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Breast Augmentation

Breast augmentations or breast enhancements are the number one surgery performed by plastic surgeons across the country. The reason they are so popular is because our culture in America is very breast-oriented. Men see breasts on a woman as attractive and sexy. Women see attractive breasts as self-esteem building and also power. I once performed a breast augmentation on a female attorney and asked her what breast implants meant to her. Her reply was, “Now I can negotiate better.”

Modern breast augmentations have come a long way since they were invented in Houston, Texas in the early 1960’s. The quality of the implant has also improved tremendously. There are two basic types of implants – silicone and saline. Each has its purpose, and in the hands of a well trained, Board Certified Plastic Surgeon, one or the other will be used correctly to get the best possible results. Breast implants are used for either purely cosmetic reasons or in breast reconstruction. I do not perform breast reconstruction, but we are fortunate in Hawaii to have several excellent reconstructive breast surgeons.

It is my opinion that you will get the best result from a surgeon who has an opinion. I personally like, not only surgeons, but people in general, who have a point of view. That way, it is easier for me to agree to disagree with them. Here is my point of view.

Implant Style or Variation:

I do not like anatomic or tear drop shaped breast implants because if they rotate, which sometimes they do, it gives a very strange breast shape. I do not use textured breast implants because I feel they do exactly what they are not supposed to do – lead to hard breasts. I believe round, smooth implants give the patient the consistently best breast augmentation in the short and long run. From 1991-2006 silicone breast implants were unavailable for breast augmentation except when done by an FDA investigator. Saline was the only implants that were used routinely at that time. Saline has many problems and it rarely is as good as silicone in cosmetic breast augmentation. In a thin-skinned woman with small breasts, silicone is always the implant of choice.

Incisions for Breast Augmentations:

Breast augmentations through the belly button is a bad idea. None of the Board Certified Plastic Surgeons in Hawaii use this technique. The results are very unpredictable and uncontrollable, and implants can only be placed on top of the muscle.

Incisions in the crease at the bottom of the breast, called inframammary incisions, leave an unacceptable scar and should only be used in very unusual circumstances for cosmetic breast enhancement. Incisions at the edge of the areola are acceptable, especially for redo’s, but they can leave a scar on the breast. Any visible scar takes away from the beauty or aesthetic appearance of the breast.

Transaxillary incisions (incisions in the armpit) are my favorite route of entry for breast augmentations for the following reasons: (a) armpit scars tend to be very thin and fine because the lower part of the skin, the dermis is thin, and, in general, the thinner the dermis, the finer the scar as long as it is sewn up correctly; (b) no one, not even your mother, has ever intentionally looked into your armpits.

Positioning of Implants:

Implants can be placed above or below the pectoralis (chest) muscle. I prefer 98% of the time going below the pectoralis muscle because: (a) it gives an extra layer of covering over the implant, therefore making the implant less obvious; (b) it is common knowledge in plastic surgery that implants under the muscle tend to stay softer over time; (c) the pectoralis muscle originates on the humurus (bone of the upper arm) and inserts on the clavicle (collar bone) and on the sternum, therefore, with the implant underneath the pectoralis muscle, the breast appears to originate in an unbroken line from the collarbone to the nipple, whereas if you go on top the muscle, the breast implant appears to start much lower, giving it a less natural look; (d) mammography of the breast is made easier if the implant is behind the muscle because the radiologist sees the muscle density and knows that all the breast tissue is above this muscle density and the implant is below.

I, like most plastic surgeons in the U.S., go partially subpectoral, cutting a small strip of pectoralis muscle off the fifth rib. I feel if the implant is completely subpectoral, this does not give a natural, or tear drop shape to the breast.

Size of Implants:

I have found no difficulty getting large implants, even up to 800cc, through a relatively small incision throughout the armpit using the Keller funnel. The funnel also allows for a no-touch approach. The implant travels from a sterile box into a sterile funnel, then into a sterile sub pectoral pocket below the breast tissue. The number two reason for breast implants hardening is the implant is inserted while touching the skin, thus dragging bacteria with it into the sub pectoral pocket. Skin bacteria does not cause infection, however it does cause the body to form a thick capsule around the implant, therefor leading to hard breasts.


I do all of my transaxillary breast augmentations using an endoscope, just like gynecologic belly button or arthroscopic knee surgery. Because I have a camera inside and under the breast and muscle and I operate using a monitor, any excessive bleeding is easily stopped. Endoscopic breast augmentations leads to less bruising, less hard breasts, less swelling, and quicker recovery.


I believe, in the majority of breast augmentations, one should use a smooth, round silicone implant put in through the armpit partially under the pectoralis muscle using an endoscope for the most aesthetic results.

Schedule a consultation with breast augmentation specialist, Dr. Larry Schlesinger.