There are many considerations and options regarding breast enhancement surgery, each of which you will want to discuss with the surgeon you choose. The first decision many women are faced with once they know they want to have breast enhancement is:

What size?
The number one "wish" we have heard from women who have breast augmentation is "I wish I had gone just a little bit bigger." To document this trend, we held a poll on the Breast Implants 411 home page and asked that very question. Here are the results:

"If you could change one thing about your breast augmentation, what would it be?"
48% Have "not yet" had the procedure
38% Would have gone "bigger"
9% Should have done it "sooner"
5% Would have gone "smaller"

Keep in mind that your plastic surgeon will help you determine what size is most appropriate for you, based upon their experience as well as your own individual anatomy. The important thing is to first, know what you want, and second, decide which size, type and style of implant will give you the look and feel you desire for yourself.

When the implant is behind the muscle, the muscle covers the upper 1/2 to 2/3 of the implant. This helps to conceal the implant and provide a smoother transition from the chest to the breast. Your individual body type, amount of existing breast tissue, and the look you desire will help you determine which position is best for you, here are some general guidlines:

1). If you have very little breast tissue...
it is more likely you will want to "go behind the muscle", for the following reasons: a) When the implant is in front of the muscle, there will not be much breast tissue to cover the implant, so more of the implant roundness will be visible. Clearly, if 1/2 to 2/3 or more of the implant is covered by muscle, it will be harder for you and others to see, feel and notice that an implant is there.

2). If you have some breast tissue...
If you have approximately 3 cm or greater of breast tissue, you will have more of a choice between above and below the muscle. At this point, new considerations need to be taken into account: a) If you exercise, the implant that is placed behind the muscle is more likely to displace, or move, when doing exercises that use the chest muscles. However, there are newer surgical techniques can minimize this.

There is a slightly greater chance of capsular contracture, or implant hardening, when the implant is placed in front of the muscle.

3). If you have some breast tissue and a "saggy" or "droopy" breast...
There are different points of view on this, and it will of course depend on individual anatomy. Some favor placing the implant above the muscle for the following reason: Even though the breast (tissue and glands) itself has fallen, or drooped, down toward the abdomen, the chest muscles are still in the same place they have always been. So, if you were to put an implant behind the chest muscle, you would have the previous breast still in the same position it was before surgery (drooping low), but now you would have a breast implant protruding out from the chest wall a couple of inches above the rest of the breast...Not pretty.

Having a droopy but larger breast is not ideal, however, because if the implant does not provide enough lift by “re-inflating” a saggy breast, an unfortunate “rock in a sock” look may result. Furthermore, the gravitational pull of the breast will be increased by the weight of the implant, which could result in the acceleration of further droopiness. This is a trade-off you must consider.

1). Periarealor - Along the areola complex, which is the pigmented skin surrounding the nipple. This sometimes erroneously called "through the nipple."

(+) PROS
This is arguably the most common approach for inserting breast implants. This approach is so often used because it provides the surgeon with good visibility and accessibility for both sub-glandular and sub-muscular implant insertion. Also, because the scar often blends in less conspicuously where the darker skin of the nipple meets the lighter skin of the breast. Typically, the incision goes halfway around the areola. Many surgeons use this incision with good results.

(+) CONS
Some early studies suggested that the periareolar incision increased the chances of sensory changes to the nipple, though more recent reports have refuted this assertion. Numbbness, or partial sensory loss to the nipple, appears to occur with equal frequency with all of the incision sites used for breast implant placement. Some surgeons also believe there is a higher risk of infection with this approach, since bacteria in the milk ducts of the breast tissue might be exposed. However, this also remains unproven.

2). Inframammary - In the fold beneath the breast.
(+) PROS
Another common approach. The first thing you want to be sure of is that once your implants are in, your breast will IN FACT fold over, and thus cover, this scar. If so, this may be the best approach for you.

(+) CONS
The scar tends to be slightly more noticeable and visible than in the Periarealor or Transaxillary approach because it is not "camouflaged" by the change in skin color. Also, due to gravitation-induced changes to the breast, the scar will tend to migrate upward and could become quite obvious on the breast itself. If a noticeable scar on your breast is your worst nightmare, then this approach is not for you.

3). Transaxillary - Through the armpit.
(+) PROS
The benefits of this approach are that the scar may be the least noticeable, as it is not near the breast, and that it facilitates submuscular implant insertion. Some plastic surgeons swear by this approach and they are masters of it. Using an endoscope (a pencil-sized rod with a fiber-optic camera on it's tip), surgeons have achieved good cosmetic results with an incision under the arm, also called the transaxillary incision. Most surgeons use this technique only for smooth implants that are placed under the muscle. Placing textured implants above the muscle through this incision poses a greater technical challenge and therefore may not be offered.

(-) CONS
A potential drawback of axillary insertion is that if a visible scar does result, and you wear sleeveless dresses or bathing suits, the scar may be seen - especially when you raise your arms. No other breast implant incision is visible when clothed. Additionally, you can go through a previous periareolar or inframammary scar time and time again if another surgery is ever necessary. (A second surgery is necessary in approximately 20% of women some time in their life). You generally cannot go back through an axillary scar, and thus a new incision (and perhaps scar) may result. Finally, bleeding can be difficult to control when using this approach, and injury to the nerves for both movement and sensation of the arm and hand can occur.

4). Transumbilical - That's right, right through your belly-button.

(+) PROS
The advantage is that you will likely have no visible scar.

(-) CONS
The disadvantages are as follows:
a) It is a somewhat "blind" surgery as it is very distant from where the implants are to be placed. While an endoscopic device (a tiny camera) is used, the correct placement of the implants is most difficult from here.
b) Pre-filled breast implants may not be used, thus reducing your options for your best cosmetic look and feel.
c) Few plastic surgeons use this approach because of the lack of control it allows, and because of poor long-term results caused by not getting the new folds of the breast to the same level.
d) There is a chance of "tracks" being made in a line between the belly-button and the breast. These tracks form the shape of a "v", coming together at the umbilicus, can be visible for a long time, and are not a pretty sight.

A breast lift, or mastopexy can be performed in conjunction with breast implants. This surgery can be performed in one or two stages. If performed in one stage, the implants will be implanted during the same surgery as the mastopexy is performed. Alternatively, the breast lift could be done on one day, with the implants implanted at a later date. The logic behind this two-stage approach is as follows: Breast lifts require a relatively large incision which may better heal unchallenged. In some women, if there is a breast implant in the skin envelope that is pushing outward against the incision and stitches, it will be more difficult for the incision to heal, and can result in increased scarring. Your individual circumstances will help you and your surgeon determine which approach would be best for you. Also, silicone gel implants may be appropriate and indicated in this situation. Ask your doctor about this possibility. (I know this can be confusing, so I will tell you - if it were my sister, I would tell her to have the mastopexy and the implants done at the same time - but to emphasize strongly to your plastic surgeon the extreme importance of minimal scarring to you, and ask if there is anything they can recommend to help you scar less).

It is important you are informed that, regardless of how performed, a mastopexy will leave scars on the breasts. The extent of scarring will depend upon your own skin type, the skill of the surgeon, and your overall propensity to heal or scar. Not Smoking is critical to good wound healing after breast lift surgery because nicotine constricts blood vessels, thereby depriving the surgical area of oxygen. Also, ask your doctor if they recommend any homeopathic remedies that may be taken orally and/or applied to the skin before and after surgery to help to minimize scarring. Generally, breast lift scars will fade to a less conspicuous size and color, but they will remain visible for life.