Breast augmentation

The decision is not based on age alone: breast development should be complete, and the patient should understand the benefits, limitations and risks of implant surgery.

Regulatory limits also vary by country and device. In the United States, the FDA approves silicone-filled implants for cosmetic augmentation from age 22, and saline implants from age 18. These ages are not Brazilian law or automatic indications for surgery. In Brazil, planning must consider the selected implant's instructions for use and the patient's clinical condition.

Adolescents with substantial asymmetry or congenital differences may warrant reconstructive assessment before the usual age for cosmetic augmentation. Assessment considers physical development, impact, maturity, guardian involvement when applicable, and other specialties as needed. The aim is appropriate timing, without bringing surgery forward solely because of external pressure or temporary dissatisfaction.

References

1. U.S. Food and Drug Administration (FDA). Types of Breast Implants. United States regulatory information. View reference.

2. American Society of Plastic Surgeons (ASPS). Breast Augmentation Candidates. Institutional guidance. View reference.

3. Jordan SW et al. Considerations in Breast Augmentation in the Adolescent Patient. Semin Plast Surg. 2013. PMID: 24872743. Narrative review. View reference.

Clinical and pre-anaesthetic assessments take place before surgery. Additional tests are selected according to the procedure, health, symptoms, medications and previous results; there is no identical mandatory test panel for every patient.

A blood count and other blood tests may be needed, but coagulation, kidney function, liver function and glucose testing require an indication. NICE, for example, does not recommend routine coagulation testing for every healthy surgical patient. Likewise, the 2024 cardiovascular guideline does not recommend routine ECGs for asymptomatic patients having low-risk procedures.

For breast surgery, mammography and ultrasound take account of age, examination, symptoms, personal and family risk and previous tests. Keeping indicated screening up to date is different from repeating tests solely because surgery is planned.

If an abnormality is found, we assess whether it needs investigation, treatment or a change of plan. Assessment helps identify and reduce risks; no single test guarantees freedom from complications.

References

1. National Institute for Health and Care Excellence (NICE). Routine preoperative tests for elective surgery. NG45. 2016. Guideline. View reference.

2. AHA/ACC et al. 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation. 2024. DOI: 10.1161/CIR.0000000000001285. View reference.

3. Urban LABD et al. Recomendações do CBR, SBM e Febrasgo para o rastreamento do câncer de mama no Brasil. Radiol Bras. 2023;56(4):207–214. Joint guideline (Portuguese). View reference.

4. ASPS/Consumer Reports. Mammograms before elective breast surgery. Choosing Wisely. 2015. Used for selective preoperative testing, not to update screening ages. View reference.

For breast augmentation without combined procedures, the estimate used in our planning is usually 1 to 2 hours of surgery. This is a scheduling reference, not a mandatory duration established by studies for every patient.

Duration depends on implant position and insertion route, breast differences and adjustments needed. Replacements, revisions and surgery with a lift may take longer. Operating speed is not a measure of quality.

Operating time differs from total time in theatre and anaesthetic recovery. Preparation, anaesthesia, positioning and recovery add to the time before family can be told the patient is ready to leave this stage. The individual estimate is explained beforehand and may change depending on progress.

References

1. ASPS. Breast Augmentation Procedure Steps. Institutional guidance. View reference.

In our practice, breast augmentation is performed under general anaesthesia following pre-anaesthetic assessment. This is our team's approach; other anaesthetic approaches may be used in selected settings and are not necessarily inappropriate because they differ.

During general anaesthesia, the anaesthesiologist gives medicines to maintain unconsciousness and pain control, continuously monitors vital signs and provides respiratory support as needed. The plan considers your health, previous anaesthetic experiences and the proposed procedure.

When indicated, regional blocks or other pain-relief strategies may be added to improve postoperative comfort. Choice of a particular block, including an epidural in selected circumstances, rests with the anaesthesiologist. This combination is not mandatory.

At pre-anaesthetic consultation, report allergies, previous problems, sleep apnoea and all medications and substances used. This guides choices and care; no technique guarantees zero risk.

References

1. ASPS. Breast Augmentation Procedure Steps. Institutional guidance. View reference.

2. ASA. Preparing for Surgery: Checklist. Institutional guidance. View reference.

Procedures can be combined, but suitability depends on the total extent of surgery and health. A single recovery may simplify arrangements but may require more help at home and restrict several movements at once.

