Breast augmentation: an overview and the factors that shape results

What is breast augmentation?

Breast augmentation usually refers to surgery that changes the size and contour of the breasts by placing implants. A 2014 review described breast augmentation as the most commonly performed cosmetic surgery ^[1]. A 2021 review also explained that implant placement is a plastic surgery commonly performed on women around the world, and that it is used both for cosmetic purposes and for reconstruction related to breast cancer treatment ^[2].

In a 2024 study analyzing statistics from an international society for 2010 to 2023, breast augmentation was among the top 5 procedures, along with liposuction, eyelid surgery, tummy tuck (abdominoplasty), and rhinoplasty ^[4]. In the same analysis, breast augmentation showed a decline for the first time, while implant removal was the fastest-growing procedure since 2015, increasing by 46.3% over the past 5 years ^[4].

Since implants were first developed in 1962, they have been improved many times, and 4th- and 5th-generation products are now in use ^[5]. A 2019 review explained that these advances have led to safer and more aesthetically pleasing results, while stressing that surgeons need to evaluate results critically and keep building up-to-date data ^[5].

Key elements of surgical planning

Surgical planning starts with choosing the incision site, the layer of the space in which the implant will be placed (pocket plane), and the various characteristics of the implant ^[1]. A 2014 review explained that analyzing the patient's physical characteristics and involving the patient in choosing the implant increases overall satisfaction and reduces requests for revision surgery ^[1].

A 2012 review stressed that breast augmentation should be viewed not as a single operation but as a process ^[3]. This process includes patient education, preoperative planning based on the condition of the tissue, precise surgical technique, and a defined postoperative care plan, and the review considered the parts outside the operation itself to be more important for improving results and reducing revision surgery and complications ^[3].

A 2021 review also summarized that decisions made before surgery and surgical technique are equally important, and that the choice of implant depends on individual preferences and anatomical conditions ^[2].

Problems that can arise after surgery

A 2014 review explained that techniques for positioning the implant and handling it under sterile conditions help prevent capsular contracture, implant malposition (an implant that sits in the wrong position), and other problems with shape ^[1]. This also means that these are complications that can actually occur.

Some changes appear over time. A 2017 review used the term "waterfall effect" for a condition in which only the breast tissue slides down and sags over an implant that stays in place, and considered that it occurs more often than expected, especially long after surgery ^[6]. The review explained that certain implants, as well as implants placed under the muscle that sit high on the chest, are more associated with this problem, and that it is more noticeable in women with differences or asymmetry in their musculoskeletal structure ^[6].

This condition is visible only when standing with the upper body uncovered, and many women were satisfied with it and did not need further treatment ^[6]. For those who want it corrected, fat grafting can be tried, but a breast lift (mastopexy) is usually needed, with or without replacing the implants, and in that case scars remain ^[6].

Recent safety issues

In recent years, concerns have grown about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII) ^[2]. In response, several countries, including Australia, Korea, and the United Kingdom, have introduced national registries to oversee the safety and quality of implant surgery ^[2].

A 2021 review summarized that BIA-ALCL is a medical challenge for which data on prevention, diagnosis, and treatment are lacking, and that BII is a highly controversial topic because no diagnostic procedures or recommendations have been established ^[2].

Noting that medical tourism, in which people travel abroad for surgery, is increasing and that safety regulations vary widely between countries, the 2024 statistical analysis recommended choosing a board-certified plastic surgeon with specialized training and experience and an accredited surgical facility ^[4].

Satisfaction and revision surgery

A 2014 review summarized that some patients need revision surgery but satisfaction is high ^[1]. A 2021 review also considered that short-term and long-term results are determined by various choices and differences, and that the risk of additional complications and revision surgery should be taken into account at the planning and surgical stages ^[2].

Implants are devices that remain in the body for a long time, so even after surgery, it is important to keep watching for changes in breast shape or any unusual symptoms. The sources reviewed are mainly international reviews and international statistics, so they cannot be applied directly to Korean patients, and results vary from person to person depending on body type and the condition of the tissue.

What to check during your consultation

Breast augmentation involves many choices, and a single decision can have a long-lasting effect. It is a good idea to check the following thoroughly during your examination and consultation.

• An assessment of your physical characteristics, such as the thickness of your breast tissue and the elasticity of your skin
• Why the incision site and the layer for the implant were chosen
• How the type, size, and shape of the implant are decided
• Complications such as capsular contracture, malposition, and sagging, and the chance of revision surgery
• The schedule for care after surgery and what to do if unusual symptoms appear