5 Steps To A Perfect Breast Augmentation

By Leonard M. Hochstein, MD

The perfect breast augmentation begins by choosing the right plastic surgeon. I think by now everyone understands board certification and some of the fake boards that are out so I will not dwell on these issues, but talk about more specifics as I have seen in my experience.
I believe that the perfect result is a surgeon’s combination of talent and experience. There is no question of some surgeons’ ability to make asymmetric breasts look beautiful while others falter. Much of this is as a result of experience while seeing every type of breast that there is. There is no question that my skill improved with my experience. This translates into few insights for the patient. It is hard to find a talented young surgeon, so go for the proven one with the necessary experience to get the job done. Unless you are in the major market, it is unlikely you will find a surgeon who does 500 breast augmentation surgeries annually like I do. So what number is considered good? I would say at least 150 breast augmentation procedures annually is sufficient. This means that the surgeon is doing about 3 breast augmentation procedures on a weekly basis. Make sure to see plenty of pictures of their results. There should be good consistency there. Be wary of surgeons who will only have a few pictures to show you. You should be able to look at books that include hundreds of patients.
The next factor to consider is the site of surgery and the anesthesia provider. There are four options for setting. I would suggest either a private, accredited surgical center which is my preference or an outpatient ambulatory surgery facility. The other two options are a non-accredited private facility or hospital. I would avoid the former because there is no quality control standards and the latter because hospitals are dirty environments with infection risk being unacceptable for my standards.
If there is a problem in the surgery, it is generally anesthesia-related, but it seems few patients asked me about who will be putting them to sleep. There are two options here. The first is a board-certified anesthesiologist and the next option is a CRNA or nurse anesthetist. I use Dr. Livschultz, a medical doctor who is a board-certified anesthesiologist. He has been working in my office for the last 2-1/2 years full time. This familiarity allows us to offer the safest experience for my patients. Most doctors, because of their inconsistency, book their anesthesia provider based on availability which puts you at the mercy of the anesthesiologist who is available on that day. This relationship fosters unfamiliarity and inconsistency. I have a very close relationship with my anesthesiologist where we are able to discuss any pitfalls and make adjustments. For example, we recently came up with a protocol of providing totally intravenous anesthesia or TIVA for first time patients thereby avoiding any risk of malignant hyperthermia. Using a nurse (CRNA) is also frequently used, but not in my practice. In this situation, the physician is overseeing the anesthesia and since I am not trained in this field, I do not believe I am qualified to do so. Be aware of this because it is a cost cutting maneuver; go for the physician anesthesiologist instead.

Now that you have picked your physician, it is time to decide on the type of implant, the incision, and the size. I am not going to talk too much about placement as implant should always be placed submuscularly and if you have chosen a competent surgeon I will assume that is their preferred placement. I am not aware of any experienced breast surgeon who would put the implants above the muscle or in a subglandular location. There are two types of implants available, saline or silicone. The shells in both are made of silicone. They only differ in that saline implants have a balance that they can be inflated once they are positioned. The shells are smooth or textured. Texturing is a process where smooth implants are given a rougher feel. The idea here is to decrease the risk of capsular contraction. The downside is that by making the shell thicker, it also raises the risk of rippling or wrinkling. I do not use textured implants unless there is a significant risk or history of contracture. In this situation, they are indispensable. The main difference is what the implants are filled with. One is filled with saline solution and the other with silicone gel. There are subcategories of each. They come in round or teardrop and the silicone also varies in level of cohesiveness. I prefer the round because they allow for better cleavage and more fullness superiority, but mainly because the teardrop implants tend to shift, which can create an unnatural appearance. I also prefer silicone as they feel much more like breast tissue and have much less wrinkling or rippling than do the saline counterparts. All silicone implants today are cohesive, meaning the silicone will maintain its shape even if there is a defect in the integrity of the shell. But there are now 2 levels of cohesiveness, namely Level 1 and Level 2. The Level 1 implants which are currently used in the United States are semi-liquid whereas level 2 (gummy bear) are semi-solid. The level 2 implants, which come in teardrop shape only are currently unavailable in the United States as the study is now over (there is a prominent plastic surgeon in the Los Angeles area who advertises that he is still using these implants which is not true, so do not be fooled). I have had the opportunity to work with some of these level 2 implants and have found them to be unsatisfactory for two reasons. The first is that they are too firm and also require a very large incision or scar to place as they are not malleable and cannot be bent to place requiring the opening to be almost as wide as the implant itself. This also limits access to the inframammary fold. I believe these implants may have a role for reconstruction in the future, but for aesthetic purposes, I prefer the level 1’s. I still see hesitance towards silicone implants due to safety issues or leak detention. But these concerns are unwarranted. Silicone implants were taken off from the market in 1991, not because they were found to be unsafe, but rather because the FDA deemed them to be inadequately studied. Since that time, there have been multiple studies which have unequivocally found them to be safe and without any links to autoimmune diseases. Simply, the women who developed these illnesses would have developed them whether they had implants or not. The other issue I regularly hear about is the risk of deflation and its treatment. Over the course of 7 years, the deflation rate for saline implants is 15% whereas for silicone it is only 2%; thus making silicone more durable. If there should be a leak, it is much easier to diagnose the saline implants as they simply go flat.
Silicone cannot be diagnosed by physical exam, but rather requires an MRI. The treatment for each is much different since the shape or volume of a silicone implant does not change, it is very easy to replace and could be done simply under local anesthesia. Saline implants are much more difficult to replace as the capsule begins to contract immediately after deflation. This is much harder and requires a general anesthetic with reconstruction of the pocket. I use Mentor implants, as I believe they are the best implant available in the market and currently they come with a lifetime warranty.

