Dr. Carli's Book on "Breast Augmentation"

Chapter 1 - Chronology of Events

Chapter 1 - Chronology of Events that led to this book.

Here begins the historical timeline referred to in our Forward and Preface sections. Much of the terminology used and the procedures described will be greatly elaborated upon in subsequent chapters of the book. This section was written to give my patients a brief but thorough understanding of the reasons for our modern-day surgical preferences, how those preferences evolved over time and how they are frequently dictated by circumstance.

1976: Dr. Rex Peterson, Chief of my plastic surgery training program and President of the ASPRS, taught me the technique of breast augmentation. Through an Inframammary incision ( see diagram on page 20), a silicone implant was inserted into a subglandular pocket (below the mammary gland). The first breast augmentation surgery, performed in 1963, was done in that fashion and until July 1976, it was still the standard.

1976: Dr. Paule Regnault, a female plastic surgeon in Montreal Canada, published an article recommending placement of the implant under the muscle to decrease the incidence of capsular contracture (scar tissue formation).

1976: Dr. Paule Regnault, a female plastic surgeon in Montreal Canada, published an article recommending placement of the implant under the muscle to decrease the incidence of capsular contracture (scar tissue formation).

1976: Dr. Greg Hetter, Professor at the University of Nevada, Las Vegas, went to Canada to visit Dr. Regnault. He came back convinced she was correct in her assertions. He was challenged.

1978: The armpit incision was described, but only for a subglandular insertion. The technique was a brand new and controversial. Dr. Rex Peterson did not want his trainees to attempt it.

Dr. Robert McGregor, another plastic surgeon in charge of my training program, performed a surgery suing this armpit incision procedure and I followed suit.

1979: The armpit and the nipple incision became my primary choices, accompanied by a subglandular insertion of the implant.

1980: I visited Dr. John McGraw, Chairman of the Plastic Surgery Department , in Norfolk, VA. He again demonstrated the advantages of covering the implant with the muscle. Furthermore, he did it through the armpit incision. His technique combining the two procedures achieved excellent results, but was technically difficult.

1984: Dr. John Tebbetts, Professor at Baylor University, published a major article in the ASPRS journal. He described in great detail the technique performed by Dr. McGraw in Norfolk, i.e., a submuscular (under the muscle) pocket through an armpit incision. I contemplated a visit to Dr. Tebbetts, but a videotape of his technique because available just a few months after the release of his article.

1990: I felt very comfortable with Tebbett's technique. However, I still frequently used the subglandular pocket technique enabled by the silicone implants, especially those with a new textured envelope. My results continued to be quite good.

1991: The year of the silicone crisis. To the American plastic surgeon, it was considered a triumph of the media over science. Indeed, no study in any part of the world indicated any systemic silicone toxicity. In February, 1991, I returned to Paris to learn Dr. Benelli's breast lift technique. While there, I discovered physicians were still using silicone implants. Six months later, I visited Dr. Ansari in Duesseldorf who had the largest cosmetic practice in Northern Germany. While there, I met his two fellows, one British the other Swedish. The three men stated that further studies were being conducted on silicone throughout Europe. Nothing was discovered to incriminate silicone implants of any toxicity.

It was known throughout the U.S. that silicone, though still available, had been completely discredited. This was in larger part due to the media. Though the negative allegations were unfounded, the public was frightened and saline implants became the standard.

1992: In every meeting of plastic surgeons I attended, the saline implant was highly criticized. Patient feedback indicated, "It doesn't feel natural and causes rippling." In a Newport Beach meeting, Dr. Trupp, a plastic surgeon from Philadelphia, stated that the only way to compensate for the difficulties of the saline implants was to go under the muscle. I completely agreed with him. I had already begun my personal practice of placing nearly all saline implants underneath the muscle in order to obtain more tissue to better cover and support the implant. My only exceptions were made in those cases where there was ample breast tissue, adequate skin coverage and an implant small enough to enable the technique. When all these prerequisites were met, the subglandular procedure could still be used. However, it only applied to a small minority of women I examined.

I began to see an influx of patients who had their surgeries elsewhere. They came to determine if their poor results with saline implants could be improved. Almost invariably, their disappointing results were due to the saline implant having not been placed under the muscle and/or their surgeon's attempt to go "too large" with the augmentation procedure. To the day, due to technical difficulty of the submuscular insertion, surgeons do not go under the muscle.

Notes: As of October, 1992, the FDA passed an amendment allowing the use of silicone-gel-filled implants in patients who have an undesirable result with saline implants. HLA tissue typing is available to determine which patient might develop adverse symptoms to silicone gel. That test is rather expensive and is not always conclusive. It is most important for patients to realize that silicone implants are safe, FDA allowed and available.

In 1999, the FDA officially recognized the non-toxicity of silicone implants. The media hardly reported the FDA approval without apologizing to the public for creating a frenzy without any scientific evidence. Of course, that good news was not sensational and its sale was not worth a profit to the media.

Manufacturers, as a consequence, don't make silicone implants as readily available as saline and charge much more for saline and silicone than used to. Of course, they have to absorb the costs of the 10 years of litigation and the consumers, our patients, now pay for it.

Peanut and soybean oil implants are being experimented along with other substances such as polyethylene glycol . we have to wait for these experiments to be completed and the products to be FDA approved. This could take many years. Contrary to media assertions, the preliminary results are not promising.

1994: It became undeniably clear to me that there as a critical need for women to thoroughly understand the concept of the submuscular procedure. I found that verbal explanations tended to be at least partially forgotten by most patients. Therefore, I decided to write a book.

