Breast Enlargement

Breast augmentation is a surgical procedure to enhance the size shape of a woman’s breasts. There are a variety of reasons that women choose to have this procedure. Most commonly, women choose and breast enlargement to improve their contour when they feel that their breast size is too small. Another reason may be to correct a reduction in breast size after pregnancy or to balance a difference between breast sizes. Implants may also be used in breast reconstruction after mastectomy.

The number of women who choose to have breast enlargement surgery performed each year has tripled in the past five years.

The evolution of the surgery for breast enlargement has created a number of choices which allows women to achieve the results that are most consistent with their own personal wishes and desires. Dr. Nein offers all his patients choices in breast augmentation.


The woman wishing to have a breast augmentation has a number of options and choices open to her. This gives her the best opportunity to achieve the appearance and result that she wants. These choices include implant style, placement, and size as well as incision location. Just as there are many different sizes and shapes of women, so are there a number of choices that can give each woman the best possible result.

Submuscular vs. Subglandular

One of the primary choices in breast augmentation is whether to have the implants placed “under” or “over” the muscle (submuscular or subglandular). This muscle is the pectoralis major muscle which lies over the rib cage and underneath the breast. It is the chest muscle that is commonly developed in weight lifters.

Traditionally, when the majority of implants were silicone, implants were most often placed underneath the breast gland and on top of the muscle. With the more common use of saline filled implants, it was noticed in women who were thinner or who had relatively little breast tissue to cover the implants, that there was a tendency to develop “rippling” or a waviness in the skin overlying the implant. This is especially true with the use of the “textured” or rough surfaced implants. In an effort to decrease the incidence of rippling and the potential for capsular contracture, there has been a move to place implants in the space beneath the pectoralis major muscle. Submuscular placement increases the padding overlying the implant offering more coverage and camouflage to the shape of the implant. Using this technique, rippling has become a rare problem.

There are, however, some breast shapes that are better suited to a subglandular (“over” the muscle) placement of the implant. These women typically have breasts that at one time were much larger than the present. When there is a very large volume decrease and there is little or no shrinkage in the size of the skin envelope surrounding the breast tissue, then the shape approaches that of an “empty bag”. Under these circumstances it is sometimes better to place the implant in a subglandular position in order to allow the implant to fill out the skin envelope of the breast.

In the event that the skin envelope has stretched to the point that the nipple is low on the breast (below the lower breast fold), it may be necessary to reposition the nipple upward again and reduce the size of the skin envelope by means of a breast lift (mastopexy). This can be done in conjunction with an augmentation or on its own.

Incision Choice

There are three incisions commonly used to place the implant. Either an inframammary crease incision (in the natural fold where the breast contacts the lower chest), a periareolar incision (around the areola where the skin of the nipple changes to the lighter breast skin), or an axillary incision (in the armpit). The decision as to which incision to have rests entirely with you. There are certain differences, however, of which you should be aware.

Over the last few years there has been a significant increase in the use of the so-called anatomical implants.

The inframammary crease incision made by Dr. Nein is 4 cm long (about 1 1/2 inches). It has the advantage of being in a natural skin fold where it is well camouflaged and is generally covered by the natural curvature of the lower breast. It will probably always be covered by any clothing – even the smallest of bikini tops. This incision is close to the pocket where the implant will be placed. The distance to dissect is short and it is possible to very accurately create the size and shape of the pocket for the implant and to carefully control the position of the implant within that pocket.

A periareolar incision can also be used to place the breast implant. The dissection is carried through the gland, down to the chest wall. A sub-glandular pocket is created for the implant. If the woman wishes to have the implant underneath muscle, the muscle is elevated and moved out of the way to place the implant.

The third option is an axillary incision. This incision is placed in the armpit and dissection is carried out either above the muscle or below the muscle bluntly to create a pocket for placement of the implant. Because the incision is at a remote distance from where the implant will be placed, it can at times be a little more difficult to get very accurate control of the exact position of the implant, especially with anatomical implants.

