The media’s long-running emphasis on breast enhancement (from Baywatch to the Kardashians) has cultivated a deep familiarity with what has come to be known as the “boob job.” Breast augmentation surgery, or augmentation mammoplasty, is a popular cosmetic surgery that has been around for almost 60 years and typically refers to changing the size or shape of the breasts for aesthetic purposes. It continues to be the leading cosmetic surgery worldwide, with approximately 193,000 procedures performed in the U.S. alone in 2020.
Even in a world where television shows like Botched have painted a false picture of bad boob jobs running rampant, the popularity of the procedure remains largely unchanged. However, patients are now entering surgeons’ offices wielding more information than ever before. Contrary to popular belief, breast augmentation is not just about larger-than-life sizes. “I think what’s happened over time is patients are becoming savvier about what works and what has complications,” says board certified plastic surgeon and breast reconstruction specialist Dr. Lisa Cassileth.
If you’re curious about breast augmentation, below is everything you need to know about the procedure.
How To Choose A Plastic Surgeon
The first step to an ideal breast augmentation is finding a surgeon that aligns with your desired aesthetic. “You have to study a surgeon’s work. If he does a lot of porn stars and you’re looking for a small petite implant, that might tell you he's not the right surgeon,” advises Board Certified Plastic and Facial Surgeon Dr. Deepak Dugar.
Some questions to consider asking your potential surgeon are whether or not they are board-certified, what type of plastic surgery and breast augmentation methods they specialize in, where your surgery will be performed, and how they handle potential complications.
Dr. Dugar suggests also asking how many breast augmentations a surgeon performs in a year. “Doing more than 100 of a certain type of procedure a year, they're probably quite proficient at it,” he says. “If they're at less than 100 per year, then it really depends on their global experience because their active experience may not be enough.”
What to Expect At A Breast Augmentation Consultation
Like most cosmetic procedures, a comprehensive pre-operative plan sets the tone for success. “What will yield a great outcome or an unsatisfactory outcome is how well the doctor communicates,” says board certified plastic surgeon Dr. Steven Levine. “It’s important the patient explains exactly what they’re looking for and the doctor can reflect that all back to them so the patient is confident.” Patients should come to a consultation prepared with photos that illustrate their desired end result for their breasts. In addition to a breast exam, your surgeon will ask health and lifestyle questions to determine if you are a proper candidate as well as the best treatment course.
During the consultation, cup sizers allow patients to feel implants and try out various looks using prosthetics that fit in their bra. Make sure you bring a few different types of tops, including a fitted t-shirt, to give you the best understanding of how the implant will change your shape. 3D-imaging technology is a newer consultation tool that creates highly accurate renderings of how implants will look on a patient’s unique body composition.
One of the biggest mistakes Dr. Levine sees is patients placing too much emphasis on their perception of size. “They have preconceived notions about sizes, but it’s important for patients to understand the final size is a combo of what you started with and the implant,” he says. “That’s a nice way of saying that whatever size implant your friend has means nothing.”
Being cognizant of trends may narrow your choices by helping you avoid outgrowing your decision over time. “The trends are changing. People are choosing smaller sizes because they understand bigger sizes weigh their breast down over time and actually age you,” says Dr. Cassileth.
Your surgeon may also suggest alternative methods depending on your goals. A breast lift alone can help achieve a “perkier” look and is sometimes required in tandem with an implant for the best results. Fat transfer, although highly debated amongst surgeons on its efficacy, can avoid an implant altogether and help you gain volume using unwanted fat from other areas of the body.
Also, you can expect to pay an average of $200-$500 dollars upfront for a consultation. Depending on a surgeon’s availability, consultations are sometimes free.
Saline vs Silicone Breast Implants
After choosing your implant size, you will have to decide between a saline or silicone option.
Saline implants are FDA-approved for use in patients 18 years and older. They are filled with sterile saltwater and encased in a silicone shell. These implant types are typically less expensive and can be filled with the saline solution after implanting, which requires a smaller incision. In the event of a rupture, sterile saline poses no threat to a patient. However, saline implants are firmer and prone to rippling, making them more likely to be visible within the breast. These implants are not typically recommended for patients with less natural breast tissue or those looking for a dramatic change in cup size.
Silicone implants are filled with medical-grade silicone gel and better resemble the look and feel of natural breast tissue. Concerns over the safety of silicone implants and the integrity of the type of silicone being used prompted the FDA to ban them in 1992. The ban was lifted in 2006 for both reconstructive and cosmetic breast augmentation but then only approved for use in patients age 22 and older. Ruptures of silicone implants are considered a medical emergency and require more frequent monitoring.
Both saline and silicone implants can have either a textured or smooth outer covering that contributes to security within the breast tissue. Be sure to have a discussion with your surgeon about what pros and cons each type and texture of implant is best for you.
How Much Does Breast Augmentation Cost?
