The Shape You Want. A More Confident You.

What Most Patients Experience

Many women postpone breast augmentation because they have heard stories about severe pain—particularly when implants are placed beneath the muscle. In my practice, that is generally not the experience. Most patients awaken feeling slight pressure or tightness rather than actual pain, and many are surprised by how comfortable their recovery is.

The reason is not simply stronger pain medication. The most effective way to reduce pain is to avoid creating unnecessary injury in the first place.

Numbing the Surgical Area Before You Awaken

Once you are comfortably asleep, I carefully numb the pectoral muscle and all the surrounding tissues with a long-acting local anesthetic. Because the entire surgical area is already numb, only a relatively small amount of anesthesia is required to keep you asleep and comfortable. You awaken quickly, with the operated area still profoundly numb.

Less Cutting and Less Tissue Trauma

Using GlidePlane™, I enter the natural plane beneath the muscle and create most of the implant pocket through gentle finger separation rather than sharp cutting. The muscle remains almost completely intact, with remarkably little bleeding or tissue trauma.

For most patients, surgery takes less than 30 minutes. Easier recovery comes from respecting the anatomy—not speed alone. Less cutting, gentler tissue handling and less time under anesthesia generally mean less inflammation, swelling and discomfort.

Staying Ahead of Discomfort

Pain medication is started while the surgical area is still numb, rather than waiting for pain to develop. This allows us to remain ahead of the discomfort as the local anesthetic gradually wears off. Most patients describe tightness or muscle pressure rather than significant pain, and the vast majority are back to work and many ordinary daily activities within just days.

Every Patient’s Experience Is Individual

No surgeon can promise that every patient will experience no pain whatsoever. However, after thousands of breast procedures, I have found that combining profound local anesthesia with an almost completely atraumatic pocket dissection makes breast augmentation far more comfortable than most patients ever expected.

Why I Usually Prefer a Periareolar Incision and Placement Beneath the Muscle

Breast augmentation can be performed through several different incisions: beneath the breast, around the edge of the areola, through the armpit or, in limited cases involving saline implants, through the belly button. Each approach has advantages and limitations. My preference for most patients is a carefully placed incision along the lower border of the areola, with the implant positioned beneath the pectoral muscle.

Why I Generally Avoid the Armpit Incision

The nerves responsible for nipple and areolar sensation travel from the chest wall in the back, through the armpit and around the outer side of the breast. An armpit approach begins in this same general region and requires the surgeon to work toward the breast along the path of the nerves.

The periareolar approach allows me to stay away from the principal nerve supply entering from the outer side of the breast.

Why I Do Not Use the Belly-Button Approach

Placing an implant through the belly button provides the least direct access to the breast and is generally limited to saline implants. It also gives the surgeon considerably less control over the inframammary fold—the important crease that defines the lower border of the breast.

Precise control of that fold is essential to creating a breast that looks natural both standing and lying down. I would not sacrifice that control simply to move the incision farther away from the breast.

Why I Usually Avoid the Incision Beneath the Breast

The inframammary incision provides access and is widely used. My concern is the resulting scar. The skin along the border of the areola almost always produces a finer, less conspicuous scar than the thicker skin of the chest and abdomen. When someone cuts their lip, they usually have a very fine, nearly invisible scar. When someone cuts their cheek, it’s very obvious. The difference between the areola and the chest skin is similar. When placed along the transition between the pigmented areola and the surrounding skin, the incision can become extremely difficult to see.

Why I Prefer the Periareolar Incision

The incision is placed along the lower edge of the areola—not through the nipple.

Using my technique, the lower portion of the areola is gently positioned against the chest wall while the breast tissue is lifted away. This allows me to pass around the breast tissue rather than cutting through the central breast, glands or milk ducts.

The principal sensory nerve approaches the nipple and areola from the outer side of the breast. My dissection is designed to remain away from that area while providing direct, controlled access to the exact plane in which the implant will be placed.

No breast operation can guarantee that nipple sensation or the ability to breastfeed will remain unchanged. However, this approach is specifically designed to preserve the nerves, breast tissue and ducts while placing the scar where it is most likely to blend naturally.

