Dr. Steven Levine gives us the boob-job 411.
By: Hannah Baxter
In the world of plastic surgery, breast augmentation—otherwise known as a “boob job”—is consistently the leading procedure year after year. According to an annual report from the American Society of Plastic Surgeons, of the 1,811,740 cosmetic surgeries in 2018, over 17 percent (or 313,735) were breast augmentations. That number increased 4 percent from 2017 to 2018, and a whopping 48 percent from 2000.
Clearly, there is no lack of interest in increasing, refining, and perfecting the shape of one’s breasts (we were surprised by the amount of interest just in our office), but it is important to remember that this surgery, like all surgeries, is not to be taken lightly. Being an informed patient is crucial for safely achieving your desired outcome, in whatever form that takes. To help guide you through the process, from pre- to post-op and everything in between, we spoke with one of New York’s top plastic surgeons, Dr. Steven Levine. Keep reading for everything he had to say about breast augmentation.
BREAST AUGMENTATION BASICS
Whatever you want to call it—boob job, augmentation, mammaplasty, etc.—the procedure involves the careful placement of implants within the patient’s breasts. And while you might assume that most breast augmentations involve a significantly larger implant than the patient’s natural size, Dr. Levine assures us that that is very much the opposite of his aesthetic. “Most people I see want small augmentations.”
Breast implant size is measured in cubic centimeters, or CCs. He explains that the majority of sizes he uses are in the 140 CC to 250 CC range (for context, a 5 CC difference is roughly a teaspoon in volume). The correct size, which is altogether objective, is determined during your initial consultation.
“It’s all about implant selection and implant size,” he says. “I’m sure you’ve seen implants where people have sort of circular-looking breasts. What’s happening there is that the implant is overriding the actual breast tissue and giving you that circular shape. If I put in an implant that is smaller than the base width of the person’s breast, that means that they get to keep their natural breast shape for the most part, and all we’re doing is pushing things forward.” When done well, your breasts will retain their natural teardrop shape after the augmentation, regardless of size.
WHAT TO ASK AT YOUR INITIAL CONSULTATION
The primary focus is to discuss exactly how you want your breasts to look after the procedure, as well as what makes you unhappy about your natural size or shape. And while you may find it helpful to bring in a photo of your favorite celebrity to a haircut, Dr. Levine does not recommend doing so for an augmentation. “Frequently what they see in photos is either photoshopped or somebody is wearing a bra, so it’s not particularly helpful. But most women who come in have fantasized, at least somewhat, about what they’re going to look like after surgery. Whether it’s how you look when you get out of the shower or how you look in a certain type of dress or bathing suit, those are the things that are really helpful to convey.”
To help inform a patient who is considering various implant sizes, many doctors, including Levine, use 3-D imaging to provide a sample “after” image. “It’s a quick 3-D scan—it takes [about] a minute, and you can show someone a catalogue of implants. It’s really helpful to be able to show somebody how they’re going to look without clothes.”
3 DECISIONS TO MAKE PRE-SURGERY
Aside from the implant size, there are three other major decisions to make ahead of your breast augmentation: a silicone versus saline implant, the location of the incision, and placement of the implant above or below the muscle. The patient can weigh in on the type of implant, but the latter two will be primarily determined by your doctor.
1. SILICONE VS. SALINE
Do you want a silicone-filled implant, or a saline-filled implant? Both contain an outer silicone shell, but saline is filled with sterile salt water. Saline implants are inserted into the breast empty and filled once they’re in place. Silicone implants are pre-filled with silicone gel, which closely resembles the feel of human breast tissue and fat.
Says Dr. Levine, “I tell all my patients, silicone is just a better product; it’s a better device, and it feels more natural. They’re better built than they used to be, so in general I put silicone implants in almost everyone.” They also come in three different shapes and textures: smooth round, textured round, and textured anatomical teardrop. Textured implants have recently been linked to a very rare non-small-cell lymphoma, ALCL, which is why many surgeons, including Levine, no longer work with them. Silicone implants are also not FDA-approved for patients under the age of 22.
In terms of additional risks for each type, if a saline implant ruptures, you will know right away because the implant will deflate almost immediately. With silicone, you likely won’t know if they rupture unless you get a mammogram or an MRI. It won’t deflate as quickly, if at all.
2. INCISION LOCATION
There are four possible places for the incision. The two most common are the inframammary fold (the crease beneath the breast) or the periareolar, which is around the height of the areola. The third, which Dr. Levine says is the least common of modern accepted techniques, is the transaxillary—an incision in the armpit. The fourth is a belly-button incision—a procedure called a tuba—which can only be done with a saline implant (because it is empty and filled once in place).
“Ninety-five percent of my augmentations are done with a small, 3 cm incision in the inframammary fold,” says Dr. Levine. “It gives me the best visibility to put the implant in under the breast tissue, and nothing is more important than your surgeon’s visibility. You’re creating a space that didn’t exist, so the better visibility I have, the better results you get. It heals incredibly well, with all types of skin tones. It basically blends into the natural skinline.”
