Breast Implant Incision for Women with Small Bust

Around 20 million women have breast implants worldwide, a clear proof of the devices’ popularity among patients who want to improve their appearance or reconstruct their breasts following mastectomy or cancer surgery.

If used for cosmetic reasons, the common goal of patients wanting to have breast implants is to increase their bust size.

The bust size and appearance, natural tissue and fat, type of implant used, goals and expectations, and doctor’s expertise determine the appropriate incision sites in breast implant surgery.

Women with very small breasts (AA cup) should bear in mind that in breast augmentation, the “bigger the better” principle does not apply because of certain risks.  For instance, it is unreasonable and even precarious to use large implants that would give them DD cup due the higher chance of rippling and wrinkling.

And more often than not, small breasts are usually associated with small areola complex, making this incision site not ideal with the use of silicone implants, particularly large ones, because of the higher risk of visible scarring.

Silicone implants require longer incisions than saline implants because they are only available in pre-filled version.

By contrast, saline implants are filled with a sterile mixture of salt and water once inside the breast, for this reason small-breasted women may choose the areola incision if this type of implant is used.

Another good option for women with small bust is the breast crease incision, which is the easiest technique because it allows plastic surgeons to work close to the breasts unlike the armpit and navel incision sites.

However, there is one concern with the use of breast crease incision to augment a small breast.  First and foremost, women with AA cup often lacks a defined “fold” that separates the base of the breast from the chest; for this reason, there is a chance that the scar sits too high or too low that makes it visible.

But because most plastic surgeons are very adept with breast crease incision, low- or high-riding scar rarely occurs.

Meanwhile, the transaxillary or underarm incision is another good substitute for women with small breast and areola particularly if they choose saline implants.  While it is possible to use silicone implants, ideally they should come in small size so they can easily fit into the surgical slit.  

But whether a woman has small or large breast, the transaxillary technique is not used if there is an existing deformity because the distance between the incision and chest area can make the surgery extremely more challenging.  The same is true with the navel incision site. 

The First Woman Who Received Silicone Breast Implants

In the spring of 1962, Timmie Jean Lindsey from Houston, Texas received the first silicone breast implants and turned her from B to C cup.  Meanwhile, the plastic surgeons who operated on her did not realize that this would be one of the most popular cosmetic surgeries worldwide that in 2010 alone, about 1.5 million women had the procedure.

Today, 80-year-old Lindsey said she has no regrets of having breast implants, which have boosted her self-confidence.  However, what is surprising to know is that she never really intended to have a breast augmentation in the first place.

She was in a hospital for tattoo removal when one doctor came to her and asked if she would consider getting the first silicone breast implants.  At first she was reluctant because what she really wanted was a surgery to pin back her ears.

But because the surgeons Frank Gerow and Thomas Cronin offered her ear pinning surgery at no cost, she immediately volunteered for the first-of-its kind operation.

Gerow first came up with the idea of silicone breast implants when he squeezed a plastic blood bag and realized that has an uncanny resemblance to a woman’s breast.

But before the device was implanted in Lindsey’s chest, Gerow and his team first used a dog named Esmeralda as their guinea pig.  The implant was placed under the skin and stayed there for weeks until the surgeons decided to remove it after the animal incessantly chewed the stitches.

After deeming that silicone breast implants were safe, the surgeons operated on Lindsey and other women followed her footstep.

Lindsey said she experienced pain for three or four days following surgery and described her recovery “as like something had been sitting on her chest.”

At first she had no idea of the full results until she went out in public and men gave her “the look” while others would whistle at her.

While breast augmentation resulted to higher self-confidence, Lindsey said that she never revealed it to her past relationships, and her family and friends became only aware of her operation when she told them about it decades later.

Though she remains delighted with the results, she realized thatsilicone implants would not maker her “breasts forever young” and said that they began to sag over the years.

Currently, breast augmentation is the most popular cosmetic plastic surgery in the US, with about 307,000 procedures performed in 2011 alone. 

FAQs About Breast Implant Placement

The overall result of breast augmentation surgery is largely affected by implant placement.  To better understand this issue, the California Surgical Institute has provided a list of most frequently asked questions:

1.  Question:  What are the three basic types of breast implant placement?

Answer:  The implants can be placed under the tissue (subglandular or over-the-muscle placement), behind the muscle (submuscular or under-the-muscle), and behind the tissue and partially under the muscle (partial submuscular placement).