Why I Usually Place the Implant Beneath the Muscle

For most patients, placement beneath the pectoral muscle provides an additional layer of natural tissue over the implant. This helps soften the upper portion of the breast, conceal the implant edges and reduce visible rippling—particularly in thinner patients.

Choosing the Approach for Your Anatomy

The incision and implant position are ultimately selected according to each patient’s anatomy, tissue coverage, implant choice and goals. My objective is never simply to follow a standard formula. It is to choose the approach that produces the most natural breast with the least visible evidence of surgery.

Future Breast Imaging

Another important advantage of placing the implant beneath the muscle becomes apparent during future breast imaging. In my experience—and in my many conversations with breast-imaging physicians—mammograms and sonograms are easier to perform and interpret when the implant is beneath the muscle. The muscle creates a clear separation between the implant and the breast tissue, allowing the breast tissue to be examined more distinctly without the implant sitting directly behind it.

Silicone or Saline? Why I Have Always Preferred Silicone

Breast implants have existed since the late 1800s—a frightening thought when you consider how primitive anesthesia and surgery were by today’s standards. Even modern implants, however, became the subject of enormous controversy during the early 1990s, driven largely by negative news stories questioning the safety of silicone.

In response, the FDA required silicone implants to start over—as though they had just been invented—and undergo an entirely new approval process. A small number of experienced breast surgeons affiliated with academic institutions were selected as investigators to continue using and studying them under FDA supervision. At the time, I was Chief of Plastic Surgery at my hospital and already had a very active breast practice, so I was selected as one of those surgeons. I therefore continued working with silicone implants throughout the years when they were unavailable to most cosmetic surgeons.

In November 2006, after years of additional study, the FDA approved silicone implants once again for general cosmetic use. I did not suddenly begin using silicone implants at that point; I had been implanting and studying them throughout the entire period.

The Difference Is What Fills the Implant

So, what is the difference between silicone and saline? The first thing patients should understand is that there is no such thing as a breast implant without silicone. A saline implant is filled with sterile saltwater, but its outer shell is made from silicone. The part of the implant that touches your body is therefore essentially the same—the principal difference is what fills the implant.

How Modern Silicone Gel Is Different

Modern silicone implants contain a cohesive gel rather than the thinner, more liquid silicone found in implants manufactured between 1978 and 1986. That older silicone could escape from a damaged shell and disperse into the surrounding tissues. Today’s cohesive gel is designed to remain together, even if the outer shell develops a rupture. A rupture should be evaluated and the implant will generally need to be replaced, but it is a correctable implant problem rather than a danger to the patient’s general health.

How the Implants Feel

Silicone and saline implants can look very similar and weigh almost the same. The meaningful difference is how they feel. Through thin skin and breast tissue, a saline implant may feel more artificial—sometimes almost like a water balloon—and its edges or ripples may be easier to detect. A silicone implant generally feels much more like natural breast tissue, provided that significant scar tissue has not formed around it.

What Happens if an Implant Ruptures

If a saline implant ruptures, the breast visibly deflates as the saltwater is harmlessly absorbed by the body. If a modern silicone implant ruptures, the shape changes and the cohesive gel remains together within the implant pocket. In either case, the treatment is similar: the implant is removed and replaced.

Why I Have Always Preferred Silicone

Because silicone implants provide the most natural feel when someone touches the breast, I have always strongly preferred them for patients who are eligible—and most of my colleagues and patients make the same choice.

Choosing the Right Breast Implant Size

How I help you see the result before surgery—on your own body and in your own clothes

Your Size. Your Choice.

One of the first questions patients ask me is, “What size should I be?” My answer is simple: I’m not going to choose your breast size for you. I’ll use my experience to guide you toward implants that suit your anatomy and proportions, but the final choice should reflect what you want. You’re the one who will look in the mirror every day, and you should love what you see.

Why Cup Sizes and Implant Volume Don’t Tell the Whole Story

Cup sizes are almost meaningless. It’s all marketing... “I’m a size 2” used to mean something. Now marketers realize big clothes make small sizes fit. Pretty smart marketing! What one bra maker calls a C cup, another may call a D or even a DD.

