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).