Breast augmentation has become more common due to the increased safety and the reliability of implants. Patients have become more focused on optimalization of results in individual cases. This article addresses specific concerns of a sophisticated patient population. The author's experience is based on a busy aesthetic surgery practice in a major metropolitan area.

Site of Incisions
Options for incisions of breast implants have been clarified and after the recent approval of the Federal Drug Administration (FDA) of saline filled implants. The approve sites for placement of implants include: axillary, periareolar, and inframammary placement. The FDA specifically eliminated placement of implants via peri-umbilical approaches and to individuals under 18 years of age. Incisions are approximately 4cms in length and are placed in skin in creases when feasible.

Axillary
Axillary incisions are not on the breast. They are hidden in a crease in the armpit. The scars are only seen when the arms are raised. When I utilize this technique, I employ round implants, which are placed sub-muscularly. It should be noted that with this approach the implants initially are much higher than with other approaches. It takes approximately 12 weeks for the implants to drop into their final position. Massage to facilitate proper displacement of the implants post-operatively is absolutely imperative.

Periareolar
A small periareolar incision may be used for subglandular or submuscular placement of round or shaped implants. The incision should be made inside the pigmented region of the areola, not at the junction of the pigmented portion of the areola and skin. Periareolar incisions may be difficult, if not impossible to perceive postoperative. Some periareolar incisions, however, may heal with a widen scar that increases their visibility. This is a small minority of cases. In cases with visible scarring, I have found it useful to revise the scar or tattoo the scar to match the areola. Incidence of decreased sensation with this approach is comparable to other approaches.

Inframammary
A small incision in the crease of the fold under the breast may be employed for placement of implants. These small incisions, approximately 4cms in length are difficult to perceive under optimal conditions. Implants may be placed above or below the muscle via this approach. This is the most commonly utilized approach for placement of implants today.

Comparison
The scars, under optimal conditions, are relatively comparable. Incision sizes are also comparable for the three approaches listed above. The final decision really comes down to where the individual would like the small scar.

Submuscular versus Subglandular
Differences between the two procedures are maximized in thin individuals. Implants placed in the subglandular plane tend to sit slightly lower then submuscular implants. Submuscular placement makes the transition from the implant in the superior pole of the breast more difficult to perceive.

Shaped Implants versus Round Implants
Shaped implants are fuller inferiorly and narrower superiorly. The shaped implants provide slightly less cleavage and a different final appearance with the majority of volume in the inferior half of the breast.

Conclusion
As experience with breast implants now spans 40 years, we have become more focused not only on merely achieving an increase in size, but refining the shape of the breast to match the individual's desires and needs.