The decision considers thrombosis risk, bleeding, expected duration, areas treated and hospital monitoring needs. Staging treatment is sometimes more appropriate, even when all areas concern you at once.

In São Paulo, CREMESP Resolution 400/2026 prohibits scheduling elective surgery initially expected to last 6 hours or more in a single operation, except for the specified, technically justified exceptions. This rule guides planning; being below six hours does not automatically make every combination safe.

At assessment, I explain what can be combined, what is better staged and how this affects recovery. The aim is a plan compatible with individual risk, not the maximum number of procedures in one operation.

References

1. Regional Medical Council of the State of São Paulo. CREMESP Resolution 400, dated 26 May 2026. Published in the Federal Official Gazette on 25 June 2026. Surgical planning and safety regulation. View reference.

Yes. Report cigarettes, vaping, hookah, cannabis, hormones, medications, supplements and herbal products. Each may affect healing, anaesthesia, bleeding or thrombosis differently.

Tobacco and nicotine: smoking impairs recovery and needs to be addressed in preparation. For vaping and other products, composition and frequency matter. Therapeutic nicotine replacement should not automatically be equated with cigarettes, but should not be started without discussing surgery and a cessation plan. Cannabis differs from tobacco and should be reported specifically to the anaesthesiologist.

Contraceptives and hormones: oestrogen-containing products require attention to thrombosis risk, particularly with major surgery and prolonged immobilisation. Not all methods should be stopped in the same way: decisions consider formulation, route, individual risk and prevention of unintended pregnancy.

Medications and supplements: aspirin and anticoagulants may require adjustments, but stopping them also carries risks. Fish oil should not be equated with an anticoagulant: the OPERA trial, involving 1,516 cardiac surgery patients, found no increased bleeding with the supplementation studied. This does not replace assessment of the product and patient.

Bring a complete list and obtain written instructions. Include diabetes and weight-loss medications so the team can plan appropriate preparation.

References

1. American Society of Anesthesiologists (ASA). Smoking and Anesthesia. Institutional guidance. View reference.

2. ASA. Cannabis and Surgery. Institutional guidance. View reference.

3. CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024: Appendices. MMWR. 2024. Contraceptive eligibility guideline. View reference.

4. Akintoye E et al. Fish Oil and Perioperative Bleeding. Circ Cardiovasc Qual Outcomes. 2018. DOI: 10.1161/CIRCOUTCOMES.118.004584. Analysis of the OPERA randomised trial. View reference.

5. Patel SM et al. Impact of Nicotine Replacement Therapy on Breast Surgery Outcomes. J Reconstr Microsurg. 2024;40(3):239–244. PMID: 37467771. DOI: 10.1055/a-2133-1130. Retrospective study; does not establish universal safety of nicotine replacement. View reference.

6. ASA. Drugs for Diabetes or Weight Loss: What To Know Before Surgery. Guidance based on the 2024 multisociety statement. View reference.

The result may be subtle or have more upper-pole fullness, depending on anatomy, the implant and patient preference. Natural appearance is personal: show and explain what you want rather than assuming everyone seeks the same shape.

Planning considers breast width, tissue coverage, skin elasticity, nipple position and chest proportions. A larger implant does not always give a better result, and a small implant does not guarantee invisible edges in someone with little tissue.

Photographs and simulations can aid discussion but cannot reproduce your body's response exactly. Some pre-existing asymmetry may remain.

Satisfaction studies help assess patient experience, but satisfaction is not an objective measure of natural appearance. I therefore do not use satisfaction percentages to promise an unoperated look. The aim is an option compatible with your tissues and expectations.

References

1. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005–2016. PMID: 16327616. View reference.

2. American Society of Plastic Surgeons (ASPS). Breast Augmentation Candidates. Institutional guidance. View reference.

Selection starts with anatomy and expectations. Volume in millilitres is only one characteristic: two implants with the same volume can have different widths and projections.

I assess breast base, spacing, tissue thickness, skin elasticity and crease position. These measurements help determine dimensions compatible with your body. Tissue-based planning was structured, among other work, in Tebbetts and Adams' High Five method; it supports decisions rather than replacing clinical judgement with a formula.