1998: I finished polishing the book with photographs and diagrams to better illustrate what I had written.

Chapter 2 - Your Choice of Size

Many patients evaluating breast augmentation come to our office after first visiting other plastic surgeons. Some women are led to believe that the surgery can increase the breast size as large as the patient desires. This is a fallacy. In some very rare cases, the surgery can greatly increase the size of the breast, but for the great majority of patients the size must be determined by:

  1. The size of rib cage.
  2. The amount and type of soft tissue covering the rib cage.

The final size of the breast can be large if the patient has a large rib cage and an ample amount of soft tissue on her frame to cover the implant well. If the implant is too large for the size of the rib cage and/or if that implant is not properly covered with soft tissue, it will look and feel "fake". In short, the size of the implant must be proportionate to the size of the woman's frame and is subject to the nature of the tissue covering it.

The "before and "after" photos (see photo a below) illustrate an average result with saline (salt water ) implants placed under the muscle. Note that the shape of the breast is not altered, only the size. Any pre-operative asymmetry can be improved with the augmentation. Asymmetry is the rule rather than the exception. Most women do not notice it until their breasts are augmented.

Please understand, a small implant can make a big difference to a small slender chest. Conversely, a large implant may only make a small difference to a large heavy chest.

Despite the cosmetic appeal, it is very important for patients to realize that the larger the implant, especially with the saline implants, the higher the risk of soft tissue damage around the implant. Poor results usually come from lack of coverage and support of the implant.

As long as the soft tissue of your rib cage has not been damage and if the patient wishes to increase her breast size later on, it is safer to perform a second procedure in the future. We can then stretch the tissue more gradually once a protective shell of scar tissue has formed around the implant. This lowers the risk of tissue damage. For more details refer to chapter 7 "tissue-to-implant interaction".

Therefore, more is not always better. Larger saline implants too often tend to become palpable (can be felt) under the skin and can often look unnatural.

We cannot overemphasize that the two main goals, beside the appearance, are proper coverage and support of the implant for good, long-term results. Large implants, frequently associated with lack of tissue coverage and inadequate support, give poor long-term results.

The introduction of saline implants has not only modified the choice of size but also the technique of breast augmentation. The interaction between saline implants and the tissue around them will be discussed in greater detail in Chapter 6, "Your Choice of Saline Implants."

Here is another critical point to keep in mind; the larger the implant, the more difficult it is to correct post-operative problems and to perform secondary procedures. The larger the implant, the larger the risk of creating a cosmetic result that is not ideal. This is because the surrounding tissue may become thinned and can no longer cover or support the implant well.

Resist the temptation of going too big.

Again, if you wish to increase the size later on, you can. This option is safer than going too large the first time around. The reason is this; after the surgery, scar tissue forms a protective layer between the implant and the breast gland. That layer of scar tissue works like a buffer zone that minimizes tissue erosion. Replacing the original implants later on is a much easier procedure than the initial surgery and less expensive. But more important, it is safer than the first surgery, because the erosion and thinning of the soft tissue will be less severe. This beneficial condition will allow for more stretching. Also, the larger the implant, the more it can effect the sensory of the nipple and breast. Indeed, the larger the implant, the more stretching of the nerve endings can occur and make the recovery of the sensory longer, though I have never seen it permanent. Inter-operatively, the limiting factor is again, the amount of tissue you have to cover and support the implant. I routinely try to go as large as possible to accommodate the patient. However, I go only as larger as the tissue can take it intra-operatively without being irreversibly damaged.

Photo B depicts a slender woman who wears a 32A size bra. The implants placed under the muscle are rather small (260cc). However, the result is good because the breast has been augmented in proportion to her small frame. Again, the key is not the size of the implant itself but the proportion between breast and rib cage.

Cleavage, Shape & Stretch Marks

Many women are under the impression that the larger the implant, the more likely they are to obtain good cleavage and an improvement in the shape of the breast. These are two common misconceptions.

The cleavage has very little to do with the size of the breast. It is due to the position of the breast on the rib cage. Many women have laterally tilted ribs that are, in some cases, quite pronounced. In these instances, regardless of the size of the breast, the breasts will point laterally, resulting in minimal cleavage. That is the reason why you see some heavy women with large breasts and no cleavage.

Conversely, women who have ribs tilted toward the sternum (breast bone) can obtain good cleavage with rather small breasts. In short, cleavage depends on the inclination of the rib cage, not the size of the breasts or implants.

The shape of the breasts, likewise, is influenced very little by the size of the implants. Augmentation surgery enlarges the breasts without significantly modifying the shape. True, there are different shapes of implants that can be used for reconstructive procedures, such as after cancer surgery. However, they do not aid in breast augmentations, as has been proven over the past twenty years.

Again, notice Photo C that the shape of the breast remains the same. It is only augmented. This woman's small frame with her think skin required only a 240 cc, i.e., a small implant, which I placed under the muscle. The procedure gave her a good result.

To the contrary, in Photo D, this woman has a larger frame with thicker skin. 500cc implants, i.e., larger implants, were necessary to create a visible change in contour.

Stretch Marks:
Contrary to popular belief, stretch marks are not due to the distention of the skin. They are caused by hyper-secretion (excessive discharge ) of feminine hormones that break down the elastic fibers of the skin. The patient with pre-operative stretch marks will still have them post-operative stretch marks will still have them post-operatively. However, they may become less conspicuous. The reason for this is related to the stretching of the skin and the decrease of the appearance of stretch marks over a larger breast mound.

