Dr. Dirk Lazarus
Plastic Surgeon

Tel: 021 424 1112
Fax: 021 424 1118

86 New Church St
Tamboerskloof
Cape Town, 8001
South Africa

Breast augmentation is one of the commonest operations that I do. The operation is relatively simple, quick and has immediate results. The recovery is fast and the risk of early complications is low. In my practice, patients are discharged on the day of surgery with a light dressing and a surgical bra. I use no drains and patients can shower or bath on the day after surgery. Exercise can be resumed usually within a week of surgery. Bruising and swelling are usually minor. The main advantage of surgery is that your new look is almost instantaneous and the effect of surgery is permanent.

There are however some choices to be made, each with consequences. As a result, the pre-op consultation often takes longer than the surgery itself!

Choice 1: Incision

Incision options include under the breast (infra-mammary fold), the armpit (axillary), around the areola (peri-areola), belly button (umbilical) and existing scars.

I favour the infra-mammary fold approach: the incision is well hidden underneath the breast, lies in the natural lines of the skin and so tends to form an inconspicuous, and I believe, the best scar. Placement of the implants through this incision is easy, even for silicone gel filled implants which are firmer, control of bleeding is easy and the risk of putting the implants in at different levels is low.

The armpit incision can be visible especially if you are in a vest, bathing costume or sleeveless. It is difficult to make the pocket and there tends to be a higher incidence of having the implants at different heights (some studies show this to be as high as 15%). Control of bleeding is more difficult and therefore there is a theoretical higher risk of complications. The armpit is not a clean area with sweat and other glands. The scars tend to be more red than those placed under the breast

The scar around the areola can also be very visible. The natural junction between the darker areola and the lighter skin of the breast is not a sharp line as created by a scar, but a soft transition area. To create the pocket for the breast one needs to go through the breast and because the breast has ducts open to the surface, there is a theoretical higher risk of infected complications and perhaps hardness.

The umbilical approach is used by less than 3% of surgeons in the USA. Special equipment is needed, the operation takes a very long time, saline implants are the only type which can be used and there is the risk that the implants subside down the tract created for their insertion, in other words, that they eventually sit too low. The belly button approach is generally regarded by plastic surgeons as making a simple operation complex.

Choice 2: Placement

The implant can be sited directly underneath the breast itself, so called sub-glandular; or it can be placed deeper, under the muscle, so called sub-muscular. I tend to favour sub-glandular placement as this puts the implant close to the breast and it therefore feels and looks like breast. The approach is quicker, easier and less bloody than sub-muscular making the recovery quicker and the complication rate lower than sub-muscular. Although the sub-muscular approach can provide additional padding for very thin patients, one should understand that the conventional sub-muscular approach only covers the top and inner part of the implant as the bottom of the muscle runs from the lower part of the breast bone to the arm. In patients who exercise a lot, the sub-muscular approach is also less desirable as contraction of the muscle can cause distortion and displacement of the implant. Sub-muscular placement is favoured where surgeons place saline implants, but more natural feeling silicone gel filled implants are, in my opinion, best placed sub-glandular.

Choice 3: Implant type

There are essentially two types of implants on the market today: silicone and saline. Both types have a silicone outer shell, but it is the inner content which can vary.

Where surgeons and patients have the choice of either saline or silicone, about 85% will choose silicone. This is because silicone has a more natural feel and appearance. Saline is salt water and like water it can slosh. The consistency of saline implants is that of a bag of water. Saline implants are prone to deflation and wrinkling. They are the implants used in the United States as there remains a moratorium on silicone gel filled implants (despite approval by the FDA and a policy statement by the American Medical Association stating that silicone gel filled implants are not associated with any known human disease).

For my patients I recommend the softer, more natural-feeling silicone gel filled implants. The modern implants have cohesive gel (like honeycomb, as opposed to the more syrupy older silicone in older implants). The silicone wall of the modern implants is also better constructed, decreasing the risk of leaks and the texturing of the surface of the implants is of a better quality (texturing helps lower the risk of hardening).

Whilst there are still surgeons who believe that smooth saline implants inserted through the armpit and placed under the muscle is the way to go, I believe and prefer to use in most cases a textured silicone gel-filled implant inserted via an infra-mammary crease incision (which I keep short) into a sub-glandular placement. This allows me to perform all my surgery as day case surgery, avoids complications, ensures a rapid recovery and allows me to attain aesthetic breasts and predictable results.

If you want to before and after pictures of some of my breast augmentation patients operated on with this technique, then please feel free to email me and I will send you the pictures.