Before the initial plastic surgery consultation it is recommended to get as much information about the chosen (preferred) clinic, operation and particular doctor as possible. Nowadays you can use various available info sources like internet, popular science editions, former patients’ experience (impressions) that can provide you with details about plastic surgery. It would be the best to prepare all your questions beforehand in writing and share all the concerns and expectations during consultation. It is also very important that the interview and the surgery is done by the same surgeon who is supposed to present postoperative pictures of the patients who went through identical surgeries you are interested in. The ideal option is to get different plastic and aesthetic specialists (experts) opinions.
It is very important to specify all possible complications and limitations of the procedure to be performed in order to prepare the informed consent to operation. Choice problem
During the consultation one can decide about the implant manufacturer, size and method of its inserting and positioning. The physician will examine chest ratios as well as assess anatomical characteristics - specifically, the skin, muscle, fat, bone and supportive structures. The optimal implant size choice is based on chest volume, classical body ratios and manufactures specification tables.
Pic. 1 Sometimes in order to talk a patient out of extra large size implant choice is enough to let her weigh the desired one. For example 500 cc (ml) implant which corresponds size В bra/cup and weighs about a kilo. Now just imagine there are two of them.
In cases when large size breasts are a job requirement (business need) the surgeon has to make a written concession and perform a series (set) of surgeries with a few months interval to get the skin stretched over time to accommodate larger implant. In this regards the patient signs written informed consent which specifies that woman’s natural body ratios (about the possible body disproportion misbalance as a result of the operation…) may be not preserved. Placement of large implants is associated with the risk of skin nutrition disorders and can cause significant straining of the back. 
Pic.2. Подбор имплантанта. Иногда, для того, чтобы отговорить пациентку от излишних объемов, достаточно дать ей подержать изделие заказанного объема, внушительный вес которого скажет все сам за себя. Например, имплантант объемом в 500 мл, соответствующий 4 размеру чаши бюстгалтера, весит около килограмма. А теперь представим себе, что их два...
В случае если род деятельности обязывает женщину иметь большой объем груди, хирургу приходится идти на уступки и делать серию операций с интервалом в несколько месяцев, для того, чтобы растянуть кожу. При этом пациентка подписывает документ, в котором оговаривается, что естественные пропорции ее тела будут нарушены. Последствия установки больших имплантантов могут быть самыми неблагоприятными: нарушение питания кожи, большая нагрузка для позвоночника. 
Pic.3. 24 year old woman with mammary glands losing (loss) in volume after breast-feeding (post-lactation-hypoplasia)
One month after breast reconstruction by large, moderately textured 290 cc teardrop shape implants, placed
under the muscle (subpectorally) through an inframammary fold incision Indications: - Congenital, specific body built with small size breast.
- Personal dissatisfaction about the insufficient breast size
- Native or acquired breast asymmetry
- Size change, after breast-feeding period.
- Sagging of the breast (ptosis)
- Other breast surgeries and implant placements
- Conditions after breast enlargement using polyacrylamide gel (after its extraction)
- Breast enlargement related to the woman’s professional activities (show-business).
- Post breast removal state (following mastectomy for breast cancer).
Pic.4. 28 year old woman with mammary glands losing (loss) in volume after breast-feeding (post-lactation-hypoplasia)
5 months after breast reconstruction by large, moderately textured 315 cc tea-drop shape implants, placed
under the muscle (subpectorally) through an inframammary fold incision The type of inserted implants depends on whether a woman is going to give birth and breastfeed. Woman’s breast tissue should completely cover the implant with some spacing left between the implant and skin surface thus minimizing the risk of capsular contracture *. When the breast soft tissue covers the implants insufficiently it creates so called “stepped” deformity which represents an abrupt and unnatural transition (junction) between the chest and the upper pole of the implant. Another type of deformity known as “scalloping effect” occurs in case of insufficient amount of soft tissues along the internal radius of the mammary gland when the patient is in upright and bending position.
There are two main types of breast implants placement. 1 – Subglandular: This means placement of the implant above the pectoral muscles but below the mammary gland.
It is used in cases of sufficient breast tissue coverage is present (skin and cellulocutaneous tissue) along the upper pole of the gland.
Pic.5. 2nd Subpectoral, often referred to as "submuscular," subpectoral means placement of the implant below the pectoralis major muscle. In subpectoral placement, the implant is only partially submuscular due to the nature of the pectoral muscle under which the implant is placed. The lower half of the implant is not covered by muscle in this type of placement (Pic.5). This placement is also referred to as retropectoral.