2.  Q:  What is the most ideal implant placement?

A:  The most ideal implant placement is dictated by a patient’s overall anatomical features including the amount of tissue and fat to work with, and her goals and expectations.

 3.  Q:  When is subglandular or over-the-muscle implant placement ideal?

A:  In general, this breast augmentation technique is ideal for women with ample amount of tissue and fat that provides enough “coverage” to prevent visible and palpable wrinkling.  And because the top edge of the implant has little tissue, the method provides a distinct cleavage line.

4.  Q:  When is submuscular or under-the-muscle implant placement ideal?

A:  The technique is highly ideal for patients with little amounts of tissue and fats who are prone to wrinkling and rippling.  Also, many plastic surgeons believe the implant placement is recommended for women who are concerned with sagging or bottoming out since the weight of the implant is supported by the muscles rather than by tissue and skin alone.

The submuscular placement is also ideal when using large breast implants (e.g., full D cup) because it prevents visible and palpable rippling.

To further reduce the risk of rippling, doctors recommend silicone implants, which are filled with a cohesive gel notable for simulating the feel of breast tissue and fats.  By contrast, women with little tissue are often advised to stay away from saline implant due to its watery consistency, thus increasing their risk of wrinkling.

Using smaller implants when dealing with small-breasted women is another effective way to reduce the risk of rippling and wrinkling.

5.  Q:  Is it true that women with submuscular implant placement can go braless without having to worry about sagging?

A:  Technically speaking, the answer is yes.  However, many plastic surgeons believe the breasts still need a good support to prevent or at least postpone sagging.

6.  Q:  Why is it that submuscular implant placement often results to longer recovery and more postoperative pain and discomfort?

A:  In this technique, the muscle is literally compressed and pushed by the breast implants, leading to more swelling, pain, discomfort, and longer recovery than if the subglandular implant placement were used.

7.  Q:  How long does it take for the implants to settle naturally?

A:  If the submuscular implant placement were used, it would take longer (several weeks or even months) for the implants to settle down naturally than if subglandular technique were used.  But regardless of which method is used, patients should expect that their newly augmented breasts will appear unusually firm and that they will sit higher on the chest.

Within a few weeks or months, the breast implants will settle downward, leading to a natural appearance.  In some cases, a strap is wrapped around the chest area to achieve a more desirable result.

8.  Q:  Does implant placement affect the rate of capsular contracture or tissue hardening?

A:  Some plastic surgeons believe that submuscular implant placement somewhat reduces the risk of capsular contracture because it limits the contact between the implant shell and tissue where most of the bacteria live.

However, this is just an anecdotal observation rather than a scientific conclusion.  And to put it succinctly, capsular contractures are quite unpredictable and may happen to some patients, regardless of which breast augmentation technique is used.

9.  Q:  Does implant placement affect the accuracy of breast screening test?

A:  In general, breast implants—no matter what type of placement is used—make it more challenging to perform breast X-ray and mammogram.  Fortunately, many radiologists nowadays have experience screening women with these devices.

Most experts agree that the submuscular implant placement is less likely to obscure mammogram readings than the subglandular technique. 

10.  Q:  Does a certain implant placement prevent symmastia or “uniboob?”

A:  The implant placement will not affect a patient’s risk of symmastia, a condition in which the breasts settle in the middle of the chest.  This problem happens if the implants are “inappropriately” large or there is over-dissection of the muscles at the breast bone.

As with any problems caused by implant displacement, symmastia can be only treated with revision breast augmentation surgery.

Breast Anatomy—How It Affects the Breast Augmentation Technique

About 307,000 breast augmentation procedures were conducted in 2011, according to data released by the American Society of PlasticSurgeons.  But despite the growing popularity of this surgery, many patients are still not aware that their breast anatomy and even their overall body frame can affect the final outcome.

Breast Anatomy:

* Areola complex

This is the pigmented part of the skin, and at its center is the nipple which contains tiny ducts responsible for breastfeeding and are very sensitive to manual stimulation.