When How will the size be determined:
During your second consultation with me, you will bring with you the bra you would like to wear. We will determine the difference between the current size of your breasts and how large you would ultimately like them to be. From the comparison them to be. From the comparison, we will determine a size range and will be able to approximately calculate the size of the implant we need to order for you. An initial determination, therefore, is made pre-operatively.

Additionally, the size will be reassessed during the surgical procedure. Depending upon the anatomical (internal arrangement of the body parts)findings, the pressure, the stretching of your type of tissue, etc., some changes may be made.

I will try to make your augmentation as large as prudently possible, provided it is still proportionate with your anatomy and safely consistent with your individual characteristics.

When the size reassured during surgery, the main concern is not damaging the tissues with a larger foreign body, but only stretching the tissues. The stretching can reach a maximum or critical point, past which irreversible tissue damage can occur. It is always safer to stop when we feel we have stretched the tissue to the acceptable maximum. Later on, if you wish to go larger, we can go back and stretch the tissue further with a much lower risk of tissue damage. Indeed, the scar tissue from the first procedure will have built up around the implant and will constitute a protective shell that prevents, to some extent, tissue damage when the tissue is stretched further. In other words, the same principle we currently use for breast reconstruction with tissue expanders applies to cosmetic breast augmentation when we want to achieve a larger size.

It is also important to know that the implant does not stay exactly where it was placed during the surgery. It can move a little in different directions, especially downward or upward. This has to do with muscle tension and the formation of scar tissue.

The Cup

When I ask my patients the bust size they would ultimately like to achieve, they tend to speak in terms of Bra cup size, such as B, C, D. Because the cup size differs a great deal between brands, the variables are too great to use this as a standard. This why at the time of the second visit, I ask my patients to bring with them the bra they would like to fill. This helps to determine the size range they have in mind.

Sagging of the breast

When a woman's breast tend to sag, she frequently wants to:

  1. Lift the breast, keeping the same size or
  2. Lift and enlarge the breast.

When a woman has a sagging breast but she is content with the size (without enlargement), a breast lift should be performed. She may need a "mini-lift" or a full breast lift. The nature of the procedure depends upon the degree of sagging. No breast implant is required.

  1. >When the patient wishes to have both a lift and an enlargement, there are three possibilities. The preferred procedure depends upon the degree of sagging.
  2. When there is mild sagging that can be corrected just by breast augmentation, a breast implant alone can correct the problem.
  3. When there is too much sagging for the implant to correct it all, the patient will require and augmentation and a mini-lift, consisting of removing the skin from around the nipple and moving the nipple upward.
  4. When the breast has lost a lot of its mass as well as its shape then we recommend performing a full breast lift. This consists of re-shaping the gland itself. An augmentation can be performed at the same time or later on.

Late in 1998 you may have heard on television that the FDA recognized the safety of silicone implants. They are not toxic to the human body. The FDA now permits use of the silicone implants in all reconstructive cases. This includes correction of breast sagging. I recommend silicone implants as allowed by the FDA in cases of pronounced breast sagging. They would be placed sub-glandular with or without mini lift, depending on need.

The advantage of silicone over saline is a more natural feel.

Chapter 3 - Your Choice of incision

To gain a thorough understanding of the breast augmentation procedure, many of my patients ask about the various incision techniques. Their concern is post-operative distress. The pain is due to the insertion of the implant, particularly when the insertion is under the muscle. Discomfort is the natural outcome of the procedure.

Two incision techniques, through the nipple or in the armpit, are both valid and are techniques I use. However, each has its benefits and drawbacks. Regardless of the incision site, the incision length will be the same- between one and one and half inches. I will also describe two additional incision techniques I do not recommend: the umbilical approach and the Inframammary fold incision.

1. Armpit

The armpit incision is my first choice because it is less traumatic to the tissue. There is no cutting through breast tissue or muscle. The muscle is simply spread, not cut. The incision is made within a crease of the armpit. I have never seen a problem with the scar resulting from this method.

Please note that the armpit incision is placed high in a skin crease. In most cases, the scar is practically invisible within one year to eighteen months.

However, should a secondary procedure be required, such as removal of scarred tissue which has caused any hardening, another incision may be needed later on. That is the sole drawback of the armpit incision.

Photo E, illustrates the scar you can expect from an armpit incision, one year after surgery.

2. Nipple

The incision around the nipple is another very good approach (see Diagram F). However, it consists of cutting through breast tissue and muscle, which can create more breast tissue damage. That is why it is my second choice. I use this incision when it is the patient's need or the patient's preference.

Loss of nipple sensation is not a concern, because the sensitivity of the nipple is provided by the underlying breast tissue and not by the surrounding skin.

The nipple incision leaves no scar. But to create a suitable surgical pocket (see chapter 4), breast tissue and muscle must be cut through. These elements make the nipple incision more traumatic than the armpit incision. In addition, the nipple incision could create some internal scarring within the breast tissue making reading of mammograms more difficult, i.e., cancer detection.

One other item needs to be mentioned at this point. The breast tissue contains bacteria. Therefore, cutting through it can increase the risk of contamination that in turn can trigger an infection and/or a capsular contracture. However, this objection is fairly theoretical.

3.Umbilical (Navel) Approach

It was mentioned above that there are two other incision types when we perform breast augmentation surgery. The umbilical incision is used by some physicians. You may have heard about it. However, this approach is not recommended for the following reasons:

  1. We cannot insert the implant underneath the muscle with this technique. It can only and exclusively be placed underneath the gland.
  2. The incidence of asymmetry or unevenness of the breasts is definitely greater than with the other incisions.
  3. A certain number of implants are ruptured while being passed through the endoscopic tube. The manufacturers have notified all plastic surgeons that any implants the rupture while physicians are using the umbilical technique will not be covered by the manufacturer. They will be replaced at the patient's expense.
  4. As of the date of this publication, the FDA does not recommend the umbilical approach.