Profile describes relative implant projection, but classifications differ between manufacturers. A high-profile implant in one range should not be compared with another without checking dimensions. Nor is there an exact conversion between millilitres and bra size.

I explain alternatives and trade-offs: more volume may mean more weight and tissue tension. The aim is a shared choice considering desired appearance and long-term support.

References

1. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005–2016. PMID: 16327616. View reference.

An implant may be placed in front of the muscle or partially beneath it. The plane is selected according to tissue coverage, anatomy, physical activity and goals.

Subglandular and subfascial: both are in front of the pectoral muscle but are different anatomical planes. They avoid distortion directly caused by contraction of muscle covering the implant. With little tissue coverage, edges or rippling may be more noticeable.

Subpectoral and dual plane: the muscle covers part of the implant. Dual-plane planning combines upper coverage with accommodation of the lower breast. Initial discomfort and movement or shape change during pectoral contraction, called animation deformity, may occur.

No plane offers every advantage. Studies compare complications by placement, but differences in implants, patient selection and techniques prevent turning a single rate into a universal rule. Discussion should include appearance at rest, activities and tissue quality.

References

1. ASPS. Breast Augmentation Procedure Steps. Institutional guidance. View reference.

2. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005–2016. PMID: 16327616. View reference.

3. FDA. Risks and Complications of Breast Implants. Safety information. View reference.

Volume changes are visible soon after surgery, but initial shape is affected by swelling and tissue tension. Appearance changes over weeks and months.

As a clinical follow-up reference, shape is often more stable between 3 and 6 months, sometimes longer. This is not a guarantee of a final result and should not be confused with the end of scar maturation.

Settling does not mean every implant must drop. The aim is correct placement during surgery and monitoring tissue response. The sides may progress differently, but sudden enlargement of one breast, increasing pain or a significant position change requires assessment.

Scars may continue changing after volume and shape become more stable. Follow-up distinguishes expected progress from problems requiring care; there is no single end date for everyone.

References

1. ASPS. Breast Augmentation Recovery. Institutional guidance. View reference.

2. FDA. Risks and Complications of Breast Implants. Safety information. View reference.

Return depends on the activity, technique and recovery. For office work, planning often allows around one week, sometimes longer; physically demanding work needs specific assessment. This is a clinical guide, not automatic clearance.

Driving requires no medicines that impair alertness, the ability to wear a seat belt and safe movement for an emergency manoeuvre. The calendar alone cannot determine this.

Exercise restrictions should match the procedure. A randomised trial analysed 225 patients after breast augmentation and assessed exercise started one week after surgery, without identifying increased complications under the studied protocol. This does not authorise any exercise, load or movement after one week, or automatically apply to breast lifts or combined surgery.

Return should be gradual with team clearance. Walking, intense weight training and pectoral exercises are different activities and may have different timelines. Explain exactly which activity you plan to do.

References

1. Basile FV, Oliveira TS. Exercise after Breast Augmentation: A Randomized Controlled Trial. Plast Reconstr Surg. 2022;149(1):18e–24e. DOI: 10.1097/PRS.0000000000008676. View reference.

2. ASPS. Breast Augmentation Recovery. Institutional guidance. View reference.

Pain, pressure and restricted movement may occur in the first days. The team advises on medication, dressings, hygiene, sleeping position and permitted activities. Gradual improvement is expected, but discomfort varies.

A surgical bra and, in selected cases, a band may be part of the protocol. A band is not mandatory for every implant and should not be used to correct breast position yourself. Style, fit and duration must be set by the team.

Relative rest does not mean remaining motionless in bed. Permitted movement and arm care should be explained for your operation. Avoid comparing recovery with someone who may have had a different technique.

Between visits, report increasing pain, marked one-sided swelling, spreading redness, discharge, fever or wound opening. Shortness of breath, severe chest pain, fainting or significant illness requires immediate medical attention. Follow-up guides results and helps identify complications early.

References

1. ASPS. Breast Augmentation Recovery. Institutional guidance. View reference.

2. FDA. Risks and Complications of Breast Implants. Safety information. View reference.

Breast and nipple sensation may decrease, increase or change. Some changes improve over months, but they may persist.

In a prospective study of subfascial augmentation, around 4% of nipple–areola complexes still had sensory loss at 12 weeksunder the conditions assessed. This is not a permanent-loss rate: twelve weeks is limited follow-up, and the technique does not represent every operation.

