Breast Augmentation Incisions

Breast Augmentation Incisions

There are basically two incisions I use for a straightforward breast augmentation. By straightforward, I mean, not needing a breast lift at the same time. These two incisions are the inframammary incision and the periareolar incision.

The Inframammary Incision

The inframammary incision is about 5 cm or so and is placed above the bra line. This means that if you are wearing a bikini top or bra, your incision will not be seen. These scars fade very nicely with time. How much time, varies from person to person. Over the years, these scars can be very difficult to see at all. In a person with red hair or very blonde hair with a very fair complexion, these scars, can initially be quite pink, but with time, they will fade beautifully. With a women, with olive or Asian or dark skin, there is always a risk that the scar may hyper-pigment ie heal with a darker scar. If this occurs, it is not due to any mistake on my part or your part, but is just the way your skin heals. I always use dissolving sutures and never use drains.

Periareolar Incision

The other incision I use, is the periareolar incision. This is on the lower half of the areolar. This scar is very hard to see, even right after surgery. This incision is unlikely to affect either breast feeding or sensation. This  is my preferred incision for most women and especially those with non-white skin since it almost always blends superbly. Also, if you need a lift, then I will need to make an incision all around the areolar, so there is no need to add in an inframammary incision. Thanks to the Keller funnel, I can almost always place the silicone implant through this incision. Saline implants which are placed in the pocket, can easily be placed with either incision. Some women just do not like the thought of having an incision placed close to their nipple and they will prefer an inframammary incision. 

Both incisions are able to give you an equally excellent result to your breast augmentation.

Breast Augmentation and Smartlipo – Can They Work together?

Breast Augmentation and Smartlipo – Can They Work together?

The answer is yes and no.

I do my breast augmentations in a surgicenter, outside of my office, because I use general anesthesia (GA). I do my Smartlipo cases in my office. I will do regular liposuction when the patient is under GA.

What does this mean in practical terms?

I am a huge fan of Smartlipo. I have had many patients, who have had Smartlipo with me in the week or weeks before having their breast augmentation. This works great. Many patients prefer that since they are already asleep, for both cost and convenience reasons, to have their breast augmentation done and at the same time, have their liposuction done.

There is no absolute right or wrong answer to this question. In general, for those wanting the absolute best result from their liposuction, it is generally preferable to do the Smartlipo in my office, in advance of the breast augmentation. You can return to work the day following Smartlipo. This approach does require more time from you and me, and since the Smartipo is much more time consuming procedure, and requires additional equipment, this will cost more. However, you will be saving some time under general anesthesia, which will raise your OR costs and your anesthesia costs.

I will discuss both these options with you, when you come in for your consult since the decision, will be an individual one.


What if I Don’t Like My Breast Augmentation

Breast Augmentation – What if I don’t Like My Breast Augmentation?

It is very, very unusual, in my experience for someone to not like their breast augmentation. I think the most common reason people may have slight regrets is that it is early on in the healing and settling phase and the patient does not realize that with time the appearance will become much more natural.

It is important to remember that the post-operative swelling will actually get worse for 3 days. Also, the swelling will not be even. You will swell disproportionately in the upper pole, making it look like they were placed too high. I remind my patients frequently, that you need to allow 3 months for them to drop into the correct position.

Another reason for possible early dissatisfaction is that the implants can feel very firm. I use the analogy, it is like getting 9 months pregnant in one hour. It takes time for the soft tissue in your breasts and the overlying muscle to stretch and soften. They will get softer and more natural for over a year, so once again, it is important to be patient.

Sometimes, after surgery, gravity will cause the nipple-areolar complex to sag with time. This is not too difficult to correct and usually can be fixed in the office under local anesthetic. I sit you up at the time of surgery and make sure that the nipple is properly positioned. However, if the elasticity of your tissues is not very good, it can descend in the weeks after surgery. Remember, it is relatively easy to raise the nipple position, but next to impossible to lower it. Thus, if I am not sure a nipple elevation (mastopexy) is required, it is much better to allow a few months to elapse to see how the breast settles with time.

There is always an asymmetry between the breasts. Sometimes, I can make them somewhat more similar but I rarely can make them exact. Also, realize that I will sometimes put in different size implants to even up the volume, but sometimes the actual shape between each breast is different. This will lead to there being some asymmetry between the breasts. It is very rare for a woman to have exactly identical breasts. Sometimes after surgery, a patient will be much more critical of each breast and will notice differences that she failed to notice pre-operatively.

There are certain “tricks” and “skills” a good plastic surgeon can utilize. However, doing a BA is not the same as doing sculpting or working with clay and there are some limitations of what can be achieved. As I tell all my patients, your expectations of cosmetic surgery must be realistic. After a breast augmentation, just as in life, it is best to aim for good and be satisfied, rather than aim for perfection and be assured of almost certain disappointment.

How to choose the right size implants?

How to choose the right size implants?

You should always choose a Board Certified Plastic Surgeon and NOT some wanna be. Don’t be shy about asking if they are board certified as a plastic surgeon, since it is very common for doctors to misrepresent their training.