Besides these disadvantages, there's no real advantage to the umbilical incision, other than its use as a marketing tool. Patients are not usually informed of the drawbacks of this approach.

4 Inframammary Fold

The imframammary incision (see illustration on page 20 ) was the very first breast augmentation incision used. Today, it is only a good option if the patient has an inframammary fold that is well delineated, and lies low enough.

The inframammary fold incision gives adequate access to create the pocket, but muscle and sometimes breast tissue are severed. This disadvantage adds to the drawbacks of the incision, as explained later on. Photo G illustrates the inframammary incision procedure.

I rarely use the inframammary incision unless the fold is already deep. Of all the incision types, this is the most likely to leave visible scarring. In the event that the implant migrates lower with time, the scar will then lie above the fold, on the breast.

As shown in Illustration H, in case of capsular contracture (scar tissue formation), the implant is pushed up by the scar tissue. The scar may then become visible below the raised inframammary fold.

Note: In some very rare cases (less than one in one thousand), a second incision may be needed intra-operatively (during surgery) to control bleeding or perfect the shape of the pocket. Personally, I have not yet encountered that occurrence.

My Favorite Incision

The armpit incision. As already discussed, the armpit incision is my first choice because it is less traumatic to the tissue. There is no cutting through breast tissue of muscle. The muscle is simply spread, not cut. The incision is made within a crease of the armpit.

Notice the technique in Illustration I. The incision is barely noticeable and avoids cutting through gland and muscle. They are simply raised just enough to create the pocket.

Chapter 4 - Your Choice of Pocket/Insertion

During breast augmentation surgery, a surgical pocket for the implant is created. The insertion can be either subglandular which means in front of the muscle or it can be submuscular which means behind the muscle.

Subglandular Insertion -
Diagram J depicts a subglandular insertion. The pocket is only under the gland, not under the muscle.

The subglandular insertion is my least favorite pocket for six reasons:

  1. Less coverage and support of the implant, unless the patient already has ample breast tissue and/or thick subcutaneous (below the skin) and cutaneous (skin) tissue.
  2. Higher incidence of capsular contracture than under the muscle.
  3. Risk of forming scar tissue within the breast gland itself. This could pose a problem for cancer detection later on in life.
  4. Mammograms are more reliable when the implant is under the muscle, since the gland has contact with the implant.
  5. Higher incidence of bleeding and infection than under the muscle.
  6. Slightly higher risk of loss of sensation of the nipple than under the muscle.

Submuscular Insertion

Diagram K depicts a submuscular insertion. Notice the pocket for the implant is under both the gland and the muscle. With the submuscular insertion, the pocket is primarily shaped by stretching the muscle. Stretching produces the best pocket to cover and support the implant.

On very rare occasions, the muscle may need to be partially incised, due to an implant that is too larger or a muscle that is too small.

Another note on the pocket is when the distance between the lower border of the areola (small circle surrounding the nipple) and the inframammary fold is short (less than 5 cm ), the fold may need to be lowered by dissecting the pocket inferiorly (under the skin), A typical "before and after" is shown in Photo L.

Chapter 5 - My Favorite Approach

The approach used for breast augmentation is the combination of incision location and insertion location. As you read in chapter 3, you have a choice of three incision types: armpit, nipple and imframammary fold, In chapter 4, you learned about the two insertion types: subglandular and submuscular. Now it is time to combine the incision and insertion to determine the approach to be used. Since the advantages an d disadvantages of teach incision and insertion have already been discussed in the prior two chapters, I'd like to share with you may favorite approach or as entitled on the cover of the book, my "Personal concept."

The Armpit Incision

As already discussed, the armpit incision is my first choice because it is less traumatic to the tissue. There is no cutting though breast tissue or muscle. The muscle is simply spread, no cut, The incision is made within a crease of the armpit. Notice the technique in Illustration M in the next page. The incision is barely noticeable and avoids cutting through gland and muscle. They are simply raised just enough to create the pocket.

The Submuscular Insertion

Notice the technique in Illustration N. The implant is under the muscle. The pocket is primarily shaped by stretching the muscle instead of cutting it. The submuscular insertion also provides more tissue to cover and support saline implants creating a more natural look and feel. Additionally, saline implants themselves have influenced the submuscular insertion as my pocket of choice. Let's read how by turning to chapter 6, "Your Choice of Saline Implants."

My Favorite Approach

Indeed, the armpit approach is less traumatic because the breast gland and muscle are lifted and not cut through to make the pocket for the implants. That is why, in 1976 when we started using that armpit approach, we noticed less scar tissue formation, that is to say less capsular contracture due to the fact that there was less trauma to the tissue, In short, it is my favorite approach because:

  1. There is less trauma to the tissue going through the armpit by lifting the tissue, i.e., less risk of scar tissue and capsular contracture.
  2. There is better coverage and support of the implant going under the muscle.

However, the other 2 incisions as well as the subglandular insertion still have their indication but they are Rare. I use them in some very selective cases or when the patient prefers another approach.


All cases are performed under general anesthesia and not local anesthesia.

Chapter 6 - Your Choice of Saline Implants

Saline implants have modified the technique of breast augmentation and the choice of size.

