Public opinion and recent scientific studies have once again swung the pendulum in favor of breast implants in the United States. After the FDA restricted the use of silicone implants in 1992, plastic surgeons experienced a precipitous drop in the number of breast augmentations they performed. The government's concern at the time were reports that silicone implants were causing generalized symptoms in some women (Rheumatoid arthritis, lupus and other auto immune diseases).

In the years that followed multiple large studies were performed at leading medical centers yielding consistently favorable data. In 1997, the Institute of Medicine independently reviewed this data for the US Congress and found conclusively that there was no evidence that silicone implants were responsible for any major diseases of the body and that these devices did not increase the risk of primary or recurrent breast cancer. Since then, many other studies have solidified these conclusions reassuring the public that silicone and saline implants are indeed safe.

With this increased confidence in implant technology, more women chose to have breast enhancement in the year 2004 than ever before. In fact, the American Society of Plastic Surgeons reported that 254,140 American women underwent the procedure in 2003 compared to 32,607 in 1992. This number continues to rise steadily and Charlotte is no exception. Breast Augmentation has become one of the most commonly performed cosmetic procedures in the US.

Improving breast contours and unevenness may seem trivial and vain at the surface, but the emotional implications are far reaching. The boost in self-confidence that we witness in our patients makes this procedure extremely rewarding. A significant number feel a lack of femininity and have an altered body image similar to our mastectomy patients before their reconstruction. Those that are severely underdeveloped avoid bathing suits and instead wear bulky t-shirts to obscure their flat chests.

Their gratitude after the surgery is unparalleled and they invariably become an important source of referrals to our growing practice. These days, once women have decided to undergo augmentation they are faced with a plethora of options: silicone vs. saline, round shape vs. contoured, smooth surface vs. textured, pre-filled vs. inflatable, under the chest muscle vs. over, in the hospital vs. the office, sedation vs. general anesthesia; not to mention the different size implants and manufacturers available, as well as which incision to use and whether or not other procedures are required. It can become overwhelming?

First, the issue of silicone vs. saline implants. Although the Institute of Medicine unequivocally ruled out the association between silicone gel implants and systemic diseases, local problems with the breasts such as silicone leaking and hardening, while not life-threatening, were concerning to this committee. My personal preference is to use saline implants. These can and do eventually deflate but the salt water used to fill them is completely harmless to the body and gets reabsorbed, making them safer than silicone implants.

Furthermore, unlike saline deflations where the patient soon notices a decrease in size and seeks attention, the ruptured silicone implant can go undetected for years until the breast starts hardening and becomes painful.

The next choice to be considered is smooth vs. textured (rough) surface. My bias has changed in the last decade from mostly textured to mostly smooth implants. Research in the early 90's indicated that textured silicone implants hardened less frequently than smooth ones. It may not be the case for saline implants however. Some studies show a small difference, others no difference.

When it comes to choosing pre-filled (fixed volume set by the manufacturer) or inflatable implants (inserted empty into the breast and then inflated in-situ), I prefer the latter. Using an inflatable prosthesis allows fur a much smaller incision to be made and more flexibility in choosing the final size, especially when the breasts are uneven to begin with.

Placing the implant behind the chest muscle (pectoralis major) or in front is another intensely debated issue. More surgeons, as I do, feel strongly that behind the muscle is better. The major advantages is a lower rate of hardening, better preservation of nipple sensation, improved breast contour (the edges of the implant are obscured by the muscle) and improved visualization on mammogram.

The disadvantages are that there is more pain after the surgery, the breasts look fuller at the top the first month and the implants occasionally "bounce" when the chest muscle is contracted forcefully (as in some body builders). Despite these inconveniences, behind the muscle is definitely the way to go.

Which incision to use for placing the implant, by contrast, is much less important. Excellent results can be obtained with all four approaches: under the fold, in a crease of the armpit, through the areola (nipple) or the belly button. I generally prefer the armpit crease incision as it is a more direct route behind the muscle and leaves no scar on the breast itself Nipple sensation and breast feeding potential remains intact.

The two dominant manufacturers of implants in the US, McGhan and Mentor, are equivalent in most respects. As to the size of the implant, the majority of our patients are conservative: wanting simply to restore fullness after having children or slightly enhancing underdeveloped breasts. The width of the chest, how much breast tissue exists, and what the target cup size is desired, are the major factors in choosing the volume in "cc's" of the implant.

The aesthetic "norm" in the US appears to be a full "c" cup unlike Europe and South America where B/small C is more common. Although not an exact science, the majority of patients are content with their final volume. In our one year post-op survey that patients fill out, 91% of women are happy with their size. 6% would have liked to have gone bigger, and 3% smaller.

Be knowledgeable about the complications that can arise. No surgery is without risks. but these should be minimal.

Finally, take your time to do the research. Don't rush into the surgery. Know that it is safe and ever-more popular, but do it for the right reasons: mainly to feel better about yourself.