Perfect Breasts

By George Bitar, MD

First of all, there is no such thing as the perfect breast-augmentation technique, so opinions differ among plastic surgeons about the best way to perform this procedure. I believe that transaxillary submuscular breast augmentation, performed using saline implants without endoscopy, is a simple procedure associated with a high level of satisfaction and a low rate of complications.

The main reasons for breast augmentation are small breasts and breast asymmetry. The decision to have breast augmentation should be explored in the initial consultation. The patients answer to, “Why do you want to have breast augmentation?” can be very telling. Reasons stated by women seeking breast augmentation have varied tremendously.

Typically, a woman who is having the procedure to enhance her own self-image (without concern for external forces) will have the highest likelihood of success and happiness.

During the initial consultation, the patient is asked to place silicone breast implants of a known size in her bra and to wear a shirt that reveals her silhouette clearly. The patient tries on implants of different sizes until she finds the size she likes.

Figure 1. The marked area of the axilla is where the incision is made (left), leaving a virtually imperceptible scar (right).

In preparing for surgery, the patient is marked while standing. The inframammary folds, the superior border of where the implant should lie, and the midline are marked. A 2-cm line is drawn at the lower aspect of the hair-bearing area of the axilla. The breasts are infiltrated with tumescent solution (in a fashion similar to that used for liposuction).

Surgical Technique

After the tumescent solution takes effect, a 2-cm incision is made in the lower pole of the hair-bearing area of the axilla.

Next, digital dissection is carried out to establish a plane between the pectoralis major and minor muscles. Care is taken to avoid trauma to vessels and musculature.

Implant sizers are used and are filled to the size which the patient and surgeon have agreed. Adjustments can be made until the surgeon is satisfied with the size and shape of the augmented breasts. This is probably the step where experience helps most.

The muscle should be elevated enough to create nice cleavage, but not too much. If the surgery is too aggressive, the patient will complain that, when she lies down, the implant ends up under her arm.

During the next phase, one sizer implant is removed and the surgeon empties the air from the saline implant, rolls it, and inserts it through the incision. When the implant has been completely inserted, it is filled with the desired amount of saline using a closed system and a one-way stopcock to ensure the sterility of the saline. Next, the implants and general shape of the breasts are inspected with the patient sitting.

Postoperative Care

The incisions are covered with flexible skin-closure strips, and foam tape is placed around the breasts to ensure healing in the proper position. A bra is put on the patient, and dressings are used to cover the axillary incisions.

The patient is seen the following day, and the incisions and appearance is inspected. Any early problems are addressed promptly.

Most patients heal uneventfully, and daily activity is resumed after a few days. Work can be resumed in about a week, and exercise can be resumed after the third week, in most cases.