The edge of the areola can be used as an incision site during breast augmentation, allowing doctors to create a “pocket” and insert the implant.  And while this technique hides the scar, the tradeoff is the higher risk of temporary or permanent loss of sensation which happens if too much nerves are severed.

Fortunately, patients can choose from other breast augmentation incisions including breast crease, underarm, and navel.

* Cooper’s ligament and connective tissue

They support the entire breast and define its shape.  But after several pregnancies and weight loss, they start to become slack, leading to sagging appearance.

Breast implant alone cannot correct sagging, although this can further improve the appearance of the bust after a breast lift surgery.  Combining these two procedures are particularly ideal for women who have drooping breasts and want to add more volume in their chest.

* Inframammary fold

Also called breast crease, it separates the breast mound from the lower chest wall.  Meanwhile, this area is a great incision site because it allows plastic surgeons to work close to the chest, making it easier for them to position the implants; for this reason, the technique is ideal for patients with existing breast deformity.

However, the inframammary fold incision is more ideal for women with a defined breast crease as it can prevent them from having a high- or low-riding scar.

Most board-certified plastic surgeons are very familiar with inframammary incision technique that unsightly scars rarely happen.

* Chest width

This breast anatomy dictates the right implant profile which is the projection off the chest wall.  In general, petite women should use high-profile implant that has small base but offers more protuberance.

By contrast, patients with a wider chest width should use low-profile implants which have a broader base but offer less protrusion.

Meanwhile, patients can choose moderate-profile implants that provide projection according to their amount of filling (which is measured by cubic centimeter or cc).

Thinking About Having Bigger Breast Implants?

As its name suggests, breast augmentation surgery aims to increase the bust size and a fuller appearance especially in the upper and medial cleavage.  However, it does not necessarily mean that you can go as large as you want because several factors can play a role in your ability to accommodate larger implants.

Currently, the biggest implants available are filled with 800 cubic centimeter or cc of saline or silicone gel.  Going larger than this size means you will need a customized implant, which means additional fees.

But common sense suggests that implants larger than 800cc do no guaranty better results or more beautiful appearance.  In fact, most self-respecting plastic surgeons would likely decline a patient whose aesthetic goals are too extreme that these will push the body’s limits.

While breast implants are reasonably safe, this may not be the case if yours would be too large for your tissue and fat to accommodate.  Imagine that an implant shell needs “enough coverage” to prevent palpable rippling and visible wrinkling, and using extreme sizes can lead to this kind of problems.

And if you are leading an active lifestyle, unreasonably large breast implants will definitely not work for you.

A “reasonable” size should not just depend on what you want to achieve with breast augmentation.  First and foremost, you should also consider certain anatomical features such as chest width, waistline, and natural breast tissue and fat.  Always bear in mind that the less tissue you have, the more ideal it is for you to choose small- to moderate-sized implants.

By considering your anatomical features—including your body frame (e.g., petite, athletic, big-boned)—it would be easier to achieve a more natural appearance.  Take note that the “heavy top look” which is arguably popularized by Pamela Anderson is no longer the in thing; in fact, the star has been rumored to undergo a revision breast augmentation to downsize her implants.

Even Dolly Parton and Denise Richards were reported to have had breast augmentation to downsize their implants and achieve a more natural look.

Even before consulting with a plastic surgeon, you should be 100 percent sure on the bust size you want to achieve; in this way, you will most likely be satisfied after the surgery.  Always bear in mind that a significant number of revisions happened because the patients thought they have gone too big or too small, so making it right the first time is crucial. 

Silicone Breast Implants Do Not Increase the Risk of Cancer

In the early 1990s, silicone breast implants were pulled out of the market due to concerns that they might increase the risk of breast cancer and systemic diseases.  But in 2006, the US Food and Drug Administration has lifted the moratorium after extensive studies found no link between using the devices and serious illnesses.

The FDA’s decision to lift the moratorium is supported by many oncologists; in fact, silicone breast implants are increasingly becoming popular among post-cancer patients who have breast deformity following their mastectomy (partial or complete removal of their breasts).

Meanwhile, leading LosAngeles plastic surgeon Dr. Tarick Smaili believes that silicone breast implants are reasonably safe both for cosmetic and reconstructive surgeries.

