Breast augmentation is a surgical procedure that increases the volume of the breasts through the insertion of prosthetic implants. Implants range in volume from 90 to 900 millilitres and also come in different shapes. They have either saline or silicone filling and smooth or textured silicone or textured polyurethane envelopes.

As every woman's physiology and presenting conditions are different, a skilled surgeon chooses from a range of procedural options to suit the patient and her desired outcome. In some cases augmentation surgery is accompanied by a mastopexy, or lifting procedure, which involves more scarring but may be needed to ensures an aesthetic outcome in patients who have sagging breasts.

Prior to the procedure decisions will be made about the size and type of implant, depending on the patient's anatomy, body size, chest measurements and desired final result. Almost all patients who request a breast augmentation desire some degree of cleavage. Cleavage is defined by the distance between the breasts and it can be enhanced by narrowing the gap between the breasts as well as increasing the fullness of the breast at the inner edge of the breast.

In most cases, an appropriate implant type, size and specific placement of the implant can certainly enhance the cleavage in the majority of women having this type of surgery. However, in some women, particularly those who are extremely thin with minimal soft tissue and with widely separated breasts, a well-defined cleavage will not be possible without causing the risk of implant visibility and worse, being able to feel the implant. In these patients, cleavage can only be further enhanced by a suitable bra.

The breast augmentation procedure involves the surgical placement of a saline or silicone gel-filled implant in each breast to push the breast tissue forward. The patient is anesthetised, either with general anaesthetic or twilight sedation, and the chest area is cleaned and marked up with guidelines by the surgeon. Then the surgeon makes an incision that enables them to lift the breast tissue to create a pocket above or below the pectoral muscle for the implant. Depending on a patient's anatomy, breast condition and other factors, the implant can be inserted through four different incision sites according to the patient and doctor's choice of which will work best and takes into account where the residual scarring will be located. This should be discussed in detail before the procedure.

The incision is made to access the breast tissue and a pocket is then created to receive the breast implant. As with the incision site, there are options for the location of this pocket in relation to the pectoral muscle and other structural parts of the breast.

After making the incision, the surgeon cuts a channel through the tissue to the final location of the implant. Having created the path, the surgeon then separates tissue and/or muscle to make the implant pocket. In deciding the location of the pocket, the surgeon must predict how the breasts will look once the implants have been inserted. In more complex augmentation procedures, repositioning the nipple and areolar and creating a new crease under the breast may be involved.

The surgeon considers the patient's existing breast tissue and the thickness of the skin, as well as the look she wants, to decide how to locate the pocket. Again, this should be discussed in detail during consultation prior to surgery so the patient thoroughly understands what each option involves.

Surgeons create the pocket to receive the breast implant using one of two methods: blunt or electrocautery dissection. With blunt dissection, a curved, blunt steel instrument or the doctor's index finger is used to separate tissue to create the pocket. While blunt dissection can cause bleeding and trauma, it is fast and effective.

Electrocautery dissection employs electrical current to cut tissue and coagulate bleeding vessels at the same time, resulting in greater visibility and consequently greater accuracy for surgeons. Because using electrocautery dissection causes less bleeding and tissue trauma, it can shorten recovery time.

Some surgeons use a sizer to help create the pocket. This is an inflatable balloon attached to a tube that the surgeon inserts into the pocket to help determine placement and ensure the pocket is of an adequate size for the implant. It is then removed and the implant is inserted.

The implant is inserted through the incision and positioned in the pocket. When saline inflatable implants are used, they are rolled up like a cigar and pushed into the incision, through the channel and into place. If the patient has opted to use pre-filled implants, the incision needs to be larger. Inserting textured, pre-filled implants requires the longest incision, providing enough room for inserting an implant with a rough shell and for manipulating the less pliable implant once it's in place.

The surgeon then manually adjusts the positioning to achieve the desired result. If the implants incorporate a valve, they are then filled. At this point, the surgeon may sit the patient upright to check for symmetry and balance. Depending on the operating technique used by the surgeon, drainage tubes may be necessary to allow removal of blood and fluids that accumulate during surgery.

Finally, the incision is closed with sutures or surgical glue and covered with tape, which helps the tissues adhere. In some cases additional dressings may be applied or a surgical bra may need to be worn, but advances in surgical techniques mean that a sports bra may be sufficient or no bra at all may be needed.

After surgery the patient is moved to a recovery area and, in straightforward procedures, may be able to go home a few hours after surgery. In the case of more complex surgery, an overnight hospital stay may be necessary or longer if there are any complications.

A complete understanding of the procedure is important for anyone considering breast augmentation and surgeons should provide all of the relevant information during consultations before making plans for and going ahead with surgery.

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