Implant Choice

Traditionally, implants were all round. Viewed from the front, they are circular and in profile they appear to be half moon shaped. Over the last few years there has been a significant increase in the use of the so-called anatomical implants. These anatomical implants are slightly taller than they are wide and are fuller in the bottom – having a slightly more natural shape to them. When using the round implants, the breast has a slightly more circular appearance to it whereas the anatomical implants give the breasts a more natural look. There tends to be a smoother transition from the upper chest wall to the top of the breast and not quite so much of a “step-off” as is commonly seen using round implants.

The anatomical implants are somewhat more expensive than the round implants. The manufacturer charges slightly more for them. However, neither the hospital nor Dr. Nein charges any additional fees for placement of the anatomical implants. The decision of which implant to use lies entirely with the patient. It is the opinion of Dr. Nein and the nurses who have helped him put in these implants over the years that the anatomical implants give a slightly “prettier” appearance.

“The final breast size and shape is a combination of the shape of the implant plus the shape of the breast that is present.”

One must realize that the final breast size and shape is a combination of the shape of the implant plus the shape of the breast that is present. If the implant is small compared to the breast then the final result will appear like the natural breast but larger. On the other hand, if the breasts are small and the implant chosen is relatively large so that the dominant structure becomes the implant, the final result tends to be shaped more like the implant. Consider that a basketball covered with an ordinary sheet looks just like a basketball covered with a sheet, whereas a tennis ball covered with a comforter appears like a bump in the comforter.

Choice of Implant Size

The final consideration is size of the implant. Implants come in a wide variety of sizes and it is possible for any woman to comfortably carry a variety of sizes on her chest. The objective during the examination is to determine which implant will give the desired appearance. As you can imagine, any given implant in a very small framed woman will achieve an entirely different result than the same implant in a larger and heavier woman with different shaped breasts. Identical implant, different women with different breasts equals different results. The key, therefore, is to choose an implant that will give you the look that you desire. In order to accomplish this, we use a number of techniques. One of which is to take specific measurements of the size and shape of your breasts. This information, combined with the dimensions of the implants, and your desire for size and shape will help us determine which implant will most closely give you that look.

Identical implant, different women with different breasts equals different results.

Bigger is not necessarily better. In choosing a very large implant it is important to be aware that as the volume of the implant goes up so do its dimensions, which includes the implant width. If you choose an implant that is excessively large, the edge of the implant may extend around beyond the breast and potentially even under the arm pit. This would be undesirable. Also, as the implants become excessively large, the potential for rippling and other long term adverse cosmetic consequences increases.

A very attractive look is a slight bulging on the silhouette of the lateral portion of the breast outside the chest wall and then down to the waist and hips to give that classic “hour glass” figure.


With any procedure, no matter how complicated or how simple, there are always certain risks of complications. As a general rule, breast augmentation is an extremely safe procedure preformed as an outpatient. You will have some breast soreness for a few days, however, that can readily be controlled by pain medication and most women do extremely well. After the recovery is complete there is no restriction on activities. One can go scuba diving, sky diving or any activities that you wish.

Capsular contracture is the problem that is most likely to happen after breast augmentation. Anytime anything is implanted into the human body, the body builds a thin layer of scar tissue around the implant, whether that is a breast implant or a cardiac pacemaker. In the past, when the majority of breast implants were smooth-walled silicone implants placed in a sub-glandular position, there was a rate of capsular contracture (which is the formation of scar tissue that you can tell is there) of about 15-to-25 percent. Usually what this meant was that the implant felt slightly firmer than it did originally. In a smaller percentage of cases, the capsule thickened to the point that it put some pressure on the implant and made it appear like a balloon or a ball stuffed under the breast. On rare occasions it would become thick enough and tight enough to actually be painful. These conditions are all treatable, however, and in an effort to decrease the likelihood of capsular contracture, alternative techniques have been developed. Recent studies presented at the American Society of Plastic and Reconstructive Surgery meeting in 1998 about saline filled implants placed underneath the muscle, showed that the rate of capsular contracture with this method is approximately seven percent. The majority of these will only be a slight firmness to the implant and rarely will there be any pain associated with this capsular contracture.


