Breast Augmentation Los Angeles

Breast augmentation is performed to improve self-confidence or decrease symptoms of gender dysphoria for cisgender, transgender, gender non-binary, and gender non-conforming individuals. There are multiple methods for augmenting breasts. The most common method is through the use of implants. This technique often provides the most reliable permanent increase in volume. It is possible to perform breast augmentation with fat grafting, but the effect is often less than using implants and can decrease with time.

Dr. Mittermiller

About Dr. Mittermiller

Dr. Mittermiller is a plastic surgeon who is passionate about aesthetic surgery and gender affirming surgery. He was an undergraduate student at Yale University, went to medical school at UCSF, and completed a 7-year plastic surgery training program at Stanford University.

Dr. Mittermiller’s approach to breast augmentation

Breast augmentation is important for increasing confidence and affirming one’s gender. It helps people feel comfortable in their own skin and out in public. There are some aspects of breast augmentation that require significant input from the patient. These involve desired breast size and location of the incision. Dr. Mittermiller takes care to provide an individualized approach to each patient and consider their individual needs and desires.

Introduction

What is breast augmentation?

Breast augmentation is a surgical procedure that is performed to increase the volume of the breasts.

Who is a candidate for breast augmentation?

Individuals who are hoping to increase breast size and who are healthy enough to undergo general anesthesia are candidates for breast augmentation.

Certain individuals are better suited than others for breast augmentation. Patients with ptotic, or “droopy,” breasts may not be great candidates for augmentation alone since augmentation does not shrink the skin envelope. In scenarios where patients have ptotic breasts, they may require a breast lift, or mastopexy, with or without breast augmentation.

What are the benefits of breast augmentation?

Breast augmentation changes the shape and appearance of the chest to create a more proportional contour. The procedure allows for increased cleavage and breast projection. It can restore lost volume that occurs with aging or following pregnancy. It increases clothing options by improving one’s confidence in bathing suits and under garments.

What happens during a consultation?

During a consultation for breast augmentation, there will be multiple questions about your health. You will be asked about other medical conditions, medications that are being taken, allergies to medications, and any prior operations. Dr. Mittermiller will want to have a full picture of your health and surgical history before offering additional operations.

With regard to the actual surgery itself, Dr. Mittermiller will discuss sizes for implants and locations for incisions. You will discuss the risks of breast augmentation, the surgery itself, the recovery, and the long-term results of the operation.

Surgery

How is a breast augmentation performed?

Breast augmentation is performed by creating a pocket between the natural breasts and the chest wall. Once this pocket is created, the implants will be inserted and the entry point will be closed with sutures. There are multiple different techniques for approaching the pocket and placing the implants. These approaches are described below.

Inframammary incision (underneath the breast)

An inframammary incision describes an incision that is placed at the junction between the lower portion of the breast and the chest wall. This incision is well hidden within the natural crease in this location.

Periareolar incision (around the nipple-areola complex)

A periareolar incision is one that is designed at the border between the areola and the breast. The areola is the colored portion of skin around the nipple. This type of incision often blends well since it is placed at the junction of two different types of skin.

Since the size of this incision is limited by the size of the areola, the volume of the implants may be limited with this approach if silicone implants are desired. Larger implants can be placed with saline implants since they are filled after being placed through the incision.

Axillary incision and umbilical incision

Axillary incisions are placed within the arm pits. Umbilical incisions are placed at the belly button. These types of approaches can help to further hide the scars during breast augmentation, but they can be difficult and time consuming.

Where are breast implants placed?

Breast implants can be placed in a few different locations in the chest. The terms commonly used to describe the location of these planes are subglandular, submuscular, and dual plane.

Subglandular

Placing an implant in the “subglandular plane” means that the implant will be placed underneath the breast gland and on top of the major muscle of the chest (pectoralis major). This type of placement is also commonly referred to as being “above the muscle.” The benefit of placing an implant in this location is that some people consider it to be the most natural location of the implant. With breast augmentation, one is hoping to increase the size of the breast gland. Therefore, it would make intuitive sense to place the implant near the location of the natural tissue.

One of the downsides of placing an implant in the subglandular position is that the implant can be more easily seen or felt if there is not enough natural breast tissue to cover the edges of the implant. Historically, this position of implant placement has also been thought to more readily contribute to the complication of capsular contracture. Capsular contracture is where the body forms a firm, thick scar around the implant, which can cause the implants to feel firm, can be painful, or can distort the appearance of the breast.

Submuscular

Placing an implant in the submuscular plane means the implant will be placed entirely underneath the major muscle of the chest (pectoralis major). This type of placement is commonly referred to as being “under the muscle.” This position allows for more soft tissue to cover the edges of the implant and for patients with minimal fat tissue, this can better hide the edges of the implant.

With implants above a certain size, it is not possible to place the implants entirely submuscular in one operation. The muscle creates a tight pocket and implants above a certain size will not fit entirely within that pocket.

Dual plane or partial submuscular

The dual plane approach to placing implants means that the top portion of the implant will be covered by the major muscle of the chest (pectoralis major) and the bottom portion of the implant will be covered by the breast gland. This type of placement offers the benefit of better coverage of the top part of the implant while not limiting the size of the implant that can be used.

The downside of placing an implant in the dual plane or partial submuscular location is that activating the muscle of the chest can cause the implant to move. This type of motion is referred to as an “animation deformity.” This type of motion does not occur normally with breasts, so the result is an unnatural appearance of the breasts when using the muscles of the chest.

What are the types of breast implants?

Breast implants are most commonly created with a silicone shell and varied fill material. The fill material is either saline liquid or silicone gel.