By now you know that saline implants have replaced silicone implants. Silicone implants are available only for breast reconstruction after cancer surgery and in some cosmetic cases where saline implants are causing problems. Other implants are now being tested but are not yet FDA approved (see Chapter 1). It will be a long time before any new implants are virtually the only implants available for cosmetic breast augmentation in the U.S.

Saline implants do not cause any systemic disease such as cancer or auto-immune conditions.

The saline implant envelope s silicone and the content is common saline (salt water), a fluid readily accepted by the body. If a leak occurs, the breast will go flat within two to three days without any other problems and the implant can be easily replaced. If the leak is related to a faulty implant, the manufacturer will pay for the implant, the manufacturer will pay for the implant replacement. The leak rate is 1%. Until recently, the most commonly used saline implant was textured vs. smooth, because less scar tissue forms around this type of implant. Textured implants have helped decrease the incidence of capsule formation. At the same time, however, they increase the risk of rippling, wrinkling and thin spots. Smooth implants, conversely, increase the risk of capsule formation but decrease the incidence of rippling, wrinkling and thin spots. That is why many present-day plastic surgeons are going back to smooth implants. I primarily choose smooth implants, keeping textured implants for some subglandular cases or if it is the patient's preference. As a reminder, subglandular means in front of the muscle and submuscular means behind the muscle. The various types of saline implants are covered later in the chapter.

However, textured or smooth, the envelope of the saline implant is thick. The fluid content (common saline) tends to create some shearing forces (movement by cutting) we didn't experience with silicone implants. These two factors, the thick envelope and the saline within the envelope, tend to cause some tissue around the implant, If the tissues becomes too thin, the implant can be felt and sometimes even show underneath the skin. This looks unnatural. We need more tissue to cover and support saline implants than we did with silicone implants.

This interaction between the saline implant and the tissue around it has modified the technique of breast augmentation and the choice of size.

Looking at Photo O, we can see that a natural, well-shaped breast rests on the muscle of the chest wall.

Underlying Anatomy

As you'll notice in Diagram P, the breast gland lies on the pectoralis major muscle, located anteriorly (in front)and high on the thorax. The muscle part extends a little below the nipple before thinning down to a fascia upon which lies the lower pole of the breast.

The implant, once inserted inside the surgical pocket, is then inflated with saline. We make one final assessment of size and symmetry (evenness of shape and size ) between the two sides.

A subglandular insertion is possible through either incision IF there is enough tissue to cover and support the implant without need for the muscle as padding and support.

As illustrated in Diagram Q below, the external oblique and serratus anterior muscles cover the lateral and lower thorax (chest). Deeply seated, they are not in the breast augmentation.




Three types of saline implants

  1. The smooth saline implant. This is the implant most commonly used today. Safe and reliable, it provides very good results. See Photo R.
  2. The biocell or textured saline implant. This implant is less commonly used because the tissue thinning and rippling disadvantages outweigh the only advantage it has over the smooth implant; less scar tissue forms around it. We find five to ten percent less incidence of capsular contracture when using the textured implant. See Photo S.
  3. The drop-shaped or anatomical" implant.

Though the drop-shaped implant is available to women who ask for it rather than the round implant, I rarely use it unless requested by the patient. This is because, with the passage of time, gravity will stretch and increase the size of the lower pole of the breast. Why is this a problem?

When we use the drop-shaped implant, that lower pole development with time can become over-accentuated to the point of creating a disproportion between and over developed lower pole and an underdeveloped upper pole. This condition is due in large part to the initial shape of the implant itself. Additionally, the drop-shaped implants are more expensive, as much as thirty percent higher than the first two types of implants. See Photo T.

The pictures below illustrate a six-month post-op result where we've used the drop-shaped implant. We have achieved a very good cosmetic result. However, the lower pole of the breast may become over developed in a few years at the expense of the upper pole that would be underdeveloped. Besides the drop shaped implant is made only textured, causing more tissue erosion than the smooth implants. In 1999, a large study has been published by Dr. Patrick Maxwell, showing that round implants are actually more anatomical than teardrop implants.




Fat Transplant

It might be logical to consider avoiding all of the problems posed by synthetics by using the patient's own tissue. Fat transplant was a surgical concept investigated at one time.

However, it is fraught with major drawbacks such as steatonecrosis (fat gland disorder) which causes micro calcification (deposition of calcium salts in the tissue) making cancer detection more difficult later on in life.



Chapter 7 - Tissue-to-Implant Interaction

The reaction of your tissue to the implant cannot be precisely predicted; it will depend upon your type of breast. Again, the breast is made up of glandular tissue and fat. The ratio of these two components varies between women and changes with age. The glandular tissue tends to decrease with time and is replaced by fat. Fat is much less resistant to stretching than glandular tissue. As a matter of fact , it will actually shrink. This condition is accentuated by pregnancy.

Because we cannot exactly determine the fat-to-glandular tissue ratio, we cannot predict the tissue-to-implant interaction. Furthermore, fat and breast tissue have less blood supply than muscle. It is the reason why capsule formation (scar tissue) is diminished when the implant is placed under the muscle, another reason to select the submuscular insertion of the implant.

An augmented breast will neither interfere with pregnancy nor breast feeding, but pregnancy and breast feeding can damage the augmented breast. Tissue loss around the implant can result from pregnancy and lactation (secretion of milk).

Please remember: The main difficulty with breast augmentation surgery using saline implants is that we cannot know before surgery using saline implants is that we cannot know before surgery how your tissue will react. How much pressure and stretching your tissue will accommodate without being damaged cannot be precisely determined. Even during the procedure, the eventual tissue/implant interaction cannot be predicted. Only the passage of time post-operatively will determine the outcome. As mentioned, if the patient wishes to increase her breast size later on, it is safer to perform a second procedure in future.

