Routine pre-operative mammograms are recommended for patients who are 35 or older. After surgery, the usual recommendation is for a mammogram every 2 years after 50 years of age.

Saline implants placed under the muscle allow for a better mammogram picture than what was previously possible with silicone gel-filled implants, but an extra mammogram picture taken from a different view is advised to achieve about 85% of the accuracy achieved in patients without implants.

Deciding on the new size of breasts

In the past, the methods used to determine the new breast size were, surprisingly, often only dependent on the surgeon's sense of balance and esthetics.

Often, patients are first asked to buy a bra of the size they want to be. The bra should be selected by trying on bras while wearing a sheer blouse or T-shirt and stuffing the bra cup with tissues or other fillers. The patient then goes to the surgeon's office and puts on the bra. A temporary type of implant that can be filled with water is placed in the bra until the bra cup is filled to the desired volume. This volume is used along with measurements of the patient's chest dimensions to determine size. Adjustments can be made for differences in size between the two breasts, however, exact symmetry is difficult to achieve. The most important aspect is that the patient determines the breast size, with their physician's assistance.

Deciding on the position of implants and incision locations

The implant can be placed either above or below the pectoral muscle. Placing the implant above the muscle is feasible in women who have a moderate A-cup breast or larger. This can be done under local anesthetic with sedation ("twilight anesthesia"), and allows the patient to return to her usual activities a little faster than if it is placed below the muscle. The implants settle into position earlier than with under the muscle placement.

However, the under-muscle (sub-muscular) placement offers a significant advantage of lower "contracture" (hardening) rates and in very small-breasted women, saline implants have a risk of appearing rippling or "wavey" during movement if they are placed above the muscle. This is reduced when the implants are under the muscle. This approach requires a general anesthetic, results in slightly more post-operative pain, and takes a little longer to achieve the final esthetic result.

The choice of incision locations is based on keeping the scar as inconspicuous as possible. The armpit approach gives the least risk of significant scars, but requires specialized equipment and expertise.

Benjamin Gelfant, MD, 
in association with the MediResource Clinical Team