3. OVER OR UNDER THE MUSCLE
The majority of Dr. Levine’s patients have their implants placed below the muscle, especially if they don’t have a lot of breast tissue to begin with. “If you choose the position over the muscle, which is a perfectly acceptable thing to do, your chances of seeing and feeling that implant are very high.” Your percentage of body fat and breast tissue will help inform your doctor of the proper placement for your implants.
BREAST IMPLANT RISKS
As crazy as it may seem, there is a chance that your implant could migrate through the body due to a technical error during surgery. If they do so, it’s often downwards (thanks to gravity). The decision of where to dissect the tissue and create a pocket either above or below the muscle is the single greatest indicator of whether or not this complication will arise. As Dr. Levine explains, it’s not as simple as “making a big pocket and throwing an implant in there. There is finesse to this surgery.”
AFTER THE IMPLANTS ARE IN PLACE
Says Dr. Levine, “Whenever you put a foreign body in someone—this is true for a hip replacement, knee replacement, etc.—the body forms scar tissue around it. That scar tissue is called a capsule.” He explains that, for many people, “capsule” is a dreaded word and something to be avoided, but what you actually need to be wary of is a capsular contracture. This is when the capsule becomes thick and can displace or misform the implant, thereby causing pain and disruption of the normal contoured implant.
Luckily, given 21st-century advances in the procedure, these are now quite rare, although every patient will inevitably still create a thin capsule around their implant (like a shell). If you’re still wary, consider this: If you have a rupture of your implant, it will most likely be contained by the capsule, thereby preventing the silicone or saline from migrating elsewhere in the body.
DAY OF THE PROCEDURE
Dr. Levine works out of a private operating room at his Manhattan practice, which functions similarly to a hospital. After his patients change into a robe, he marks them standing up so he knows where to make the incisions and where the perimeter of the breasts naturally fall. A nurse will take your blood pressure, and you’ll meet with the anesthesiologist to go over your medical history. Once you’re in the OR, you’ll get an IV and be placed under a deep sedation, or general anesthesia, if you prefer. The procedure takes about an hour and a half, and then you’ll wake up in the recovery area.
“You feel like someone is sitting on your chest, and then it’s usually three to five hours after surgery that 50 percent of my patients tell me that they have almost no discomfort at all. The half that do have discomfort say it’s really rough for about 24 hours. [Instead] of narcotics, I usually tell people to take Valium, because it’s a muscle relaxant, and what you’re not liking is the fact that your muscle feels stretched. And just try not to use your arms.” That means giving yourself plenty of time to rest, so plan your work and social life accordingly. He also advises his patients to avoid the gym for three weeks.
Every surgeon has different after-care protocol, but Dr. Levine requires his patients to return one or two days after their procedure. “I’d have you come in another four times over the next six weeks or so to make sure that the implants are dropping the way I want.” Why so frequently? Because young, healthy women have well-developed pectoral muscles, and when the muscles are engaged, they will push the implant up. “Almost everybody has an implant that rides a little high to begin with. So frequently, I will give you what’s called a breast band—a piece of elastic that you put over top of your breast that applies a bit of counterpressure to your pec muscles.”
Everything will fully settle in about a year, says Dr. Levine. Three months is typically when the implants have migrated downward to the ideal location—the changes that happen during the remaining time can usually only be detected by a professional, if at all.
NO NEED FOR REPLACEMENTS
The old lore was that breast implants needed to be replaced every 10 years, but Dr. Levine explains that that is no longer true. “There is data that supports up to 30 percent of women get a second surgery within 10 years.” However, there is no additional research into why those women seek out another surgery. Some of them may have had children and just wanted a breast lift or decided they wanted bigger implants. “The health answer to ‘Doc, I’m 50 years old, I had these implants placed when I was 25, do I need to change them?’ I say, ‘Are they bothering you? No? Then you don’t have to change them.’”
Like other cosmetic procedures such as rhinoplasty or liposuction, the cost can vary greatly depending on where you live. For major cities like New York, Miami, and Los Angeles, the price can top $16,000 (although that also includes your initial consultation, pre- and post-op care, as well as follow-up appointments). For breast augmentation, like all cosmetic surgery, price should not be the deciding factor in choosing your physician. Quality of care, similar aesthetics, and safety are all priorities to consider, in addition to cost.
BREAST AUGMENTATION MYTHS
“I think the biggest misconception is that breast augmentation has to look fake, and that’s just not true. I think it can look augmented, if that’s the look that you’re going for, or it can look very natural. The second would be that you really do have a big say [in your augmentation]. The size that you choose is a huge factor in how you look afterwards. So if you don’t get good guidance in helping you choose [your] size, then you’re kind of stuck. It’s your body, and you should do whatever you want with it, but you want to make sure that you have the same aesthetic as whoever is operating on you.”
[Editor’s Note: As ever, we are not doctors or medical know-it-alls. And everybody is different, so make sure to check with a doctor before trying anything new.]