Pre-operative examination
Mammography needs to be obtained prior to the surgery no matter the age in order to secure against negative consequences for just ultrasound examination (also known as sonography) may not be enough. Possibility to detect impalpable tumors using mammography is 100%, by Ultrasound – 50 %
Mammography is safe (harmless) diagnostic examination of the breast using low-dose x-rays
Because of the high rate of breast cancer, annual mammography screenings are recommended regardless the implant placement. Mandatory pre-operative blood testing is also taken to evaluate woman’s general health state.
Incisions placement:
There are 3 main and one historical type of implant placement incisions.
The incision is made in the inframammary fold below the gland, commonly known as the crease. (1) It should not be longer than 3.5 – 5 cm. The inframammary incision provides consistently excellent access to the area for breast implant placement with no trauma to the breast ducts or gland and a good visualization of the operative field. This also helps to maximally control intraoperative small vessels bleeding as an important condition to prevent postoperative complications. Breast-feeding is not affected by this type of incision. Both round and contoured (“teardrops”) can be conveniently inserted using this type in incision. Implants Placement Skin Incisions diagram 
Pic.6. - Inframammary fold incision – is made in the crease below the gland.
- The periareolar incision or around the areola at the junction of the dark and light colored skin of the areola.
- Axillary incision – is made in the hair bearing skin of the armpit.
- Periumbilical incision is made around the umbilicus (navel).
- Abdominal incision is made along the belly front wall skin excess removal (excision) line.
The incision around areola (2) is more aesthetically acceptable but less convenient to perform surgical approach (or more difficult for a surgeon to perform) This approach usually results in the least conspicuous scar but it is not recommended for women who are going to breastfeed as it may hurt milk ducts and interfere the with lactation. Axillary incision (3) is less commonly used and limits the plastic surgeon as far as control, symmetry, visualization and secondary access to the breast pocket. It is related to the long healing period and causes patients lots of inconveniences during first two postoperative weeks. However if this procedure is done properly, the resulting scar becomes practically invisible afterwards.
Psychological consultaion
Aesthetic or plastic surgery is necessary when a woman is constantly preoccupied with an existing cosmetic (appearance) defect and becomes more and more self-critical. This may result in the lack of self confidence (decreasing self esteem) and create communication problems with other people. Then she tries to disguise her defect by gesticulating, or various postures and by wearing different styles of clothing. Such patients have to limit their life style and try to avoid the situations when their drawback becomes evident. When this happens at a younger age it may have a negative impact for the future life and deprive from enjoying life. Life quality.
Breast augmentation patients do not have a poorer overall self-image, nor are they and with their appearance than other women
A person's self-image plays a key role in the development of personality. Young men and women with a subjective negative impression of their self image develop defense mechanisms to cope with low esteem. Later in life, they may request cosmetic surgery to "normalize" a perceived abnormal appearance
Surgery is performed under general anaesthesia and it takes between 1.5-2 hours. Pre-operative marking around the crease of the breast or ‘inframammary fold’ will assist in maintaining accuracy during breast augmentation. With the patient on her back the incision is made to create pocket under the muscle along the pre-operative marking. The wound closure is done with compressive antiseptic bandaging and specialized postoperative taping (Steri-Strips) 
Pic.7. Post-lactation breast involution, hollow breast deformation. Result of teardrop implant placement using submammary approach. On the next day after the surgery breasts will get new shape. Although both teardrop and round implants will remain expanded at the upper pole after a certain period of time especially in those cases when axillary approach is used. That is related to upwards muscle tightening and swelling.
May be appear somewhat swollen after surgery, but within a few weeks, the actual shape and size of your breasts will be apparent so you can begin to wear bras and clothes that you prefer.
The swelling gets resolved within 4- 8 postoperative weeks and the implant will slightly shift downwards. Patients can get out of bed in 24-48 hours after surgery but they can feel some weakness and discomfort. Possible after-surgery pain and nausea can be treated by appropriate antibiotics and pain medications. The average removal time for drains is 1-2 days but in some cases they can stay in place up to 7 days. Patients should stay in clinic for the first 24 hours and then come to the doctor to have the dressing changed.
Special compressive support bra is worn during 3-4 postoperative weeks after the drains and elastic bandaging are removed. It should be kept for 24 hours. In most cases self absorbable sutures are used that disappear within 7-10 days otherwise they will be removed once the scar gets healed.
Breast implants do not affect fertility, pregnancy, or a woman’s future ability to nurse, there are no evidences found to prove otherwise.
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