A breast implant is a soft silicone shell filled with silicone gel or saline that increases the breast volume and size.

Types of implants

The silicone gel implants are made of a silicone shell and filled with silicone gel. They are relatively permanent as they do not deflate. But they require a larger incision size to insert. They have a natural feel, and the new highly cohesive gel implants do not leak even if punctured or cut.

The saline implants are silicone bags into which saline is injected to fill it up. The advantage of these implants is that we need smaller incisions to place the implant, and the sizes can be increased or decreased in case of volumetric discrepancies between the right and the left breasts. But, the disadvantage is that the saline may leak over many years and need replacement. But these are no longer available freely in India but can be ordered if desired.

We also find implants of different sizes, shapes, and textures. The breast surgeon discusses these options with the patient during the consultation and then decides. The choice of the implant is usually left to the patient and forms a significant component of the cost of breast augmentation surgery.

We can place the incisions in one of three places for implant introduction. Incision choice is dependent on the implant type and size and the comfort level and experience of the physician with that specific incision.

Inframammary (crease) incision: 

The incision is placed just in the skin crease where the breast meets the chest wall, usually along the breast meridian. It allows easy placement of the implants. This approach is helpful if bigger-sized implants need insertion. But the problem is that there is a visible scar on the lower part of the breast, which generally settles with time but doesn't vanish. The scar usually merges with the skin crease over time. This is the most commonly used approach to breast augmentation the world over.

Transaxillary incision:

The incision is placed in the armpit. The benefit of this incision is that it is in a natural crease. There is no chance for increased scar stretching since there is no weight or tension against the incision after implant placement. But since the incision is away from the site of actual implant placement, it restricts the size of the implant that can be inserted. Secondly, the dissection is more extensive; hence the pain is a little more. Thirdly, the scar may be visible when wearing sleeveless dresses and lifting the arms. 

In some cases, the nipple sensation recovery also takes longer. The most crucial drawback of this incision is that we need a new incision to change or correct the implant as we cannot do it through the same incision. Also, we need to convert the cut to the one below the breast.

Periareolar Incision:

The periareolar incision is done at the areola and skin border and remains hidden. However, the skin may stretch during healing, and the scar may widen slightly. This approach limits the implant size we can insert based on the areola size. There is a chance for decreased nipple sensation for a few months. Some ducts may get damaged during this approach but usually don't cause any problem during breastfeeding.

Trans-umbilical or TUBA Incision:

Here the incision is placed inside the umbilicus or belly button and is hidden. We can insert only saline implants by this method, also called the "scarless breast augmentation."

Planes of Implant Placement:

Subfascial: 

This is a newer approach popularized by Dr. Ruth Graf from Brazil. Here the implant is placed under the covering or (fascia) over the pectoralis major muscle. This approach gives all the advantages of a sub-muscular placement without the pain of a muscle dissection. Sometimes though, this layer is not well-formed, so we do a sub-muscular placement. This placement has been our preferred area of placement for the last 4-5 years.

Submuscular or Subpectoral:

Placement of the breast implant under (behind) the pectoralis muscle is preferred in women with less breast tissue since the results are more aesthetic. The pectoralis muscle covers about two-thirds of the upper part of the implant. With this placement, there are fewer chances of rippling, though it may still occur in areas not covered by the muscle, specifically the outer sides and bottom of the breasts. The advantage is that the normal breast tissue is far away from the implant and hence does not interfere with self-breast examination and mammography at a later date. Muscle contractions may flatten the implant out a little. Placement behind the muscle does not preclude the exercise of those muscles, and one can get back to regular activities in a few weeks. Also, the incidence of capsular contracture is decreased with this placement. This is the most common area of placement of implants.

Sub-glandular or Pre-pectoral:

 Placement of the implant over the pectoralis muscle provides a more distinct cleavage line than placement under (behind) the muscle. It also allows for larger implant placement. The recovery time is shorter, pain is less, and the implant shifts less compared to placement behind the muscle. Patients who are bodybuilders, highly muscular women, or sportswomen go with this placement. But capsular contractures are more, and if breast tissue is thin, then the ripples of the implant and edge of the implant may be seen on the skin.

Breast Augmentation with stem cells is being tried in combination with autologous fat transfers. Initial results look promising, but we still await long-term findings. Fat is harvested via liposuction; some of it is sent for mesenchymal stem cell isolation and culture. After three weeks of culture, the stem cells are injected into the breast tissue.

The patient experiences some pain and discomfort for two to three days after the operation, especially along the incisions that are manageable with simple pain medication. Some slight discomfort and tenderness may continue for up to two to three weeks, ultimately settling with healing.

Breast enhancement with implants is a surgical procedure with scars along the incision lines. However, the scar's location depends on your surgeon's placement of the incisions. In the inframammary approach, the incision is made beneath your breasts along the natural crease and is easily hidden. In the periareolar incision, the scar gets camouflaged along the areolas. The transaxillary incision has no scar on the breast and is placed in the underarm region. With healing, the scars will settle and start to fade. It may take up to even a year or more for scars to completely heal.

With breast enlargement with fat grafting, there are no scars.