Implant volume alone isn’t much more helpful. A 375 cc implant can look completely different on two women, because your result depends on what you already have plus what we add. Your height, chest width, breast tissue and overall body shape all affect how an implant will look on you. That’s why someone else’s photos, or a friend’s implant size, can’t reliably tell you what’s right for your body.

Measurements matter, but far less than what you see in the mirror. I don’t believe beauty can be picked from a chart or a catalog. Choosing an implant from measurements alone is like ordering a wedding dress online without ever trying it on, and an implant is a lot harder to alter afterward.

You Will See the Size on Your Own Body

About a week before surgery, you return for a sizing visit. Wearing a sports bra, we try on implant sizers. Your natural breast combined with the sizer provides a remarkably accurate preview of your eventual breast size and proportion. You stand in front of a full-length mirror, compare the choices and see for yourself what feels attractive and natural.

Bring the Clothes You Actually Wear

I encourage you to bring a small suitcase with a selection of the clothing you actually wear. Try the sizers on beneath a fitted white shirt, a dress, workout clothing, a bathing-suit top and a heavier sweater. The same breast size may look dramatic beneath one outfit and surprisingly subtle beneath another. You need to see how it works with your body, your wardrobe and your life.

My Guidance. Your Final Decision.

My role is to make certain the implant is appropriate for your anatomy, explain the differences between the choices and help you recognize when a size is beautifully proportioned—or when it may be too much. But the final decision is not based on an arbitrary cup letter, an internet photograph or my personal preference. It is made by you, looking at yourself in the mirror.

Implant Shape and Profile: What Really Creates the Look

Why I usually prefer Motiva Ergonomix®—and why the final choice is still yours

An Implant Is More Than a Label

Patients are frequently told that a moderate-profile implant looks natural, a high-profile implant looks artificial and a teardrop implant looks most like a natural breast. Those statements sound simple, but they are not necessarily true. After more than 30 years of breast surgery, I have learned that an implant cannot be judged by one label. Its appearance depends upon its volume, width, projection, gel characteristics, your existing breast tissue and the size and shape of your chest.

Profile Is About Where the Volume Goes

Profile describes how an implant distributes its volume. Comparing implants of similar volume, a moderate-profile implant is generally wider and projects less from the chest.

A high-profile implant places more of that volume forward within a narrower base.

That does not automatically make moderate profile natural and high profile artificial.

A high-profile implant may look beautifully proportioned on a woman with a narrow chest, while a wider implant could extend too far toward her sides. A moderate-profile implant may provide more width and cleavage on another patient but insufficient forward projection on someone else.

The correct profile is the one that places the desired volume where it best fits your body.

Shape Is Different From Profile

Traditional anatomical—or “teardrop”—implants were manufactured with a permanently defined top and bottom. They were intended to provide less fullness above and greater fullness below. The problem is that they remain teardrop-shaped even when a woman lies down, while a natural breast relaxes and spreads. If the implant rotates, its fixed shape can also distort the breast. Many of these implants therefore used a textured surface intended to hold them in position—another reason I did not favor them.

How Motiva Ergonomix® Moves With Your Body

Motiva Ergonomix® is something very different. It is technically a round implant, so it does not have the rigid top and bottom of a traditional teardrop implant. What makes it anatomical is the way its softer, responsive gel behaves inside the breast.

When a woman is standing, gravity allows the gel to slightly settle naturally, creating a gentle upper-breast slope with more fullness below. When she lies down, the implant becomes rounder and spreads more like natural breast tissue. It provides an anatomical result through movement, rather than forcing the breast into one permanently manufactured shape.

Why I Usually Prefer Motiva Ergonomix®

For most patients today, my starting preference is Motiva Ergonomix® because it combines the advantages I value: a smooth surface, a soft feel and natural movement, with an anatomical appearance that changes appropriately with the patient’s position. It offers the natural upper-breast slope many women want without the stiffness, orientation problems or fixed appearance of the older teardrop implant.