Saline breast implants

Saline breast implants have a silicone shell that is filled during the operation with saline liquid. There are a few advantages of saline breast implants. Smaller incisions can be used with saline implants since the implant is filled after the implant has been placed through the incision. If the implant ruptures, it will be immediately, easily identifiable because the implant will deflate. This can also be a downside of saline implants since a rupture warrants more expedited implant replacement in order to maintain symmetry. These implants are more likely to create ripples that can be seen or felt through the skin in comparison to silicone implants.

Silicone breast implants

The silicone gel used in modern implants is more firm than prior implants and is commonly referred to as a “gummy bear” implant. This term comes from the similarity to the feel of a gummy bear and the fact that when the implant is cut in half, it maintains its shape, similar to that of a gummy bear. Silicone breast implants are often preferred over saline breast implants due to their more natural feel. The downside of silicone breast implants is that they often require a larger incision in order to have them placed.

What are the risks of breast augmentation?

Breast augmentation is a relatively safe procedure. However, there are multiple complications that can occur to the implants and breasts themselves. These complications are listed below.

Capsular contracture

Capsular contracture describes a condition where scarring occurs circumferentially around the implant and causes a constriction on the implant. A capsular contracture can result in breast pain and can cause visible deformities of the breast. There is often very little that can be done to help reduce the degree of capsular contracture.

Infection

Infection is a rare complication for breast augmentation. When it does occur though, it may require removal of the breast implant.

Implant rupture

Implant rupture was previously more of a concern with the older generation implants. When this occurred, it leaked liquid silicone into the body. This silicone had a tendency to migrate. Newer implants, which are often described as “gummy bear” implants have an inner gel that is cohesive and less likely to migrate through the body.

Implant rupture can occur with saline-filled implants. When this occurs, the implant deflates and will need to be either removed along with the contralateral implant or replaced to maintain symmetry.

Recovery and Results

How is the recovery from breast augmentation?

Breast augmentation is usually performed on an outpatient setting. This means you will go home on the same day as the operation. Ideally there should be a friend or family who can stay with you the first night in case you need assistance. People can usually return to work around a week after the operation and it is often best to avoid any strenuous activities for the first few months.

Is there scarring?

Any surgical procedure will leave a scar. They key is to hide the scar in ways where they are less noticeable. See the section above to review locations for the incisions that are used during breast augmentation.

How long do breast implants last?

Breast implants can have variable lifetimes. It is often suggested that implants can last for 10 years. This is an average number that is frequently quoted. This means that some implants will need to be exchanged or removed before 10 years and some can last far beyond 10 years.

Frequently asked questions

How much do breast implants cost?

According to a 2022 article by RealSelf, the average cost of breast implants is $6,375 and the cost ranges from $3,350 to $9,300.¹ These costs vary due to a variety of factors including location, surgeon, prior operations, breast asymmetries, and approach.

Transgender Breast Augmentation

Who is a candidate for transgender (MTF) breast augmentation?

In addition to the components for candidacy listed above, the World Professional Association for Transgender Health (WPATH) lists the following recommendations for transgender breast augmentation²:

1. One referral for breast augmentation/
2. Persistent, well-documented gender dysphoria;
3. Capacity to make a fully informed decision and to consent for treatment;
4. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
6. Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

How long do I need to be taking hormone therapy prior to surgery?

The general recommendation is that patients be on hormone therapy for at least 12 months prior to undergoing gender-affirming breast augmentation. The hormones will cause the breasts to increase in size. It is important for the breasts to stabilize in size prior to undergoing MTF breast augmentation. This allows you and the surgeon to best match the ultimate desired breast size.

If there is an increase in breast size that then stops before 12 months, it may be appropriate to perform MTF breast augmentation at that time. On the contrary, if the breasts are continuing to increase in size after 12 months, then it may be better to wait even longer than 12 months.

Studies have been performed looking at breast growth while on hormone therapy. Specifically, one study suggested that the majority of breast growth occurs during the first 6 months on hormone therapy. There continues to be growth during the subsequent 6 months, but this is significantly less than during the first 6 months.³

How much does it cost to undergo gender-affirming breast augmentation?

Breast augmentation is commonly a covered service through insurances for gender-affirming care. This is most often performed for transgender (MtF) breast augmentation however it can also be performed for non-binary and gender non-conforming individuals. It is important to see a provider who is comfortable providing gender-affirming surgical services.

If the procedure is not performed under insurance coverage, then the costs are similar to those listed above for cisgender individuals.

How do I find the best breast augmentation surgeon near me in Los Angeles, California?

All prospective patients should research potential surgeons prior to undergoing an operation in Los Angeles. Patients can start be checking the education and training history of these surgeons. Breast augmentation is a procedure most commonly performed by plastic surgeons in Los Angeles, although there are surgeons who were trained in other specialties who are now placing breast implants. You will want to find a surgeon who is comfortably with the process of breast augmentation and who is capable of walking you through all the necessary decisions.

References

1. How Much Does a Rhinoplasty Cost?  (2022). https://www.realself.com/surgical/rhinoplasty/cost. Accessed 8/5/22 2022
2. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. https://www.wpath.org/publications/soc
3. de Blok CJM, Klaver M, Wiepjes CM, Nota NM, Heijboer AC, Fisher AD, Schreiner T, T’Sjoen G, den Heijer M (2018) Breast Development in Transwomen After 1 Year of Cross-Sex Hormone Therapy: Results of a Prospective Multicenter Study. J Clin Endocrinol Metab 103 (2):532-538. doi:10.1210/jc.2017-01927 https://www.ncbi.nlm.nih.gov/pubmed/29165635