There are several access points for implant placement including transaxillary, periareolar, inframammary fold, and transumbilical. All these access points are available for saline implants but limited to periareolar or inframammary fold for silicone. I prefer the periareolar approach because the scars tend to heal better and are less visible when wearing a bathing suit. It also allows direct access to the inferior insertion of the pectoralis major muscle, the proper release of which is crucial to perfect placement.
The last discussion is the size of the implant and the profile, low, medium, or high. When I determine the implant size I begin by talking about the patient’s desired cup. I need to stress that this is only a starting point of the discussion as I do not create a cup size, but rather a look. We decide this by looking at some of my postoperative pictures, as well as having the patient bring in pictures of looks they like and then trying on an implant. Trying on an implant is more useful in smaller breasted women and less so in women who have more breast tissue or are in need of a lift as well. When the patient likes the look of an implant on her chest, I add 50 cc to it and that is the volume I use in the submuscular location. There is no perfect way of picking the size, but this has worked well for me. As a bit of final advice, if you are between 2 sizes, go for the larger one and do not listen to your friend’s advice. They are not you, do not know what you want, nor do they necessarily have your best interest at heart. If there is ever a regret it is that patients did not go bigger. I rarely hear that they are too big.
I choose the profile depending on the patient’s desired size and chest width. The three profiles are moderate(low), moderate plus(medium), and high(high). I typically use the moderate plus because it gives the best combination of projection, which gives a more defined cleavage, and enough width of diameter to avoid cleavage separation. For my patients who have narrow chests or wish to have a large cup size I choose the high profile implant. I rarely use the low profile implant as the only indication is for models who wish to have a very small augmentation and need the greatest diameter width as possible to avoid cleavage separation.

The recovery period is less than a week. Most of my patients are able to drive on the fifth day and return to work after one week as long as no heavy lifting is required. I allow my patients to reach above their head as long as they are not stretching to reach a distant object. I allow aerobic workouts as long as they limit to lower body after 4 weeks and full gym workouts after 6 weeks. I do have patients perform massaging exercises to stretch the muscle in the medial location by squeezing the implants together. This also helps for settling which is usually a 4-month process and rarely can take longer. I also recommend that a moisturizer be used on the incision after 3 weeks of healing and on the breast itself immediately after surgery. Scars do not create moisture on their own and they need help.
Breast implant maintenance is a topic which seems to be misunderstood. The biggest misconception is that implants should be replaced every ten years. This is simply not true and came about based on the data that the old (prior to 1991) silicone implants had a significant leak rate after 10 years. By mistake this has been extrapolated to the current saline and silicone implants used today. The current silicone implants made by Mentor are warrantied for life and require replacement only if a defect should develop. This is the same case for saline implants which are currently warrantied for 10 years (extended warranty is available for purchase from Mentor). Simply put, if there is no problem precautionary replacement is not required.
The horizon shows a few things of promise. Stem cells may one day be used for breast surgery. Their potential seems limitless. I am just beginning to work with them and will see what applications develop.
There is no question that I have some very strong opinions on breast augmentation. These opinions have been formed over many years and many augmentations. I sincerely hope my ideas will be of help to anyone interested in this wonderful operation.
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About Dr. Hochstein:
Dr. Hochstein, or Dr. H as he is known as, began his medical career when he applied to medical school as a merit scholar high school senior. He was able to surpass the customary four years of college and go directly from high school into medical school. The first in a long list of exceptional achievements to be obtained during his academic and surgical training. He attended the accelerated program at the Louisiana State University Medical Center where he graduated as Valedictorian of his class. It was during his time in medical school that Dr. H worked closely with the Department of Surgery and had his first scientific paper published. He received his M.D. in 1990.
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