“Silicone breast implants have been subjected to the most rigorous examinations which have proven that they are reasonably safe.  Another bonus is that they can provide a very natural appearance since they are filled with a cohesive silicone gel that replicates the feel and look of breast tissue and fats,” Smaili said.

Because post-cancer patients who had mastectomy often have a limited amount of tissue, silicone breast implants are usually more ideal than saline implants which have a watery consistent (because it is only filled with a sterile mixture of salt and water).

The mastectomized breast has a very low risk of cancer recurrence so placing implants during reconstructive surgery has become a common practice.

However, Smaili warns that breast implants can make it difficult to conduct mammogram and “physical” breast examinations.

“A breast augmentation patient should go to a technician who has an extensive experience in conducting mammogram screening on women with breast implants.  Also, more views are necessary to get a more accurate and clearer result,” Smaili said.

But despite more difficulty to do mammography, the plastic surgeon advised women with breast implants aged 40 years and older to undergo screening at least every year.

“In this way, their doctors can immediately diagnose any cancerous lumps even before the condition gets worse,” he added.

Meanwhile, mammography is not only performed on older women (with or without implants) but also on younger patients with silicone breast implants that are prone to “silent leak,” a condition in which the cohesive gel drips out of a damaged or ruptured shell without causing any visible signs.

But in the long run, silent leak can lead to inflammation of the tissue, pain, and visible breast deformity.

The FDA recommends mammography every two years for patients with silicone breast implants; on the other hand, this is not a requirement for younger women with saline version because a rupture would immediately show visible signs. 

FAQs About Breast Lift or Mastopexy

Breast ptosis or sagging is one of the most common problems associated with aging; however, pregnancy and significant weight loss are also known to contribute to the problem because these may stretch the ligament, tissue, and skin.

Fortunately, breast ptosis can be corrected by mastopexy or more commonly referred to as breast lift surgery.  To better understand the procedure, these are the most frequently asked questions of patients:

1.     Question:  How is breast lift performed?

Answer:  Plastic surgeons tighten and sometimes remove the loose skin and tissue using incisions placed directly in the breasts.  In most cases, the surgery also involves changing the position of the areola and nipple to achieve the most desired result.

2.     Q:  Where do plastic surgeons perform mastopexy?

A:  Mastopexy—or any type of cosmetic surgery—should be only conducted in an accredited surgical center or hospital.

3.     Q:  What are the techniques used in breast lift?

A:  Because the degree of sagging is different from each patient, plastic surgeons have come up with several techniques.  In severe cases, they use anchor lift which uses an incision around the edge of areola, within the breast crease, and another one that travels from the nipple down to the crease.

For women who need less correction, the vertical incision from the areola to the breast crease would be removed.  But for those who have a very small breast, even the donut lift—in which only the incision around the areola is maintained—would be enough to raise the bust.

4.     Q:  Who should postpone the procedure?

A:  Women who are planning to lose weight, nursing a child, and wanting to have more children should postpone breast lift because pregnancy and weight fluctuations can reverse the result of the surgery.

5.     Q:  What are the risks?

A:  As with any cosmetic breast surgery, mastopexy has its own set of risks including increased bleeding, infection, asymmetric appearance, and adverse reaction to medicines.  With this consideration, patients should only consult with a board-certified plasticsurgeon specializing in the procedure.  

6.     Q:  What are the preparations before breast lift surgery?

A:  Plastic surgeons require their patients to undergo physical and laboratory examinations (e.g., mammograms or breast x-rays) to determine any underlying health problems that may lead to more risks. 

And days or weeks before the surgery, patients should avoid aspirin, ibuprofen, warfin, and other drugs that can affect blood clotting; certain types of herbal supplements; alcohol; caffeine; and tobacco.

7.     Q:  Is there any visible scars?

A:  Within a year after surgery, the scars will remain very visible but over time they will fade.  While the incision lines are permanent, they are hidden from view that even if a woman would wear a plunging neckline, they cannot be seen.

8.     Q:  Can breast lift provide fullness?

A:  Breast lift can only raise the sagging breasts but cannot create fullness especially in the upper poles; for this reason, some doctors recommend breast implant surgery as a complementary procedure.