All of the implants that Dr. Nein uses come with a lifetime warranty.

Like any other mechanical device, a breast implant is subject to mechanic failure. The fluid that is in a saline implant is filled with is IV saline; if it should leak, it is harmlessly absorbed by the body. The silicone implants are filled with a cohesive silicone gel. The consistency of the cohesive gel allows it to not spill or leak. It stays intact. All of the implants that Dr. Nein uses come with a lifetime warranty. Dr. Nein only uses implants made by either Allergan, Mentor, or Sientra. Should the implant ever leak, the manufacturer will provide a replacement implant at no charge. Whether you choose round or anatomical implants, saline or silicone, the manufacturers also have a ten year replacement subsidy. If the implant leaks in the first ten years, not only will the manufacturer provide a replacement implant, they will also help subsidize the cost of having the implant replaced. Although there are other companies out there that also offer warranties on their implants, Allergan, Mentor and Sientra are large companies that have been in the implant business for a long time. These are stable companies and they are likely to be here for the future.

Loss of Nipple Sensation

Perhaps the most serious consequence or potential problem associated with breast augmentation is the potential for loss of nipple sensation. The nerve to the nipple comes from between the fourth and fifth rib, travels through the side of the breast to the nipple itself. In the course of creating the pocket to place the implant, the nerve can be injured. If the nerve is damaged or cut, one can have permanent loss of nipple sensation. Fortunately, this is an extremely uncommon complication. In fact, it rarely happens.


There is an extremely small risk of infection during the immediate postoperative period. If a woman develops an infection around the implant, it is necessary to remove the implant. She must be on antibiotics and no sooner than six weeks later can the implant be replaced. This is a potentially correctable, reversible situation; but it is expensive by the time one pays for a second trip to the operating room and for a third implant. The good news is that this too is an extremely rare occurrence. In fact, it is so uncommon that for most plastic surgeons it may only occur only once or twice in their practice careers.

We take every precaution to make this as safe an operation as possible.

One of the reasons for this is that we take every precaution to make this as safe an operation as possible. We perform this procedure in an approved and accredited surgical facility with every emphasis taken for safety and patient comfort. Utilizing this standard, we have not had any breast augmentation patients develop an implant infection.


In the early postoperative period one can develop some bleeding around the implant which can cause a blood pocket to form next to the implant. If this happens, it may require a return trip to the operating room to have this washed out. In our experience in this practice, this has never happened.

In general, this is a very safe operation and it is well tolerated by most women and nearly all of the women have been extremely pleased with the results. As you review this and the other materials provided by Dr. Nein about breast augmentation, we encourage you to ask any and all questions and be sure that you have a full understanding of this procedure and that you are pleased and satisfied that this is the right decision for you.

Further information about breast implants can be obtained from the FDA. A phone call to the toll free number (800-532-4440), and the FDA will send you a free copy of their “Breast Implant Information Package”. Allergan Medical will also provide you with a complimentary brochure on breast implant surgery. Call Allergan at 1-800-624-4261 and ask for their brochure “Saline-Filled Breast Implant Surgery – Making an Informed Decision”. This information and more can also be obtained at:


Women who desire cosmetic surgery are encouraged to seek out plastic surgeons who are experienced in the various techniques available and who are certified by the American Board of Plastic Surgery.

Have questions? Send your questions on cosmetic and plastic surgery to us at our Patterson Street address, or give us a call at 615-327-0201.

Breast Enlargement in Detail
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Breast Enlargement in Detail
Board-certified plastic surgeon Dr. Alexander Nein of Nashville explains the aspects of breast augmentation using silicone or saline breast implants.
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Dr. Alexander Nein
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