Different plastic surgeons will have different methods for helping you select the right size implants. One of the more common methods is for you to “try on” a variety of size implants inside your bra and see which one you like best. However, I do not like that method since an implant can look quite different inside your body than it can look when placed in your bra. Somewhat similar, some plastic surgeons will have you “try on” bags of rice or salt but that suffers from the same limitation of the above. Other surgeons will give you recommendations based on measurements that they take of your breasts and your shape etc. However, the limitation of this method is that it does not fully take into account what your wishes are.

So what is my method? I happen to love my method. I have been using it for more than 15 years. I have you go to a web site, such as, which has over 6,000 women with pre and post-op views of their breast augmentation. Almost all of the pictures will include the height and weight of the patient, as well as the size of the implant used. I have you email me one picture of someone’s picture you feel looks like you do now and a final result you like. I simply select the same implant size that this woman did and you should look very similar to the final result that you most preferred. Simple! No bags of rice or size based on a measurement algorithm.

One final word of advice: When you come across a picture you really like, stop and email that picture to me ( and my office. If you keep looking at many more pictures, you will throw yourself into confusion. Your first impression is almost always the correct one. Of course, I will review your selection and if I have any reservations or suggestions, I will share them with you.

What is a breast lift?

What is a breast lift?

There are a myriad of different techniques for a breast lift. However, I think it is best to think of them as two broad categories.

The first type of breast lift, focusing on raising the nipple. No one takes the nipple off and replaces it as a free graft (except for some very unusual circumstance such as a massive breast reduction – I once removed 26 lbs of breast tissue from a woman – 13 lbs per side and I did free nipple grafts then). Most techniques in this scenario involve raising the nipple areolar complex (NAC) and there is only a skin excision above the nipple areolar complex. This allows the NAC to slide up and can give a much better balance to the breast appearance. In general it works best, when not too much advancement is needed and also can be more dramatic if the woman is small breasted. I do these procedures very easily in the office under local anesthetic and you can return to work the next day. It takes about 90 minutes or less.

The other main type of breast lift, involves not only elevating the NAC, but involves elevating the actual breast tissue. This is done under general anesthesia in the Operating Room. This requires a “lollipop” incision or “key hole” incision and sometimes an extended incision in the lower aspect of the breast. This gives a more dramatic change and can significantly reshape the breast. It is important to remember that ultimately we are fighting gravity and the longevity of the results depend on the quality of your breast tissue. Some patients will get fantastic results that will last many, many years and for others, there can be an improvement but it may be much more short lived. Also the more ptotic (saggy) your breasts, the more dramatic and long lasting the results, usually. It can be quite difficult to give a full lift to someone who has full breasts but only a small amount of saggy-ness but who wants them very, very perky. 

Often times, an implant will be used with the lift. Sometimes the breasts are made smaller. Sometimes it is just a lift alone. Everyone is different. I encourage everyone to get a consultation to fully understand their options.

Will people know I had a Breast Augmentation?

Will people know I had a Breast Augmentation?

This is one of the most common questions that I get asked by my patients. Many women want a BA but don’t want everyone at their office to know.

This is a very normal question. For many women, having a breast augmentation is a private matter, to help them feel better about themselves. They don’t want everyone privy to this.

Rest assured. For most women, no one in your office will notice. Even if you go with a significant augmentation, if you wear clothes that are not form fitting, it is very unlikely that anyone will detect the change.

I always tell my patients who are worried that other people will know they have had a BA, that we are very self aware, but everyone else is also very pre-occupied with their own appearance and thus rarely notice much about others. Women who have gone from an A cup to a large B or C, and then worn a bikini to the pool, have been amazed, that many people don’t seem to notice. This is because most people are very unobservant and although they should notice, they just don’t. We are very self aware, but most others are not very aware of us!!!

In the early stages after a BA, there can be a considerable amount of swelling in the upper poles of the breast. This is is easily hidden by a bra and clothing. Of course, if someone sees you straight from the shower, sans clothes, then it may be obvious that you have enlarged your breasts. However, most people will not be seeing you in this state.

Thus, if you wear clothes, you can make it very, very hard for them to know that you have made any changes to your body. Of course, when you are ready, you can also make it more obvious that you have an enhanced figure. It is your choice, always.

Breast Augmentation: Silicone or Saline?

Silicone or Saline? What are the advantages to each type of breast implant?

Silicone or Saline? As I tell my patients in their initial 45 minute free consult with me, “there are no bad implants.”  However, there are certain advantages to each type of implant.

What are the advantages of a saline implant? First to clarify: a saline implant has a silicone shell which is what is holding the saline in place. Of course you cannot just put saline inside the breast or it would be absorbed immediately. So the container/bag holding the saline is silicone. Therefore, the woman who does not want to have any silicone put in her body, needs to realize that she is still having some silicone put into her body. However, silicone is very inert and well tolerated and there is no evidence that this is harmful. In fact, almost everyone, including men, have measurable levels of silicone since it is so ubiquitous in our society.

