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Stephen T. Greenberg, M.D.
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Doris J. Day, M.D.
With breast implants, it is no longer a case of one size fits all. Current breast augmentation patients have more choices than ever before -- including where they want surgeons to make the incisions. Moreover, breast inserts are now being made in various sizes and shapes so virtually any body type can enjoy an augmentation that is balanced, natural and matches the patient's frame.

According to the American Society of Aesthetic and Plastic Surgery, breast augmentation is the second most frequently done invasive surgery, with about one-third of a million women having the procedure in 2004.

Not too many years ago, almost every breast enhancement patient received a round implant. Many women did not like the look of what they often described as two large grapefruit halves applied to their chests. But now, the natural look is the "in" thing. Typical reasons for a breast augmentation include a woman thinking her breasts are too small; to correct sagging breasts after pregnancy; to make both breasts the same size and, sometimes, to lift a drooping breast.

Surgeons start a breast augmentation in one of four ways: they make an opening in one of the creases in the patient's belly button (the transumbilical procedure); in the area where the breast meets the wall of her chest (infra-mammary); in the armpit (transaxillary) or in the areola, (peri-areolar,) the area of dark skin surrounding the nipple.

Moreover, incisions don't have to be large enough to allow passage of the surgeon's hand. Almost all implants are rolled up like a cigar and then inserted through the incision, through a channel just under the skin and into a surgically made pocket over or under the chest muscles. Once in place, the implant is then inflated.

"I prefer to place breast implants through a two-inch incision just under each of the woman's breasts," says Dr. Greenberg. "It results in a very well-hidden scar, one which hardly anybody has ever noticed."

Even semi-solid silicone implants, the so-called "gummy bear" inserts, are starting to become available in various sizes and dimensions although the incision to insert a semi-solid implant must be slightly larger because that type insert can't be rolled up. Overall, surgeons report saline inserts are the most common while silicone implants are available only when the patients fit certain medical and study parameters.

Sizers are temporary implants a surgeon can first insert during surgery in the breast pocket to check which size and shape will best become the patient. Used once and then thrown away, the sizer is filled with saline once it is in place.

"I always get a perfect match to the patient's body using sizers during the surgery to judge what the final results will look like," says Dr. Greenberg.

Not only do breast implants come in various sizes - from half a cup to a cup and a half and larger - they also come in four levels of projection, which is a measurement of how far the breasts projects from the patient's chest wall. Thus, an A or B cup patient can easily become a C, D, a double D or even larger if she insists.

"For a patient who has a narrow chest, I can provide an implant that has more projection," Dr. Greenberg says. "Or, if a patient wants more cleavage, I can implant a wider, flatter insert." Some patients don't like their arms rubbing against their breasts so the surgeon selects a narrower implant. Another benefit: some implants with more frontal projection - known to surgeons as profile -- provide better lift without going through a separate breast lift surgery that involves additional and longer scarring, along with added expense.

Other choices in breast augmentation surgery include teardrop-shaped implants; smooth and textured casings and expandable breast implants which can be adjusted for a final size weeks after surgery. Round and teardrop-shaped implants, smooth and textured inserts all have various advantages and disadvantages which surgeons explain to their patients in the initial consultation before surgery. "The best results are obtained when the surgical procedure, implant type, location, and size are individualized to match the patient's specific body type and desires," says Dr. Greenberg.




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