We can then stretch the tissue more gradually once a protective shell of scar tissue has formed around the implant. This lowers the risk of tissue damage.

Chapter 8 - Other Procedures

Nipple Enhancement

In some cases, as a result of breast feeding or other reasons, a woman's nipples are too large. They can be reduced with a minor procedure performed at the same time as the breast augmentation . Nipple reduction does not interfere with nipple sensitivity.

Likewise, and inverted nipple can be corrected at the same time, again, without compromising nipple sensitivity.

Areola Enhancement

An areola over 4.5 centimeters in diameter is considered too large. It can also be reduced at the same time as the breast augmentation.

The reduction of the nipple and /or the areola can enhance the end result of the breast augmentation. Once again, these procedures do not alter the sensitivity of areola or nipple.

Chapter 9 - Post-Operatively

In Chronological order:

  • Pain and Bruising
  • Bacitracin Ointment
  • The Surgical Bra
  • Ultrasound treatment
  • Stitches
  • Shaving and Deodorant
  • Sports and Physical Activities
  • Nipple and Breast Sensitivity

Pain and Bruising

The aftermath of the surgery can be quite painful for a couple of days. The pain is caused by the stretching of sensitive tissues, particularly the muscle, not by the incisions. You might also feel nauseated. You will return to our office for a post-operative visit, usually within two days after surgery.

People recover at different rates, if two days following the surgery you discover that you feel too tired to return to the office for your first post-operative visit, you can wait a little longer. Our staff will assist you with those arrangements. Generally however, by the end of the first week of pain is quite tolerable and by three weeks you can resume normal physical activity.

Some minor residual pain due to the rubbing of the implant over surrounding tissue may linger for some months, but usually winds up subsiding and will eventually disappear.

There may be swelling and bruising down to your waist and sometimes lower. Keep in mind that a lot of tissue has been disrupted. These conditions vary a great deal between patients. There will also be a difference between the two breasts in the amount of swelling, pain and healing, Initial hardening of the breast, right after the surgery is quite normal. The muscle an skin are tight over the implant, but will gradually stretch and soften within three months. This initial hardening is different from the hardening that results from the formation of scar tissue, capsular contracture. If capsular contracture occurs, the immediate post-op hardening from the scar tissue starts developing. This situation is rare.

Bacitracin Ointment

In your medication bag, you will find bacitracin ointment (antibiotic cream used for bacterial infections). After I have removed your dressings two days post-op, you will start applying the ointment to the surgical areas three to four times a day, before and after your shower. Bacitracin should be used for the first five post-op days only. Longer use could run the risk of allergies. For the first two days, you may bathe but not shower. Thereafter, you can shower with or without a surgical bra on (next section). If you keep the bra on, blow dry it after the shower. It is often better to keep the bra on because it may be too painful to take it on and off during the first five days.

The Surgical Bra

It has been especially designed for the submuscular breast approach. The bra is used as a splint to the breast. The splint will exert compression on the breast and the implant. It has been shown that compression for the first 3 months helps prevent scar contracture.

The bra consists of a strap that could be cumbersome. An easy way to make it comfortable is to wear a sports bra with the surgical bra on top of it. It is recommended to wear it for 3 months. The splinting effect varies with patients and I therefore may need to adjust the bra in our office, especially within the first three weeks. It is important for you to keep your appointments. This type of bra is not used in patients that have a rather soft, stretchable muscle, for the strap cold push the implant too low. It must be said that some patients do not tolerate the surgical bra.

Ultrasound treatment

An ultrasound treatment is offered to all breast augmentation patients. This treatment helps minimize scar tissue formation following the insertion of the breast implants. It is done in the Doctor's office, and starts between five to ten days post-operatively. The treatment lasts approximately 20 minutes, and is done 2 times per week for three weeks for a total of 6 sessions, unless otherwise specified by Dr. Carli. There is no additional charge. That state of the art technique is performed as a complimentary adjunct to your surgery.

Until a few years ago, it was felt like massaging the breasts after breast augmentation could minimize the scar tissue formation. Studies nowadays have proven to the contrary that massaging is not helpful and in some cases cause more trauma to the tissue, i.e., more scar tissue formation.

The only disadvantage to the ultrasound treatment is that the patient has to come to our facility to benefit from the treatment , whereas massaging could be done at home by the patient.


Stitches do not need to be removed. They will dissolve by themselves within ten to fourteen days.

Shaving and Deodorant

(with the armpit incision only)

Use of deodorant and shaving can be resumed two weeks after surgery. If the presence of excess hair bothers you, you can undergo a waxing of the armpits by one of our estheticians or have laser hair removal prior to surgery.

Hair Removal

If not shaving your armpits for 2 weeks were a problem, you can undergo laser hair removal at our facility before the surgery. We are equipped with the state of the art hair removal laser and the RN's performing this procedure can give you the information you need.

Sports and Physical Activities?

Sports and physical activities can usually be resumed after three weeks.

Nipple and breast Sensitivity

There is frequently a temporary loss of nipple sensitivity, usually partial, for a few weeks to a few months after surgery It is not permanent, thought that condition is described in published medical literature. A submuscular insertion of the implant makes the condition even less likely. So far, I have never seen a case of permanent nipple sensitivity loss.

Please note: As a precautionary measure during the healing period, there should be no rigorous stimulation or manipulation of the breast for the first three months after surgery.

