing.

Transaxillary incision

It was used extensively for a period. The incision is made by entering under the muscle from the hairy area of armpit. It's fast and easy.

Disadvantages of transaxillary incision

• It is mostly a blind operation. After the incision of armpit, the process of forming a submuscular plan is performed without seeing.

• Since it is made blindly, it is weak to dominate the lower part of the breast..

• Usually, a implant filled with serum could be inserted through this incision. However, silicone prostheses are more natural and more similar to breast tissue than serum-filled prostheses.

• During this procedure, the implant contacts the hair follicles of armpit. These follicles are rich in bacteria. Therefore, capsule contracture is more common in this method.

• This section will mostly be insufficient for possible future revision procedures.

Trans-umbilical incision

It is rarely used, requires special instruments and only allows the placement of a implant filled with serum. It is preferred by very few plastic surgeons.

Types of silicone breast implant

In recent years, with the development of the chemical structure of the silicone material in breast prostheses, the variety in prostheses has increased. While previously, only round prostheses were used, with the innovation of less flowable and dense (cohesive) silicone, teardrop-shaped prostheses have been used, too.

Breast silicone prostheses can be classified according to these features:

Breast implant types in terms of shape

Teardrop prosthetis

Teardrop prostheses are said to form better natural breast folds and provide a more natural appearance. But I think the discussion of which one is best for the person is more important rather than which one is superior.

Round prosthetis

Because of their shape, round prostheses provide equal growth in every part of the breast. They may therefore be particularly preferable for people who want a fuller decolletage. For example, in thin-built women with small glands, whose skin is loosened by births and breastfeeding, especially the upper part of the breast is emptied. An appropriately selected round implant will restore the plumpness of this part.

On the other hand, in women with a larger and slightly sagged mammary gland, teardrop-shaped prostheses can provide better shape of the lower part and improve upward.

In summary, the shape of the implant to be used should be, again, selected by examination, expectations of the person and guidance of the physician. The important thing is to determine the shape that suits the person and will give a better result.

Types of breast implant in structural terms

• Silicone content

• Saline content (saline)

• Polyurethane

Both the outer shells and the filling material of the silicone implant are made of silicone which is similar to human tissue in terms of sense of touch and is one of the most biocompatible materials with human tissues.

With the development of silicon manufacturing technology in recent years, silicone-containing prostheses have also diversified. Round prostheses are mostly less cohesive (i.e.less dense) and filled with more fluid gel and are softer. Teardrop prostheses are filled with more dense (cohesive) prostheses and tend to retain their shape. Teardrop prostheses are stiffer than round ones.

Polyurethane prostheses are particularly preferred for people with recurrent capsule contractures.

Types of breast implant in terms of surface structure

• Rough (textured) surface

• Smooth surface

Capsule contracture formation is one of the most common complications of silicone implant. After the studies showing that capsule formation was more common on smooth surface prostheses with the effect of bacteria, microserrations were designed on the cover. These serrations have been shown to reduce the incidence of capsule contracture formation.

Although the main difference has been said recently to create the submuscular plan of the implant, not the serrated structure, I still use the rough surface prostheses.

Are silicone breast prostheses safe?

In 2006, the FDA, which is affiliated to the US Department of Health and responsible for the control of all pharmaceutical and medical products in the United States, has identified and declared that silicone breast prostheses do not cause any disease or breast cancer.

FDA approved prosthetics are safely used in mammography and other imaging methods without causing any problems. Women with breast implant should have routine breast checks just like other women.

Allergy to breast silicone?

The raw material of breast silicone is also included in many of the materials we frequently use in daily life. It is widely used in cosmetics and food industry.

Because breast silicone is one of the most adaptable (biocompatible) substances in the body, it is very rare to cause an allergic reaction.The allergy that occurs during surgery is mostly caused by latex substance or powder in gloves.

For this reason, I prefer powder-free gloves for all operations. We also use latex free gloves for individuals who are allergic to latex.

How is breast implant size decided? How to choose a implant?

Breast implant selection is the most important stage of breast augmentation.

Breast implant size selection is a dynamic process in which many variables are evaluated together, the body contour of the person, the features of the implant and the compatibility of these two main factors are taken into consideration.

Main variables:

1. Person’s contour: Height, shoulder width, rib cage width, skin structure, skin thickness, fat tissue thickness, sagging ratio, mammary gland / fat tissue ratio, breast placement in the rib cage, spine-rib-sternum structure, asymmetries….

2. Variables of implant: Content (serum-silicone), base width, height (low-medium-high), projection (medium-high-ultra high), shape (round-teardrop), surface structure…

3. Person's demands: What size of breast does she want? Medium size? Artsy and exaggerated or natural? Does it have to be submuscular? Will she give birth again? Does she accept the preferred incision?

4. Surgeon’s functionality: It is essential that the surgeon explains to the person what he or she can do in detail and inform them realistically about the whole process. The ones with no realistic expectations should be told what they can end up with. In addition, the surgeon should have the experience to choose the implant that will give appropriate results in different individuals. There is no round implant fits everyone, no teardrop implant either, as well as no need the submuscular plan for everyone. S/he should be able to choose asymmetric prosthetics for asymmetric bodies, in short, s/he should have perfect control over all steps of the procedure.

As stated above; tens, perhaps hundreds of variables should be evaluated individually in the entire process and the most suitable one among the hundreds of prostheses in the catalog should be selected. The most important of all these criteria is the surgeon's experience and philosophical-medical perspective on breast augmentation.