Risk depends on nerve pathways, dissection, incision route, volume relative to tissue and individual response. Objective sensory testing may differ from spontaneous symptom reports; there is no single reliable percentage for every patient.

Report pre-existing changes and how important this issue is to you. Assessment informs choices and expectations. Sensation and milk production are related in some respects but are different functions: preserving one does not guarantee the other.

References

1. Brown T. Objective Sensory Changes Following Subfascial Breast Augmentation. Aesthet Surg J. 2016;36(7):784–789. PMID: 26883217. Prospective study. View reference.

2. CDC. Breast Surgery and Breastfeeding. Clinical guidance on lactation after breast surgery. View reference.

There is no recommendation to automatically replace every implant at ten years. However, implants are not lifetime devices: complications and the need for further surgery may arise over a lifetime.

Replacement or removal may be indicated for rupture, contracture, position changes, breast changes or patient preference. Having no pain does not rule out silicone implant rupture.

Implant monitoring differs from breast cancer screening. As United States guidance, the FDA recommends ultrasound or MRI for asymptomatic patients with silicone implants at 5 to 6 years after implantation and then every 2 to 3 years. Symptoms or uncertain findings may require earlier investigation. The individual plan considers the device and medical assessment.

Keep the card with brand, model, batch or serial number. It identifies the implant used. Reoperation decisions depend on assessment, not implant age alone.

References

1. FDA. Things to Consider Before Getting Breast Implants. Guidance for informed decisions. View reference.

2. FDA. Breast Implants — Certain Labeling Recommendations to Improve Patient Communication. 2020. Silicone implant labelling and follow-up guidance. View reference.

Many women can breastfeed after augmentation, but sufficient milk production cannot be guaranteed. Placing the implant behind the gland does not eliminate possible effects on nerves, ducts or breast tissue.

In the BIFS study, 4,679 women gave birth after primary augmentation, and 79.4% reported breastfeeding at least one child. This observational analysis used data after the five-year follow-up window. It does not mean 79.4% breastfed exclusively or establish equivalence with unoperated women. Complete data on breastfeeding duration, infant weight gain or formula use were unavailable.

Individual likelihood also depends on original anatomy, surgery, breastfeeding experience and maternal and infant factors. Discuss pregnancy plans at the consultation.

After childbirth, breastfeeding support and monitoring infant weight are valuable. When production is insufficient, supplementation may be needed without meaning there is no lactation at all.

References

1. Jewell ML, Edwards MC, Murphy DK, Schumacher A. Lactation Outcomes in More Than 3500 Women Following Primary Augmentation: 5-Year Data From the Breast Implant Follow-Up Study. Aesthet Surg J. 2019;39(8):875–883. PMID: 30165661. Observational study. View reference.

2. CDC. Breast Surgery and Breastfeeding. Clinical guidance on lactation after breast surgery. View reference.

Implants do not prevent mammography but require technical precautions. They may obscure some tissue; report them when booking and attending. Additional implant-displacement views, when possible, help assess the breast.

Cancer screening remains based on age and individual risk. The 2023 joint Brazilian CBR/SBM/Febrasgo guideline recommends annual mammography from age 40 to 74 for average-risk women, with individualisation in other situations. Guidelines differ, and your plan should be discussed with your treating doctor.

Ultrasound and MRI do not automatically replace mammography. MRI to assess implant integrity and MRI to investigate cancer may also use different protocols, including whether contrast is required.

Keep the two follow-up goals separate: examining breast tissue and checking the implant. A normal result for one does not necessarily answer the other question.

References

1. Urban LABD et al. Recomendações do CBR, SBM e Febrasgo para o rastreamento do câncer de mama no Brasil. Radiol Bras. 2023;56(4):207–214. Joint guideline (Portuguese). View reference.

2. American College of Radiology. ACR Appropriateness Criteria® Breast Implant Evaluation: Update 2025. PMID: 41711626. Diagnostic imaging guideline. View reference.

The body forms a tissue capsule around an implant. If it becomes excessively firm and contracts, it can change the shape or cause pain: this is capsular contracture. In the Baker classification, grade I describes a normal breast; grade II is firmer without obvious distortion; grades III and IV are more clinically significant, with distortion and, in grade IV, pain.