All of the above instructions are generalities an might not apply exactly to your particular case. My staff and I will guide you throughout your post-operative care.

Chapter 10 - The Healing Process

You will have to wait two to three months to see the end result of your surgery, sometimes even longer. Do not be alarmed if you detect some degree of asymmetry which may result from a preexisting asymmetry between your breasts and/or the two sides of your rib cage. The difference in healing factor causing asymmetry, meaning more scar tissue forms on one side than on the other. Being right or left handed, and your activity level, etc., can cause asymmetry as well. Sometimes asymmetry can occur many months after surgery. No woman has two breasts exactly the same. Subtle asymmetry is very common for the reason explained above and does not require any treatment. A capsular (envelope of scar tissue) usually develops within the first six months, sometimes between six to twelve months, but very rarely after a year In some rare cases, however, the capsular contracture (scar tissue formation) can cause a significant asymmetry because of the tissue shrinking or hardening around the implant This condition is less commonly seen in cases where we go under the muscle.

Another surgery is usually required to correct the problem. Nationwide, the incidence is 11% and about 2-3% in my practice.

It must be noted that after a second surgery, the problem can recur. This rare. This type of unusual reaction of the breast tissue to the implant can be compared to a kind of allergy. To this day, it is neither well explained nor understood.

After breast augmentation surgery, the implants will remain a "foreign body". Therefore, for the rest of your life, you will have an area that is vulnerable to infection. It is most important to treat infection with the appropriate antibiotic, even distant infections such as a sore throat, sinusitis, bladder infection or others. Indeed, bacteria can migrate from these infection sites through the bloodstream to the site of the implant and cause infection of the breast.

Vitamin E. may be of some benefit in preventing scar tissue formation. If you like, you can take on e thousand units per day for three months following the procedure. However, the benefits are more theoretical than proven.


Capsular contracture, or more simply "capsule", is the most common complication of breast augmentation. Once a capsule has formed, the treatment is surgical. Little can be done to prevent or predict this complication.

The nation-wide incidence is 11%, which is lower than 20 years ago. In my practice, this incidence has continued to go down over the past 18 years, and is now about 2-3%.

Like all plastic surgeons, I tried and used different techniques to avoid the problem with more or less success; always looking for some type of new technique or technology. However, by combining several ways I have noticed some definite improvement in prevention and non-surgical treatment of an early capsule.


In 1995, Jaime Planas, a well known plastic surgeon from Barcelona, Spain, presented a large series of cases using ultrasound for three to four weeks, twice a week after each capsulectomy (surgical excision of the capsule) to minimize the risk of capsule recurrence.

His result was encouraging. He finished his article saying that he had started doing the same regimen after each breast augmentation, and felt it was promising. He said that he would wait until he had a very large service before publishing his result in regards to the use of ultrasound status post breast augmentation.

Five years later, in 2000, Jorge Planas, the son of Jaime Planas, a plastic surgeon like his father, published an article showing that the routine use of ultrasound after breast augmentation can lower the incidence of capsule formation. I had started in 1995, after his first article, and had the same impression. Our practice does not charge for this service.

The same year, in 2000, Andre Camirand, a renowned plastic surgeon from Montreal Canada, published a series of more than 3000 breast augmentations, all treated with a compression strap for the first two to three months status post surgery. He explained the mechanism of that treatment, based on elementary knowledge of scar tissue formation. Though somewhat bothersome, I use the strap on my patients. Again, I noticed less capsule formation. I also use the strap after a capsulectomy, and notice fewer capsules as well.

In 2003, Schlessinger, from Honolulu, Hawaii, published another large series minimizing capsule formation by giving Accolate to his patients after a breast augmentation for two to three months. His rationale was that one cause of capsule formation is inflammation, which can be partially controlled by Accolate; a medication for the treatment of asthma. The only contraindication is a liver condition since Accolate can be hepatotoxic. Accolate is now used nation-wide, and seems to be effective.

These three modalities combined have resulted in a positive result. I rarely see a capsule in patients who follow these instructions. Combined, they do prevent capsule formation; however I cannot determine which helps the most. If a patient seems to form an early capsule, in spite of that combined technique, I prolong the treatment.

In April 2008, a new tool became available. Claude LeLouarn, from Paris, France, published a new approach; again based on the theory against inflammation. Schlessinger uses Accolate, a systemic medication, to fight inflammation. Le Louarn thought of using Flector Tissue Gel, which is an anti-inflammatory patch that delivers the anti-inflammatory agent via a percutaneous bioadhesive impregnation system. These patches measure 10 X 14 cm and contains 180 grams of diclofenac-epolamine, which is the active substance.

The whole breast needs to be covered by one or two patches, depending upon the size of the breast. It is kept on 24 hours per day and changed daily for three weeks. There is no toxicity, and it can be covered by insurance, as Accolate can be. Without insurance, the cost is still minimal.

Within the past two years, I used it in three patients with an early capsule that had formed within three months after surgery.

According to LeLouarn, there is no response if Flector is used on a capsule that is already six months old. At this point the inflammation process is complete and the scar tissue has formed.

In conclusion, there are non-surgical ways to prevent and treat an early capsule.

Surgery may still be indicated, but it is a last recourse and much less necessary than in the past.

Descent of the Implant After Surgery

There are 2 phases, the first 3 weeks to 3 months and after the first 3 months.