Breast augmentation varies widely in price and depends on a number of factors including the surgeon’s fee, hospital fees, where the surgery takes place, and anesthesia. The average price of breast augmentation was $4,516 in 2020 according to the American Society of Plastic Surgeons, but that number can tip well over $20,000. “There are places that [perform the procedure] for as little as $5,000. My surgeon’s fee is probably $18,000 or $20,000,” says Dr. Levine. “There’s definitely a wide range. I wouldn't say surgeons who charge less are bad. They charge based on experience and how busy they are.” Dr. Levine adds that surgeons who charge less may have less contact with their patients and have a team of nurses or physician’s assistants who shoulder the lion’s share of preoperative care.
Keep in mind that choosing silicone implants as well as having the procedure performed in a major city will increase the overall price. Your surgeon can help guide you toward the most budget-appropriate path and may offer payment plans.
What To Expect On Your Surgery Date
Depending on your surgeon, you will visit either a private surgical center or hospital on the day of surgery. Breast augmentation requires intravenous sedation or general anesthesia, which are moderate and deep types of anesthesia, respectively, so you will refrain from eating or drinking at least six hours prior to surgery.
The procedure takes approximately one to two hours. Incision and implant placement are the most important procedural steps, both of which are decided upon beforehand with your surgeon.
Although there are several options, the most common incisions occur underneath the breast fold or around the areola. “Almost all my patients end up with the inframammary fold incision,” says Dr. Levine. “When you go through the areola there is a higher risk of capsular contraction which is a post-procedural complication where scar tissue develops around an implant.”
Traditionally, implants are either placed completely below or above the pectoral chest muscle. “I think that's completely gone out of vogue,” says Dr. Dugar of these two approaches. “We've found it has more issues in terms of placement longevity. Now a much more common approach is where you’re doing half muscle and half glandular.” This method varies in how much muscle covers the implant and gives natural fullness while avoiding the obvious breast-implant look of yesteryear.
Finally, the incision is closed with stitches and a bandage or surgical tape is applied. Afterward, you’ll be taken to a recovery area where you’ll relax until discharged, usually after one hour. You must arrange for someone to pick you up from the facility as you will not be able to drive during recovery.
What To Expect During Breast Augmentation Recovery
Swelling, bruising, and soreness are common for the first one to three weeks after surgery. “About half [of patients] wake up and feel good and the other half are uncomfortable for the first 48-hours. That wanes over the first week,” says Dr. Levine. “Then it only feels tender when they are straining. By the end of the second week, they are feeling close to back to normal.”
After-care instructions differ depending on your surgeon, but it's common to wear a support garment around-the-clock for several weeks. You may be directed to avoid showering for the first 48-hours. Dr. Dugar advises patients to sleep on their back for the first several days to decrease swelling.
Pain medication may be prescribed for the first few days, after which you may be directed to take OTC pain medication. Stitches will either dissolve on their own or need to be removed up to ten days after the procedure depending on the type of sutures used.
Most patients can return to their normal routine within one to two weeks, but ask your surgeon when you can resume more strenuous activity. Even after being cleared to return to exercise, avoid lifting over 20 pounds within the first three weeks after surgery.
What About Breast Reductions?
Breast reductions, or reduction mammoplasty, remove excess fat, glandular tissue and skin to reduce the size of the breasts. Over 33,000 aesthetic breast reductions were performed in 2020 according to the ASPS, and although breast reductions are commonly sought out for relieving pain, they are still classified as cosmetic elective surgeries and infrequently covered by insurance. Recent analyses of breast reduction policies revealed a trend of outdated criteria to consider a reduction medically necessary, greatly limiting access to coverage.
“Breast reductions are not technically considered in the breast augmentation category. However, they are similar in the sense that they are cosmetic procedures,” says Dr. Dugar. “It's still in the same general price range as normal breast augmentations. That being said, some breast reductions do employ a breast implant at the same time as the reduction, while some do not. This would be determined based on your anatomy in terms of the size that you're looking to go to with your breast reduction surgery.
Understanding Breast Augmentation Risks
Although the experts classify breast augmentation as one of the safer plastic surgeries available, no treatment comes without risk. The most common risk associated with breast implants include capsular contraction, or hardening of the breast from scar tissue, and ruptured implants. Contracture risk sits around 10% but can be decreased with implant choice and surgery techniques. In the case of contracture, surgical treatment is required.
Ruptures vary in severity depending on the implant type. Saline ruptures are immediately noticeable, but the solution is safely absorbed by the body. Silicone ruptures, however, may leak over time and in the event are considered a medical emergency. “Every three to four years you go back to your surgeon and they keep an eye on it,” Dr. Dugar says of silicone implants. “If they evaluate and feel it’s necessary, you do an MRI.”
Recent discoveries have linked textured breast implants to a rare type of immunological cancer called Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Although serious, the risk is low ranging from a one in 10,000 to one in 30,000 chance of being diagnosed. (Allergan recalled its Biocell textured breast implants in July 2019 after the FDA linked them to BIA-ALCL, although the FDA did not go so far as to completely ban all textured breast implants).
Growing reports associating breast implants with a slurry of symptoms have also coined the term Breast Implant Illness (BII). BII lacks confirming data and is therefore not an official, medical diagnosis. However, the community of patients claiming the condition holds steady.
Again, as with all cosmetic procedures, it’s crucial to find a surgeon who you feel comfortable with and who can answer all of your questions before and after your treatment so that you feel confident in your choices.