Breast enhancement has been one of the most popular plastic surgery procedures since silicone implants were first introduced in 1962. The goal is to do more than simply enlarge breasts; it is to make breasts beautiful.

Most, but not all, people believe that breasts should look natural. This means that the nipple-areola complex should be centered on the breast mound.

If the implant is placed too high, the nipple will point downward; if too low, it points up; if toward the center, the nipple points outward. Ideally, it should look and feel natural.

A recent trend is to go with very large implants. This can be done, but the breast might look unnatural, and the risk of firmness increases.

Also, the too-large implants might extend too far laterally below the armpit area and-or up toward the collarbone.

There are many choices regarding implant type and placement, and they all can affect the outcome, such as silicone vs. saline implants, behind or in front of the muscle, implant size and shape, whether or not to perform an uplift, and how to keep the encapsulation (firmness) incidence as low as possible.

Silicone implants are now cohesive, meaning if the shell tears, the silicone gel will not leak out. If saline implants leak, they go flat. If a patient has minimal breast tissue, saline implants frequently demonstrate wrinkles that might be seen and felt.

Saline implants are less expensive, and their encapsulation rate might be slightly lower.

Most plastic surgeons prefer the submuscular implant position because the encapsulation rate is lower.

Encapsulation occurs when the body forms scar tissue around the implant, squeezing the implant and making it look and feel like a ball. This scar tissue formation is from bacteria and-or something on the implant such as powder or blood.

Preventing encapsulations is a most challenging goal for plastic surgeons. Using powderless gloves, putting an antibiotic solution in the implant pocket, and mobility massaging instructions are some of the measures used to lower the encapsulation rate.

If a patient has excess sagging of the breasts, an uplift (mastopexy) might be necessary with insertion of breast implants.

Trying to correct sagging with larger implants can lead to an unfavorable result and more sagging.

Nipples located below the inframammary creases generally indicate the need for a mastopexy.

Fat transfer for breast enhancement has a future for breast reconstruction and even in certain cosmetic cases. An increase of one to two cups sizes might be achieved with fat grafts.

For patients with issues of firm implants from repeated encapsulations, fat transfer is an effective alternative.

Other indications are patients having a mastopexy who want more fullness in the top of the breast or in breast reconstruction patients.

E. Ronald Finger, MD, FACS is a board certified plastic surgeon with offices in Savannah and Bluffton.