Breast implants are introduced into the patient’s breasts through small incisions located on or near the breasts. The most common sites for the incisions are in the crease underneath the breast (inframammary fold), around the bottom edge of the areola and through the armpit (axilla).
These incisions are generally about 1.5 to 2 inches in length for saline implants and around 30% to 40% longer for silicone gel implants. This is primarily because saline breast implants are initially filled with air, which is taken out prior to insertion. This capability allows the surgeon to flatten the implant and roll it up so that it can fit through a smaller opening than if it was completely filled to size. Following such an insertion, the saline breast implant is inflated through a small fill tube until it reaches the desired volume while it is in the pocket.
On the other hand, silicone gel breast implants are pre-filled and their size cannot be adjusted to accommodate a smaller incision. Hence, silicone implants need to be pushed in through an opening which requires a slightly longer incision. The length of the incision primarily depends on the size of the implant that the patient has opted for: the larger the chosen implant, the longer the incision. If the incision is not long enough, excessive force is required to push the implant into the pocket. This can damage the implant resulting in either an immediate rupture or weakening of the implant shell predisposing to premature deflation.
After the incision is made, a tunnel is then created, reaching up to the desired position of the breast implant pocket, which is either on top of or underneath the chest (pectoralis major) muscle. Most experienced breast implant surgeons prefer implant placement under the muscle because of numerous advantages for the patient. Once an adequate sized pocket is created, the appropriate breast implant is slid in through the tunnel into the pocket and positioned with care. When every aspect is satisfactory, the surgeon closes the earlier created tunnel with several layers of sutures.
Smooth implants slide into the pocket easier than textured implants; therefore, the incisions for smooth implants can be slightly shorter. Some surgeons chose to use a proprietary funnel to insert their implants, which theoretically could reduce the risk of contamination of the implant during the insertion process. This does, however, increase the cost of the procedure, as the funnels are somewhat expensive.
It is not unusual for the surgeon to have more than one implant size available at the time of surgery. In this situation, after the pocket is created, an implant sizer is inserted and inflated with air. The sizer is basically an empty implant around the size of the implants that are available. By using a sizer before selecting which implant to use, the surgeon has a better idea as to which implant will achieve the desired cup size.
Following insertion of both implants, the patient is typically placed in a sitting position to assess implant position and symmetry so that any adjustment can be made prior to closure of the incisions.