The implant will not descend or settle within the pocket at the same pace or exactly the same way. Besides the factors mentioned before, the muscles are not quite the same on both sides of your chest wall. They vary in thickness, length and strength. For that reason they will not stretch the same. During the first 3 weeks to 3months, the muscle will start reshaping and stretching around the implant. The type of muscle and the amount of scar tissue formation will determine the descent of the implant within the pocket. This is not predictable. If you don't form scar tissue the descent of the implant will be easier and more pronounced than if you form scar tissue. After the first 3 weeks most of the swelling is gone but the first phase there will still be some further remodeling of the pocket for another 3 to 6 months. We usually wait a minimum of 6 months.

Many patients have a difference between the 2 breast they haven't noticed pre-operatively such as the size, the position on the rib cage, one being lower than the other. That difference between the 2 sides in size, shape and position on the rib cage often pass unnoticed to the patient. It can be completely or partially corrected by the surgery but most of the time there is still a little difference. Nonetheless patients are more critical post-operatively. I always underline these points to the patient pre-operatively. There is no woman that has 2 breasts that are exactly the same.

Appendix A - Before & After Photos

A few common cases of augmentation through the armpit, under the muscle:

Appendix A

A few common cases of augmentation through the armpit, under the muscle:

A few common cases of augmentation through the armpit, under the muscle:

A few common cases of augmentation through the armpit, under the muscle:

A few common cases of augmentation through the armpit, under the muscle:

Appendix B - In Summary

The armpit approach is less traumatic because the breast gland and muscle are lifted and not cut through to make the pocket for the implants. That is way, in 1976 when we started using the armpit, we noticed less scar tissue formation, that is to say less capsular contracture due to the fact that there was less trauma to the tissue. In short, it is my favorite approach because:

  1. There is less trauma to the tissue going through the armpit by lifting the tissue, i.e., less risk of scar tissue and capsular contracture.
  2. There is better coverage and support of the implant going under the muscle.

However, the other 2 incisions as well as the sub-glandular insertion still have their indication but they are rare. I use them in some very selective cases or when the patient perform another approach.

To restate my earlier assertions, the submuscular approach is technically more difficult for the surgeon and harder on the patient than the subglandular technique. However, it is a much better approach overall for long-term results. This is especially true in cases where patients do not have much tissue to cover and support the implant, such as in slender women.

For larger patients who do have ample tissue, a submuscular insertion is less necessary to cover and support the implant. In these cases, a subglandular insertion can be performed.

A very small number of patients, less than 1% , do not physically tolerate the implants and eventually have them removed.

Various options are available to you. I will give you my professional recommendations, but the choice remains yours.

This information should be carefully considered to properly prepare for your consultation and to make it more meaningful. Once again, the key is HOW MUCH TISSUE you have to cover and support the implant.

My Final Word:

The ideal patient for breast augmentation surgery is the woman who thoroughly understands the procedure. She clearly comprehends that the result is neither exclusively reliant on technique nor is it surgeon-dependent. She is self-motivated to better her own image. She may want to improve her look, in and out of her clothing. She does not make her decision at the urging of her husband or friends.

Appendix C - Glossary of Terms

Anatomical - Internal arrangement of body parts.

Anteriorly - In front.

Areola - small circle surrounding the nipple.

Asymmetry - Difference in size and/or shape of your two breasts.

Augmentation - Enlargement

Bacitracin Ointment - Anti biotic cream used or bacterial infections.

Capsular - Envelope of scar tissue.

Cutaneous - Skin

Esthetician - Expert in beauty

Hyper-secretion - Excessive discharge.

Inferiorly - Under or below the skin.

Inframammary - Below the nipple

Intra - operatively - During surgery.

Lactation - Secretion of milk.

Micro Calcifications - Deposition of calcium salts in the tissue.

Nauseated - Sick to the stomach.

Palpable - Can be felt.

Saline - Salt water solution

Shearing Forces - Movement by cutting.

Steatonecrosis - Fat gland disorder.

Sternum - Breast bone.

Subcutaneous - Below the mamammory gland, in front of the muscle.

Submuscular - Under or behind the muscle.

Symmetry - Evenness of shape and size of your two breasts.

Thorax - Chest

Umbilical - Navel

Appendix D - Bibliography

1. Aesthetic and Reconstructive Breast Surgery
John Bostwick III 1983

2. Plastic Surgery
Jane Smith and Sherrell Aston 1991

3. Plastic Surgery
Joseph C. McCarthy, M.D. 1990

4. Circumareola Techniques For Breast Surgery
T. Wilkinson, M.D. 1990
Adrien Aiache, M.D.
Luis Toledo, M.D. 1995

5. Mentor: Breast Implants 1997

6. McGhan: Breast Implants 1997

7. Breast Implant Resource Guide:
American Society of Plastic Surgeons 1992

8. Practical Procedures in Aesthetic and Plastic Surgery
T, Wilkinson, M.D. 1994

9. Aesthetic Plastic Surgery Journals

10. ASPRS Journals

11. American Journal of Cosmetic Surgery

12. Breast Augmentation
Jacque Faivre, M.D. Paris, France 1994

13. Breast Surgery
Louis Benelli, M.D. Paris, France 1990

14. Breast Surgery
Claude Lassus, M.D. Nice, France 1996

15. Aesthetic
Madelaine Lejour, M.D. Brussels, Belgium 1994

Dr. Carli, a leading plastic surgeon in the greater Los Angeles area, would be happy to help you achieve your aesthetic goals! Feel free to call us at (951) 688-8660 with any questions or concerns that you may have regarding Dr. Carli, the Magnolia Surgery Center, or cosmetic surgery. We look forward to speaking with you!

Magnolia Plastic Surgery
10694 Magnolia Avenue, Riverside, CA 92505
(951) 688-8660