When You Prefer a Rounder, Fuller Look

That does not mean every patient must choose it. Some women specifically want greater upper-breast fullness and a rounder, more noticeable look. For them, Motiva Round may be the better choice. We can also adjust the profile to provide more or less width and forward projection while remaining within what fits the chest safely and beautifully.

My responsibility is not to impose my preferred appearance upon you. It is to explain what each choice will actually change, guide you away from combinations that do not fit your anatomy and help you achieve the result you find attractive.

Your Body and Your Idea of Beauty

The important point is this: do not allow an internet photograph, a profile label or someone else’s rule to choose your breasts. I will usually recommend Motiva Ergonomix® when the goal is the most natural look, feel and movement—but if you prefer a rounder or fuller appearance, we can deliberately select that instead. The final result should reflect your body and your idea of beauty, not a catalog description.

Understanding BIA-ALCL

Patients sometimes hear that breast implants can cause cancer and understandably become frightened. BIA-ALCL is not breast cancer. It is a very rare lymphoma that can develop in the scar tissue or fluid surrounding an implant. The risk has been linked overwhelmingly to implants with a rough, textured surface—particularly the Allergan BIOCELL® macrotextured implants recalled in 2019.

Why I Never Used Those Textured Implants

Textured implants were introduced with the promise that their rough surface would help hold the implant in place and reduce capsular contracture—the formation of excessive scar tissue around an implant. I never believed that the proposed benefit justified using a thick, aggressively textured shell, and I did not use those implants in my patients. When their association with BIA-ALCL became clear and these textured implants were removed from the market, none of my breast-augmentation patients had them.

Why I Usually Prefer Motiva Today

Motiva subsequently offered a fundamentally different approach. Its SmoothSilk® surface has an extremely fine, controlled microscopic architecture and was initially described by some as microtextured or nanotextured. However, it is classified by the FDA as a smooth implant, not as a conventional textured implant. It was designed to interact more gently with the surrounding tissues and has demonstrated an exceptionally low rate of capsular contracture—without using the aggressive macrotextured surface associated with BIA-ALCL.

Motiva implants are also exceptionally soft and natural in feel. In my opinion, they provide the benefit surgeons originally hoped to obtain from textured implants—a low probability of capsular contracture—while avoiding the type of rough surface that created the BIA-ALCL concern. That combination is why I usually prefer Motiva implants today.

The Judgment That Comes With Experience

This is an important example of why choosing a surgeon involves more than finding someone capable of performing the operation. Experience also means recognizing which innovations genuinely improve patient care and which do not provide enough benefit to justify their risks.

What This Means for My Patients

For my patients, the message is simple: I never used the macrotextured implants associated with BIA-ALCL. Today, I generally prefer Motiva because it provides a remarkably natural feel, a very low reported rate of capsular contracture and an FDA-classified smooth surface.

How the Leading Brands Compare

Patients frequently ask whether Allergan, Mentor or Motiva makes the “best” breast implant. For many years, the honest answer was that the differences between the leading manufacturers mattered far less than patients imagined. Allergan and Mentor both make excellent implants, and I have used both successfully throughout my career.

The Implant Must Fit the Patient

The implant’s label does not create the result. The surgeon must choose the appropriate size and profile, create a precise pocket in the correct anatomical plane and place the implant with as little tissue trauma as possible. An excellent implant that is poorly selected or improperly positioned will not produce an excellent result. The implant must fit the patient—not the patient fit the implant.

Why I Usually Prefer Motiva

Motiva, however, introduced the first difference between brands that I consider genuinely important. Its SmoothSilk® implant combines an exceptionally soft, natural-feeling gel with a highly controlled microscopic surface. The implant feels and moves more like a natural breast while demonstrating a remarkably low rate of capsular contracture—without using the aggressively textured surface associated with BIA-ALCL. That does not mean that Allergan or Mentor suddenly became inferior implants. Certain sizes, profiles or individual anatomical needs may still make one of them the better choice for a particular patient. But when the available options are equally suitable, I usually prefer Motiva because its softness, natural movement and SmoothSilk® surface offer meaningful advantages—not merely a different brand name.