The main aim of the surgeon is to guide the person via his/her experience and provide to achieve desired body appearance with a proportionate and permanent implant.

How long do the implants last?

Theoretically, silicone breast prostheses do not have any life expectancy. Manufacturers state that these prostheses can be used by patients for lifelong. We take all protective measures in order to place a implant that will last for a lifetime.

Also, prosthetic companies provide warranty against capsule contracture or deterioration of the implant for varying periods of time.

But, skin and subcutaneous tissues and breast ligaments will loosen and sag with variables such as aging, births, breastfeeding, weight loss. So, no breast is going to stay like a 20-year-old. Over the years, the variables that we have counted will affect the prosthetic breasts as well as non-prosthetic breasts.

Therefore, the revision over time is likely, depending on the changes. For example; after having a breast implant at the age of 20, a woman who gives 3 births, breastfeeds and gains 15 kilos during pregnancy can optionally have a breast lift if her breasts sag at the age of 45. Replacement of the implant is also recommended during this procedure.

Duration of breast augmentation surgery

Breast augmentation surgery takes about 1 hours.

Anesthesia method

Breast augmentation surgeries are performed under general anesthesia by plastic surgery doctors under operating room conditions.

The age for breast augmentation surgery

Breast augmentation surgery is usually recommended after the age of 18 when the breast tissue completes its natural development.

However, in some cases where one breast develops more than the other during puberty and an excessive asymmetric appearance occurs; breast implant surgery can be decided at an earlier age in order to prevent psychological problems.

What should be the ideal breast size and shape?

As we mentioned earlier, ideal breast size is a personalized concept. Many factors such as body contour, height, weight, bust-waist-hip ratio, placement of the breast in the rib cage and the structure of the breast should be brought together. Besides, since beauty is a relative concept, the physician and the candidate must decide together on the ideal breast size.

In addition to all these subjective elements, aesthetic surgeons have also defined the ideal breast shape.

According to this:

• The nipple is located 19-22 cm away from the collarbone

• The upper part of the breast is flat or slightly concave, the lower part is plump and convex

• 45% of the breast tissue is located above the nipple and 55% is below it

• All breast tissue is on the inframammary fold or slightly descends towards this.

But as we said before, beauty is not a pure mathematical concept. The concept of beauty defines an electro-chemical level of taste, in which senses and emotions are involved. At this point, in order to create a beautiful breast, the person's wishes and the physician's experience and philosophy of beauty are the most important elements.

How to prepare for breast augmentation surgery?

7 days before the procedure, blood thinners (aspirin, painkillers other than paracetamol..), all food supplements such as vitamins and herbal teas should be discontinued. Black tea and coffee are drinkable.

You should consult your physician for prescription medications that are used continuously.

It is better not to be in menstrual period during the procedure. Because hormonal changes during menstrual period can affect the breast structure.

A basic breast imaging (ultrasound or mammography) must be performed before the procedure.

When coming to the hospital, bring clothes with buttons on the front which you can wear and take off without lifting your arms.

Healing process after breast augmentation

After this procedure, which lasts approximately 1 hour and is performed under general anesthesia, you can usually be discharged the next day.

I suggest you spend the first night in the hospital. Thus, possible pain can be controlled and the person is provided to be comfortable.

If drain is placed, it is generally removed the next day. In patients where the implant is placed under the muscle, slight tingling may occur in the arm movements for the first few days.

After the procedure, the breasts are taped and dressed in a compression bra (sports bra). This bra will be on you when you wake up. It is recommended to use the bra for 3-4 weeks while the bands are removed after a few days.

The bands are usually removed within 3-5 days. After the procedure, the whole body from under the breasts and hair can be washed. Once the tapes are removed, the breasts can also be washed and the whole body showered.

Usually there will be no need to take stitches as melting stitches are used.

It is possible to return to work 3-5 days after the procedure. The edema descends fairly in 3-4 weeks and the breasts recover their natural contour. After 3 weeks walking/jogging and non-arm sports can be possible. It is necessary to wait for the 2nd month for sports activities such as swimming and tennis, which are operated by arm and chest muscles.

Those coming from outside of the city can easily return after the first check (3rd day after surgery).

Scars

The scar remains after each surgical procedure, even if it is small and vague.

Aesthetic surgeons hide the scars in curves, folds, and natural lines of the body.

After breast augmentation surgery, there will definitely be scars. A small scar remains on the nipple, armpit or under the breast, according to the technique applied. The method we usually apply is to hide this scar under the breast, thus preventing it from appearing.

This scar is first red and prominent. In time, it firstly becomes pink and then white and fades, almost becoming invisible.

What should be considered after breast augmentation?

Physical activities that operate the arm and chest muscles after breast augmentation surgery should be strictly limited for the first three weeks and should be increased gradually after this period. In the first 2 months after the operation, it is necessary to avoid sports activities such as tennis and swimming, where there is more arm movements.

Also, sauna, excessive hot bath, Turkish bath, solarium and steam bath should be avoided within 8 weeks after the operation.

For 1 year the scars should be protected from light if you enter solarium. When entering sea and sunbathing, the sun rays will affect scars even through the swimsuit. Thus, a 50-factor sun lotion should be applied to the suture lines in the swimsuit or bikini.

Breast Plastic Surgery Types

There are different types of breast aesthetics that can be applied depending on the type of problem experienced.