Risk varies with time and context. In the MemoryGel cohort, the estimated cumulative ten-year risk of Baker III/IV contracture was 12.1% in primary augmentation and 24.4% in revision augmentation. These results concern a specific device and population, not the predicted rate for each patient.

A different retrospective series involving 856 patients and a mean follow-up of 14.9 monthsfound 2.8% contracture. The rates are not directly comparable: observation periods and study characteristics differ. It would be incorrect to conclude that risk disappears after the first years.

The cause is multifactorial. Technique, bleeding, inflammation, implant characteristics and patient factors may contribute. Prevention matters, but contracture does not prove a technical error.

Treatment depends on symptoms and findings. Mild cases may be monitored. Pain or distortion may require capsule surgery, implant removal or replacement, and possibly a change of implant plane. Off-label medications have limited evidence and should not be presented as established cures. Montelukast, for example, carries an FDA warning about serious neuropsychiatric effects. Therapeutic ultrasound and massage do not replace diagnostic assessment or indicated surgery either.

New hardening, particularly with fluid, a mass or late breast enlargement, needs investigation before being attributed solely to contracture.

References

1. Caplin DA et al. MemoryGel Breast Implants: Final Safety and Efficacy Results after 10 Years of Follow-Up. Plast Reconstr Surg. 2021;147(3):556–566. PMID: 33620918. Prospective cohort of a specific device. View reference.

2. Blount AL et al. Capsular contracture rate in a low-risk population after primary augmentation mammaplasty. Aesthet Surg J. 2013;33(4):516–521. DOI: 10.1177/1090820X13484465. Retrospective cohort. View reference.

3. FDA. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast. 2020. Safety alert. View reference.

4. FDA. Risks and Complications of Breast Implants. Safety information. View reference.

There is a rare disease called BIA-ALCL, a lymphoma that can develop in the fluid or capsule around an implant. It differs from cancer arising in breast tissue and is associated mainly with exposure to textured implants. Microtextured implants belong to this category and should not be equated with smooth implants.

The FDA compiled 1,380 case reports in its tables with data through 30 June 2024. These reports cannot establish an individual's probability because reporting and implant histories have limitations. One report involves a smooth implant with no known history of a textured implant; this does not prove causation, but means absolute claims that no reports exist should be avoided.

Persistent breast enlargement, late fluid accumulation, a lump, pain or hardening need assessment. Imaging and, when indicated, fluid or tissue analysis help establish the diagnosis. Localised disease is usually treated by removing the implant and completely excising the disease through specialist planning; advanced cases may require additional treatment.

There have also been reports of squamous cell carcinoma in the capsule (BIA-SCC), involving both smooth and textured surfaces. The risk and causal factors remain uncertain. Treatment depends on the diagnosis and extent and should not be reduced to one standard operation for everyone.

Having implants without symptoms does not automatically mean preventive removal is indicated. The decision should consider the implant model, history and individual assessment.

References

1. FDA. Medical Device Reports of Breast Implant-Associated Anaplastic Large Cell Lymphoma. Tables with data through 30 June 2024. Passive surveillance; incidence cannot be calculated. View reference.

2. FDA. UPDATE: Reports of Squamous Cell Carcinoma (SCC) in the Capsule Around Breast Implants. 2023. Safety communication. View reference.

3. FDA. Things to Consider Before Getting Breast Implants. Guidance for informed decisions. View reference.

Systemic symptoms reported as breast implant illness (BII) are different from BIA-ALCL lymphoma. Some patients report fatigue, muscle or joint pain and difficulty concentrating, among other concerns.

There is no specific test confirming BII or universally accepted diagnostic criteria. Investigation should take symptoms seriously and look for other possible causes, without automatically attributing every change to implants or dismissing concerns because initial tests are normal.

Some patients report improvement after explant surgery, but complete resolution cannot be guaranteed or predicted with certainty. Spontaneous reports support surveillance but cannot establish how many implant users will develop symptoms or prove causation.

If removal is considered, the decision takes account of symptoms, investigations, implant characteristics and risks of further surgery. Capsule treatment requires its own indication; no specific explant technique should be promised to cure all symptoms.

References

1. FDA. Medical Device Reports for Systemic Symptoms in Women with Breast Implants. Medical device surveillance information. View reference.

2. FDA. Things to Consider Before Getting Breast Implants. Guidance for informed decisions. View reference.