Breast Augmentation

Northern Virginia – Fairfax VA and Manassas VA

By: George Bitar M.D. & Robert F. Centeno M.D.
Board Certified Plastic Surgeons

How to Achieve a Natural Look

Breasts are the ageless sign of femininity and sex appeal. Breast augmentation is done now in ways that accentuate the natural healthy look and minimize the “done” look. Small breasts can be enlarged with saline or silicone breast implants placed under the chest muscle to create nice cleavage and give it a natural, sexy look and feel. The key to achieving a natural look is by choosing the right size implant, proper implant type, proper incision location, and proper implant placement. We will try to address some of the issues that a patient faces when looking to have breast implants. We understand that every patient is unique, and we have a wide variety of options from implant type, to scar placement to different sizes to individualize the procedure to the patient’s wishes.

Very rarely are a woman’s breasts perfectly even, or symmetrical. Sometimes, the lack of symmetry can cause a woman to be distressed, adding prosthetic implants in her bra to achieve symmetry. This is a common situation that women do not like to discuss. The solution is straight-forward. If a woman with uneven breasts seeks a breast augmentation, it is simple to fill one breast implant more than the other to make the breasts as symmetrical as possible. Sometimes a breast augmentation is performed on one breast and a breast augmentation and lift, or a breast lift alone, or even a breast reduction is performed on the opposite breast simultaneously. The treatment plan is agreed upon during the consultation.

The Initial Consultation

An initial consultation is set-up where we will discuss the breast augmentation procedure and to decide whether you are a good candidate for the surgery. Your medical history is reviewed and you will be asked to see your medical doctor for a physical check-up and a few labs to make sure you can undergo the surgery safely. You are asked to stop smoking, if you are a smoker, two weeks before and two weeks after surgery, for the surgery to be performed safely, and for you to have optimal results. You are given the opportunity to be seen by your own doctor to give the green light for surgery. You are given the opportunity to talk to patients who have had the same surgery you are considering. We will see you shortly after the surgery (in a day or two usually). You are seen regularly after your surgery. You are always welcome to come back for follow-up, even years after your surgery, free of charge.

Breast Implant Size

The decision of implant size can be a stressful decision for a woman choosing to have breast augmentations. The way to decide can be simplified and made stress-free.

In the initial consult, patient is asked to place a known sized silicone breast implants in her bra and wear a shirt that would reveal her silhouette clearly. The patient gets to try on different size implants until she finds the size she likes. We offer our patients the option to try sizes again on the second consultation. Usually they come up with either the same size or a very close size to the one of the initial consultation.

One of the most effective ways of reducing dissatisfaction with breast size post operatively is to use photographs in the pre-op discussion. These photos give the patient and the surgeon a common point of visual reference from which to begin the discussion about size. The old adage that “a picture is worth a thousand words” is certainly true in this situation.

Huge implant sizes can be aesthetically unpleasant and create a higher chance of problems and complications in the future. Conversely, if a patient chooses a size that is too small, then the patient will come back asking for a bigger size implant. Therefore we encourage our patients to choose implants in the range of 150-400 cc’s (325 cc’s being the volume of a regular can of Coke), with exceptions in certain situations. In the vast majority of patients, their decision on size choice turns out to be perfect!

Breast Asymmetry or Unevenness

Very rarely are a woman’s breasts perfectly even, or symmetrical. Sometimes, the lack of symmetry can cause a woman to be distressed, adding prosthetic implants in her bra to achieve symmetry. This is a common situation that women do not like to discuss. The solution is straight-forward. If a woman with uneven breasts seeks a breast augmentation, it is simple to fill one breast implant more than the other to make the breasts as symmetrical as possible. Sometimes a breast augmentation is performed on one breast and a breast augmentation and lift, or a breast lift alone, or even a breast reduction is performed on the opposite breast simultaneously. The treatment plan is agreed upon during the consultation.

Silicone or Saline

Both saline and silicone implants are FDA approved for primary breast augmentation. The choice between the two depends on patient preference, findings on breast examinations, and the surgeon’s recommendation.Silicone implants are advantageous in certain situations. Silicone breast implants feel more natural than saline. When a woman has had many breast procedures, has very little breast tissue and muscle remaining in the breast or naturally has very little breast tissue silicone implants may be preferable.. When a woman is very thin, silicone implants may provide an advantage by delivering more naturally feeling results by reducing wrinkling and palpability. In these two situations, we offer our patients silicone breast augmentations.
If a woman’s breasts have sufficient tissue and the saline implants are placed behind the muscle, as we place them routinely, the feel of the breast is very natural, making silicone implants unnecessary. Saline and silicone implants also differ considerably in price and the ability to detect rupture.

before and after photos for breast augmentation virginia

Above or Below the Muscle

Like the majority of board-certified plastic surgeons, we prefer to place the implants under the muscle for the following reasons:

  • The breast feels more natural when the implant is covered by the muscle and the breast tissue.
  • Implants placed behind the muscle are less likely to interfere with mammograms.
  • Implants placed behind the muscle as less likely to cause rippling.