After thousands of breast procedures, I do not select an implant because a manufacturer is fashionable or because a patient has seen its name online. I select the implant that will produce the softest, most natural and most reliable result for that particular woman. Today, that is most often Motiva.

What the FDA Documentation Reports

Motiva’s FDA documentation describes its SmoothSilk® surface as a controlled architecture averaging four microns and reports a 0.5% three-year rate of severe capsular contracture in primary augmentation patients.

Why the Results Are Less Predictable

Fat transfer sounds ideal: remove unwanted fat from one area and use it to enlarge the breasts without an implant. Unfortunately, the reality is less predictable, in some ways more of a problem.

The Limits of Transferred Fat

Transferred fat has no independent blood supply. Each fat cell must be placed close enough to living tissue to develop a new blood supply and survive. This places a practical limit on how much fat can be transferred safely during one operation. A modest amount of fat may survive successfully, but the body absorbs an unpredictable portion of what is injected. Attempting to create a substantial enlargement requires placing more fat than the breast tissue can reliably support. Some of that fat will not survive, and additional procedures may be necessary to approach the desired volume. Even then, the surgeon cannot offer the same control over breast size, projection and shape that a precisely selected implant provides.

The Mammogram and Biopsy Tradeoff

The fat that does not survive can form fat necrosis, firm lumps, oil cysts and calcifications inside the breast. These changes do not cause breast cancer, but they can resemble cancer on mammograms or sonograms. This can lead to surgical biopsies simply to prove that a suspicious-looking area is dead fat rather than cancer.

Having served as Director of a multidisciplinary Breast Center and worked closely with breast surgeons and imaging specialists, I place tremendous importance on preserving the ability to evaluate the natural breast clearly throughout a woman’s life. I do not believe it makes sense to perform an elective cosmetic procedure that intentionally distributes hundreds of small fat deposits throughout the breast and may make future imaging more complicated.

Why I Prefer an Implant Beneath the Muscle

A breast implant placed beneath the pectoral muscle is fundamentally different. The implant is positioned behind the muscle and clearly separated from the breast tissue.

The natural breast remains in front, where it can be examined with mammography and sonography. The implant also provides a known volume, predictable projection and dependable shape in a single procedure.

My Goal: Predictable Results and Lifelong Breast Care

My goal is not simply to avoid using an implant. It is to create the most natural, predictable result while making a woman’s lifelong breast care as straightforward as possible.

Where Your Surgery Takes Place

Breast augmentation is performed either in my fully accredited surgical facility attached to the office or in the outpatient operating facility of a hospital. I do not compromise on the environment in which surgery is performed. Our surgical facility is inspected annually and fully certified, with the equipment, safety standards and trained personnel necessary to provide careful hospital-level monitoring.

An Experienced Anesthesiologist Dedicated to Your Care

Your anesthesia is administered and continuously monitored by a board-certified anesthesiologist with decades of experience. While I perform the operation, the anesthesiologist’s sole responsibility is your comfort, breathing and safety throughout the procedure.

Comfortably Asleep and Breathing on Your Own

For most breast-augmentation patients, we use a short-acting anesthetic similar to the anesthesia commonly used for a colonoscopy. You are comfortably asleep but continue breathing on your own.

Local Anesthesia Before the Operation Begins

As soon as you are asleep—and before I begin the operation—I thoroughly numb the pectoral muscle and all the surrounding tissues with a long-acting local anesthetic. Because the surgical area is already numb and your body is not responding to pain, very little additional anesthesia is usually required to keep you asleep and comfortable.

Waking Up and Returning Home

The combination of profound local anesthesia, minimal surgical trauma and an operation that generally takes less than 30 minutes allows most patients to awaken quickly and comfortably. Most describe tightness or pressure rather than significant pain and are awake and able to leave for home within approximately an hour.

A Safe, Controlled and Reassuring Experience

My goal is to make the entire experience feel safe, controlled and reassuring: an experienced board-certified anesthesiologist, an annually inspected accredited surgical facility and an approach designed to minimize both anesthesia and surgical trauma.