The biggest advantage of saline implants is that they cost quite a bit less than silicone implants. The price difference is going to vary from surgeon to surgeon and also which type of saline or silicone implant will be selected. However the difference in price can be at least $500 and some more than $800 per implant. It is a significant price difference. Also, silicone implants require a funnel which can cost about $200. Thus, there is a significant cost saving by going with saline implants.

Who is the best patient to go with saline implants?

If you have a considerable amount of breast tissue already and you are fine going with a smaller implant size, I think it is less important in this situation to pay the extra money for the more natural feeling silicone implants since so much of your own breast tissue will be covering the implant. Also, I always put the breast implants under the muscle.

I have had many patients, who I have seen in follow up (by which point I have long forgotten whether I have put saline or silicone implants, unless I look at the OR report) and they have felt so natural that I assumed I had put silicone implants in place but, in fact, had put saline implants.

The only other advantage of saline implants, is that because they come empty and I fill them up once they are under the muscle, is that a smaller incision can be used. This is less important for most patients because the silicone implants can be placed with a fairly small incision, provided a Keller funnel is used. 

More Natural Feeling

Silicone has the advantage of feeling more natural. The density of silicone is very close to the density of fat. Breast tissues have a moderate amount of fat. This is just a more natural feel than saline (saline is like filling up a plastic bag with water) I always put the silicone implants in with a funnel since it allows a much smaller incision. This more natural feel is more implant for the patient who has small breasts, and especially, if they have low body fat. Also this type of patient is more prone to showing possible rippling which is less likely, in a silicone implant.

If you are interested in a breast reduction, I encourage you to schedule a consultation to discuss your options. Everyone is unique and they weigh benefits differently. The only way to really make a decision is to consult a board certified plastic surgeon who can help guide your decision.

Things to Consider Before a Breast Augmentation (BA)

Breast Augmentation: Things to Consider

Breast Augmentation (BA) is a very effective procedure but there are a number of things that you should consider before you have a breast augmentation. The most important thing to consider before you have a BA or any cosmetic procedure done, is what do you hope to gain from the procedure?

As you may be aware, I am also a certified life coach and I am happy to explore this question in much greater detail. 
If you want a BA by definition you want larger breasts, but the deeper question is why? If you have a deeper more hidden meaning, such as to improve your relationship with your partner or to help you become more popular, you are setting yourself up for disappointment.


Now, a BA will give you larger breasts and hopefully this can help you feel better about yourself. This boosted self confidence can lead to more openness in your relationship or feeling better about yourself, so that you are more helpful and cheerful to be around.

However, if you have real problems in your relationship or your sense of self worth, you need to address these head on and not have a BA, hoping it will solve the problem.

You also need to see if your expectations are realistic. It is simply not true that everyone can have perfect breasts after a BA. Some types of breasts will need a lift, but even some of them with a lift, although they will look better, will not look like those of an 22-year-old.

Breast implants will not last forever. However, I think the internet post that says you should change them every ten years is erroneous. You should only change them if they get hard or leak. You should, of course, always select a board certified plastic surgeon to get you the best result.

The best thing to do if you’re interested in breast augmentation is to schedule a consultation. At my practice, all my consults are free and usually last 45 minutes for women interested in breast augmentation. I never pressure you into any decision and always give my honest opinion.

Saline versus Silicone Breast Implants: How Are They Different?

I often get asked about which is better, saline or silicone implants. I also discuss this thoroughly for those patients that come in for a breast augmentation consultation.

It is important to understand that there is not a good breast implant or a lousy breast implant. Women can get wonderful results with both types. I would also add, that those people (usually men) who say that they can tell by looking at the woman if saline or silicone implants were used, I would say, “rubbish.” I have seen many women in follow up, by which time I cannot remember whether I used saline and silicone on them. I examine them and, based on my exam, believe they have silicone, when in fact they have saline implants.

The biggest advantage of saline implants is that they cost less than silicone implants. The other advantage they have, is that they come empty so I can roll them up into a cigar shape and slip them under the muscle with a very small incision. they are then filled with a connecting tube which is removed. This makes it very easy to use the periareolar incision.

There are two major advantages of silicone implants. The most important is that they definitely feel more natural. The density of silicone is much closer to fat (which is a significant component of breasts) compared to saline (fill up a sandwich bag of water and that is what saline implants feel like). The other advantage of silicone is that they are less likely to show rippling especially in thin, small breasted women.

The silicone implants come already filled. It used to be that inserting them required a large incision. However for the past several years, I have been using a Keller funnel, which allows me to insert it through a much smaller incision. I can usually insert silicone implants through a periareolar incision. Note that the Keller funnel cannot be re-used on a different patient, so they are discarded after they are used on you.

This advantage of silicone becomes less important for those women who already have a moderate amount of breast tissue. Conversely, for those women with very small breasts and who also have very low body fat, the advantage of a more natural feeling silicone implant becomes greater.

Note that I almost always put my implants under the muscle, which makes them less likely to get hard (capsule formation) and they feel and look more natural.