Everybody recognizes beautiful breasts, but just how do surgeons create them? Breast surgeons are artists that understand that augmented female breasts must have certain aspects and ratios for a natural and beautiful look.

Many patients start the breast augmentation consultation by telling me what they don’t want. One of the most frequently described — and thoroughly rejected — appearance is one often described by prospective patients as two grapefruit halves, or two half coconut shells, stuck to the women’s chests.

Highly visible clues of breast augmentation include the amount of cleavage, the degree of breast softness and the natural profile. Actually, a well done breast augmentation will enhance a woman’s natural cleavage, maintain the breast softness and improve her breast profile.

But, with apologies to Sigmund Freud, what do women really want? At least when it comes to creating beautiful breasts?

The Art of Breast Augmentation

Beautiful breasts can be created through breast augmentation with careful planning, precise surgical technique and years of experience. Women want natural-looking breasts, with an appropriate size, shape and feel that fits harmoniously with their frame and anatomy. Anybody glancing at the finished enhancements would think the woman’s bosom was created, not by the surgeon’s hand, but by nature.

The perfect breast augmentation, according to one sculptor and admirer of the classic female form, results in a breast that slopes gently down from just below her shoulder bones to the peak of the breast at the nipple. That nipple should be largely in the middle of a teardrop-shaped breast mound.

The most appealing breasts have some perkiness and gentle arcs that sweep down from the nipple to the base of the breast, along with some natural cleavage in which the breasts come together naturally over the breastbone, a long plate of bone that physicians know as the sternum. When you look front-on, you should see just a little rounded curve at the sides of the breasts – not enough bulge to interfere with a golf or tennis swing or if you are into contact sports, a left jab or right cross.

Many breast augmentation patients have drooping breasts due to childbearing and nursing – this reduces breast volume and stretches the internal supporting ligaments. Many patients are a little older and the natural aging process has taken its toll in a similar way. Some women are just born with less breast tissue and feel their smaller breasts are out proportion to their bodies and self image.

I start the consultation by first listening to my prospective patient’s concerns about her breasts – a most important step that many plastic surgeons forget. We talk about the cup size, breast shape and what they don’t like about their breasts and what they find attractive. We then examine and measure her breasts and determine the amount of breast tissue and any chest asymmetry. I then take ten separate measurements. For example, I measure the distance from the breastbone notch to her nipples, the distance from the nipples to the center of her chest and the breast width – a critical dimension.

Only then do we begin to discuss the variety of available implants. Choices include size, three profiles of projection, (how far from the chest the breast will project) and implant filler (saline or silicone). Implants can be partially or completely filled. “Overfilling” will result in a breast that is slightly firmer to the touch while an implant that is filled below the maximum will results in a softer breast.

Women have a choice of placing the implant over or under their chest muscles. However, 95 percent of my patients opt for the under muscle position, a location which offers many advantages

A critical part of our planning is determining proper implant size. I help my patients determine the proper implant size well before she enters the operating room. I ask the patient to try on the implants we have selected. She places the implants atop her existing breast and snuggly beneath a surgical compression bra. This reveals a very close approximation of the final breast size. The final breast size is usually seen several weeks after the breast augmentation when the swelling is almost gone.

The Procedure – Creating the Beautiful Breast

When the moment of surgery is at hand, the surgeon’s planning; skill and experience all come into play. The incision can be placed in one of two locations, each about an inch long. The inframammary incision is placed under the bottom of the breast where it meets the chest wall. The periareolar incision is placed just under the nipple along the dark ring of skin known as the areola. After healing, both scars heal very well and will be very light and hard to see, if not completely inconspicuous. I don’t place any external stitches on the skin and prefer gluing the skin edges together for a very fine line scar.

Perhaps the most important aspect of the surgery is performed next – creation of the implant pockets, which creates a space for the implants. The implant in its pocket forms the “foundation” of your new breasts. The placement of the pockets is everything when it comes to breast shape. It will determine the amount of cleavage and breast fullness others see.

Creating a pocket requires a small release of the chest muscle called the pectoralis major. This is a critical part of the breast augmentation which creates a more beautiful breast shape. This technique requires artistic ability, technical skill and as many years of training and hands-on practical experience.

Breast augmentation also requires a thorough knowledge of human anatomy. The pockets are only an inches away from the lungs. And if the pockets are too far apart, the patient will not have natural-looking cleavage. But if the pockets are placed too closely, the area of the chest separating the two implants can give way, allowing the implants to roll together and create what is known as symmastia or a “uniboob.” It’s a flaw that is very difficult to repair.

Once the pockets are created, I fill the pocket with a long-acting local anesthetic. This allows the patient to wake up with very little discomfort for several hours after the procedure. I then roll the implant up like a cigar and slide it into the correct position and fill it with saline. The procedure can take anywhere from 60 to 90 minutes. All patients are placed under general anesthesia for their comfort during the procedure.

After the Operation

After the operation, patients usually have a little swelling and tightness in the chest. But that’s temporary and improves daily. The patient wears a surgical compression garment for about six weeks afterwards to help her heal properly and provide support for her new breasts. Most women can go back to work about four days after the surgery.

Virtually all women with beautiful new breasts are thrilled at being able to fit into, and fill out, clothes and bathing suits again like they did years ago. They also receive a huge jump in self-confidence because they feel, and look, more feminine and have a more balanced, womanly figure.

Daniel Reichner, M.D., F.A.C.S.