Implants placed behind the muscle do however cause more pain after surgery as they cause the pectoral muscles to stretch. In spite of this, we prefer placement behind the muscle and recommend it to most of our patients. The only exception would be for women who are professional athletes and body builders in which implant placement behind the muscle might cause the implants to shift position.

Scar Location

The scar is about an inch and can be placed either in the under-arm (axillary, or armpit scar), the crease under the breast (the inframammary fold), or at the lower border of the areola (periareolar incision), or from a belly button approach (discussed below). We prefer either the under-arm or inframammary incision for the following reasons, but, at the request of patients, we will perform the procedure through any of the first three approaches.

Under-arm (axillary, or armpit scar):

Advantages:

  • The scar is about an inch, and heals very nicely, like an under-arm crease.
  • The implant can be inserted behind the muscle, so the muscle and breast issue are not cut, unlike other approaches, yielding many advantages: less time to perform the surgery, minimal bleeding, less trauma and scarring, less pain, less bruising, and a shorter recovery time with minimal complications.
  • The milk ducts are not touched, so the risk of losing ability to breast-feed after a breast implant with this approach is negligible.
  • The breast tissue is not touched, so there is no additional scarring that can be confusing to read on mammograms.
  • The scar is relatively distant from the implant, so if there is a superficial scar infection or the scar opens up, the implant is well protected.
  • A lowered probability of injuring the nerve that supplies sensation to the nipple, thus having an extremely high probability of normal nipple sensation after the breast augmentation.
  • The shape and look of the breast is very natural. Critics have cited “high-riding” implants as a result of this technique. With use of proper surgical techniques and the use of a breast binder for pushing the implants down after surgery, we have not seen this problem.

Disadvantages:

  • The scar, although small, can be evident in the underarm area the first few months before it heals completely and fades, but it will never completely disappear.
  • The difficulty to remove an implant from an under-arm scar in the future if a revision is needed, so another approach may be used at that time.
  • The possible loss of sensation in a small area of the underarm.

Peri-Areolar:

The scar is about an inch long and is placed along the lower border of the areola and the breast skin. We do not typically recommend this approach for primary breast augmentation for several reasons;

  • The incision is located in a conspicuous area even though it tends to heal well in most patients
  • This approach cuts through the breast tissue and ducts potentially contaminating the implant with native bacteria or affecting lactation
  • This incision approach is associated with the highest risk of altering nipple sensation including numbness and hyper sensitivity

Inframammary (under the breast):

This is the most commonly used approach for primary breast augmentation. The scar is about one-two inches long placed in the natural fold of the breast. The length of the incision depends on the type of implant used (saline or silicone). This incision heals very well and is well concealed even without clothing. This is typically the approach that we recommend when silicone breast augmentation is selected. The advantages of this approach are:

  • The scar is about 1-2 inches long and heals very nicely
  • The incision is hidden in the natural fold of the breast making it inconspicuous in swim suits or without clothing
  • Precise definition of the submuscular pocket and control of bleeding can easily be achieved
  • Pre filled silicone implants can be safely positioned
  • In revisionary or removal and replacement cases, this approach allows for precise capsule removal, pocket shaping and implant repositioning

Belly Button Approach or TUBA (Trans Umbilical Breast Augmentation):


A belly button breast augmentation has recently been popularized by TV shows. We do not recommend this approach for several reasons:

  • The implants have to be pushed through a tube that might damage the shell of the implant, and for that reason, some implant manufacturers will not offer the five year warranty on breast implants used in this approach that they would if it is done from another approach (under the breast, from the areola, or from the armpit).
  • The breast muscle and breast tissue have to be cut to insert the implant. That does not have to be done if the implant is inserted from the armpit.
  • The time of the procedure is about twice as long as a breast augmentation from an under-arm approach, and the dissection more, therefore causing more swelling, bruising, and pain.
  • The main reason to have a TUBA procedure is to have “no scars”. Well, the scar in the belly button is about 2cm, (less than an inch). So is the scar in the armpit. They are both virtually invisible.

How We Minimize Complications of Breast Augmentation:

At the Bitar Cosmetic Surgery Institute, we take pride in making sure we provide for our patients the best surgical experience possible. This is a process that includes the pre-operative preparation, the actual surgery, and the after care.

General Complications
General complications can occur with any surgery. Cosmetic surgery is usually a safe surgery performed on healthy patients and, as all surgeries go, is with low risk. What we do to even lower the risk of complications is to operate at a first class hospital with board certified anesthesiologists and nurses. To avoid post-operative complications, we advocate early mobilization –patients seen in our office one or two days after surgery- and active participation in their own post-operative care. When we create a partnership, the results invariably improve.

