This procedure is distinct from “reconstruction” after an injury or removal of a breast. It is usually performed when the patient is dissatisfied with the size of her breasts, she may have been teased at school, or suffered negative comments from male companions, or may think she would “present” better in the job market if she had a better figure. As in all forms of aesthetic surgery, the surgeon must be aware of the patient’s expectations and psyche.

There are standardized implants approved by the FDA for use in the USA, but since doctors in North America are frequently called on to treat persons who have had surgery in other countries, (s)he should be aware that many types of material are in use, including balls of ivory, rubber, animal cartilage, and various types of sponge and plastic materials.

In North America the choice is essentially between Silicone and Saline implants.

• Saline implants: the container is a silicone elastomer (rubber-like) container filled with salt water, either prior to or at the time of implantation.
• Silicone gel implants: the container is rubberized silicone, but the contents are already in place at the time of implantation. The device has gone through a number of stages (generations) in development, each representing an improvement or a correction of a perceived deficit, the worst of which was leakage of contents that gave rise to an (unjustified) fear of cancer.

Since the procedure is performed to enhance appearance it is highly desirable that the incision should be of minimal size and the scar should not be noticeable. The prosthesis that is expanded prior to insertion (gel) will require a larger incision than that filled after positioning (saline). Surgeons are imaginative and many incisions to gain access for implantation have been contrived. Among these are:

• Periareolar: a two inch incision around the inner aspect of the areola.
• Inframammary (IMF): under the breast at the inframammary fold, hidden by the slightly pendulous breast, but large enough to insert a pre-filled prosthesis.
• Remote tunnelling: from any direction the surgeon chooses, umbilicus, armpit, etc., and performed either bluntly (blindly) or with the endoscope; the scar is remote at the expense of diminished surgical control.

The prosthesis may be placed:

• Subglandular: into the submammary space deep to the breast and superficial to the fascia over the muscle.
• Submuscular: deep to pectoralis major muscle, whose lower attachment to the ribs may or may not be severed.