Bleeding
Bleeding after breast implants can be traumatic to a patient. It usually happens in the hours ensuing the breast augmentation, and usually happens on one side. Sometimes, a small amount of bleeding can be observed, but if the bleeding in a breast after a breast augmentation becomes significant, then the patient needs to have the bleeding removed in the operating room in a usually straight-forward procedure. The rate of hematomas or bleeding after a breast augmentation is reported to be about 2%. Before surgery, our patients are tested to make sure they don’t have any common bleeding disorders by their own physicians, and by lab tests. We use tumescent solution, similar to that used in liposuction, before starting a breast augmentation procedure to decrease the amount of bleeding. That technique plus minimal dissection, handling of the muscle during the procedure and creating the appropriate pocket size for the implant are all techniques that decrease the chances of post-operative bleeding. In our practice the rate of hematomas is about 1%.

Infection
Breast implant infections occur in general in about 1-2% of cases. The most important step in avoiding infections, in our opinion, is to perform the surgery at a first-rate surgical facility with board certified anesthesiologists and nurses. . Patients are given the appropriate intravenous antibiotics coverage throughout the actual surgery. During the surgery, the skin surface of the patient is cleaned properly. Next, the doctor changes gloves multiple times during the operation, and he is the only one who handles the implant in the operating room to ensure total sterility and avoidance of infection. After the procedure, our patients are prescribed a one-week course of antibiotics to minimize infection. As a result of these extra precautions, our implant infection rate is significantly lower than the national average.

Capsular Contracture
Capsular contracture is the hardening of the scar tissue around the implant, and occurs in 10%-15% of women with breast implants. It can also be a factor of time elapsed since the implant placement. Every implant will have scar tissue around it; that is totally natural. What is undesirable is for the scar tissue to harden and cause the patient pain or unnaturally-looking breasts. The theories behind the cause of capsular contractures vary. Capsular contractures may be caused by a sub-clinical infection, by significant bleeding during the operation, or by time alone. In the previous section, we discussed how to minimize the risk of infection. In order to minimize the risk of bleeding, we inject the breasts with a tumescent solution, similar to that used in liposuction. The reason for the tumescent solution is to decrease the bleeding during and after the operation and to provide for local anesthesia to decrease post-operative pain. As a result, our rate of capsular contracture has been less than 1%.

Rippling
Rippling is the formation of small waves or folds of the breast surface due to a breast implant. Sometimes rippling is visible, other times it is palpable, or both. In the case of breast augmentations, especially with saline implants, this potential result can lead to patient dissatisfaction in up to 10% of breast augmentation patients. In order to avoid rippling, one must understand what causes it. The chest muscle, or pectoralis major, does not cover the chest totally; the lateral edge of the breast is not covered by that muscle, which is used as coverage for a breast implant. Rippling can be avoided or minimized by giving the breast implant maximum coverage with breast tissue and muscle. For that specific reason, rippling is minimized by placing an implant under the pectoralis major muscle and by selecting an implant size that would be covered almost completely by the muscle. As a result, the implant cannot be felt from the lateral edge of the breast. Because of these two guidelines, the rate of rippling among our patients is less than 2%.

Deflation or Rupture
Breast implants are devices. Their lifespan of “looking good” varies between different types, the patient’s conditions, and the technique used, but that lifetime is not indefinite. The younger the age of a woman seeking breast implants, the higher the probability that they may have to be adjusted or replaced at some point in the future. The good news is that newer breast implants are made of better material than the old ones and have a longer lifespan, with fewer complications. It is difficult to quote rates of breast implant rupture or deflation because it is a function of time. The best way to minimize this risk is by paying attention to each step in the pre-operative evaluation of a patient, the actual surgical procedure, and the follow-up care. If an implant ruptures or deflates, it needs to be exchanged. Saline implants ruptures are easier to diagnose, but silicone implant ruptures may need MRI imaging to make that diagnosis.

Ability to Breastfeed
Women are sometimes concerned that if they get a breast augmentation, they will not be able to breastfeed afterwards. The likelihood of losing the ability to breastfeed after a breast augmentation is very small, since the dissection occurs away from where the milk ducts are located. With the breast augmentation operation described above, inability to breastfeed after a breast augmentation that we have performed has not occurred with any of our patients to our knowledge.

Loss of Nipple Sensation
Similar to what has been said about ability to breastfeed, loss of nipple sensation is a potential complication that due to the technique with which we perform this procedure is a minimal complication, with less than 1% occurrence. Temporary loss of sensation from a “stunned” nerve or a bruised nerve may occur in the time period after surgery, but sensation in the vast majority of cases returns within a few weeks.

Dr. Bitar’s articles on Breast Augmentation

Read Dr. Bitar’s Article on Axillary Breast Augmentation Here

For more information about this procedure call our office and speak to our friendly staff member at 703-206-0506.

Information on this web site is for information only. Do not use the information to diagnose or treat your plastic surgery or cosmetic surgery problems. Please contact your plastic surgeon with all questions and concerns.

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