Many changes have been made since its first introduction in 1991.  With slight variations and assorted improvements, this procedure is a wonderful option for the right candidate.  Some variations may be apparent from surgeon to surgeon, including anesthesia choices, preferred implant placements and preferred implant manufacturers.  You will have decided upon your anesthesia choice at the pre-operative appointment however, many surgeons do not offer a choice per se, and prefer their standard anesthesia method.  Please discuss this issue with your surgeon.

When you arrive at the hospital or private surgical center you will have your blood pressure taken, last minute medications given (such as anti-nausea, sedatives or other drugs), clinical before photographs are usually taken and other necessary preparations.  You will meet with your surgeon again and discuss any last concerns or determine any last size conclusions.  Your surgeon will more than likely mark your body and breasts with a surgical marker.  Such markings may look like any combination of markings in the diagram to the left.  Surgical markings vary from surgeon to surgeon or you may not be marked at all.   Some surgeons will mark their patients after they have been sedated rather than before; this is purely a preference as both are accepted.

You are then either brought to the pre-op room where a nurse may insert an I.V. (intra-venous) catheter which will be connected to a saline drip or brought directly to the operating theater.  If you were tended to in a pre-op room, after your I.V is inserted you will more than likely then be wheeled or allowed to walk into the operating theater. 

Once you are on the table the anesthesiologist or C.R.N.A. (certified registered nurse anesthetist) will attach adhesive patches with electrodes to your body which will be hooked up to the monitoring equipment to keep an eye on your breathing, pulse rate, blood pressure and other vital statistics.  Some surgeons may use a BiSpectral Index (BiS®) which is a sensor device placed on the forehead to monitor the brainwaves of the patient.  This is considered more accurate than traditional methods in determining the patient's specific anesthetic needs.  For more information please visit  

You may be given gaseous anesthetics or intra-venous anesthetics.  You may have a mask placed over your mouth and nose and be instructed to breathe deeply and count to 10, or you may be given the intra-venous medications (such as Fentanyl) and become very drowsy.  After you are sedated, you may either continue to receive intra-venous medications or be intubated for gaseous sedation (usually General).  Your vitals are noted again and the anesthesiologist or C.R.N.A. will then determine if you are fully sedated and ready for surgery.

Your surgeon and the operating technicians will then begin to scrub your abdomen and breasts thoroughly with a solution of polyvinylpyrrolidone and iodine such as Betadine™ solution to kill any surface bacteria.  This will lighten the surgical markings but will still be visible to the surgeon.  Your surgeon will then inject local anesthetics (and possibly epinephrine) into the incision area and breast area.  He or she will then make the incision in the umbilicus (navel) in the shape of a J or C and dissect the tissue around the umbilicus (left).

The dissected area around the umbilicus is depicted with maroon lines on the graphic to the right.  This enables enough room for the insertion of the endotube.

Next, your surgeon will then insert an endotube which will be used to tunnel from the umbilicus to the breasts.  Blunt dissection is used to separate the fat and skin from the muscle fascia from the navel entry point to beneath a predetermined point underneath the breasts.  This may include dissection of the pectoralis major from the chest wall for sub-pectoral implant positioning.  The dissected tunnel areas are depicted with red lines.

After and sometimes during the formation of the tunnels or general dissection, an endoscope, which is a small camera, will be inserted to ascertain the correct formation and placement of said tunnel.  Once the endoscope is inserted through the navel, your surgeon will be able to see via a monitor where and what has been done or what still must be done in order to achieve a properly placed tunnel and pocket.


After the tunnels have been successfully created either above or below the pectoral muscle (depicted as bright red tissue above the ribs), the endoscope is removed.   The diagram to the right depicts the endoscope being inserted through the tunnel, under the breast, to determine if the pocket will be centered.  This placement will be sub-glandular however it is just as easy to place the implant under the pectoralis major.  There will be a long fill tube attached to the valve through which it will be inflated.  Next, a tissue expander,  will be rolled up on both sides like a scroll so that it will easily fit within the endotube or the implant can be pushed up without the use of an endotube. 

The expander is either placed through the endotube or pushed through the abdominal tunnels on its own and situated under the breast tissue or pectoralis major muscle and breast tissue (diagram 1).  The expander is then inflated (diagram 2).

In this case the tissue expander has been placed in the sub-glandular position. Your surgeon fills the tissue expander with either saline (or air) using an electric liquid pump for saline or large syringe for either.  The tissue expander is filled approximately one and one-half (1 1/2) times the desired end volume.  The breast and connective tissues will slowly separate from the underlying muscle for sub-glandular placement or from the chest wall for sub-pectoral placement.  Your surgeon will may further situate the tissues with manual compression and by pushing the implant to each quadrant of the pocket.  This will create an oversized pocket necessary for natural movement.  After the tissue has been successfully expanded, the expander will be deflated and removed.  

Your surgeon will then insert a long fill tube into an empty breast implant and will then be rolled up just as the tissue expander was.  After the implant has been rolled up it will then be inserted into the end of the endotube or placed through the tunnel without the use of the endotube depending upon your surgeon's preferred method.  This way the breast implant will be inserted and placed just as the tissue expander was.  After the breast implants have been positioned inside their respective pockets either under the pectoralis major muscles or as in this case, in the sub-glandular position your surgeon will prepare to fill them.

Using a large syringe in combination with a closed delivery system, sterile saline is then injected into the breast implant.  Your surgeon will take note of the cubic centimeter (cc) volume of sterile saline which will have been determined beforehand for your desired size goal but may be altered intra-operatively.  Your fill tubes will be left in until the last phase of the surgery.

Subpectoral implant placement is depicted at the left bottom for comparison.

Your surgeon will then possibly elevate you to a sitting position to further determine if more saline is needed in either side, to check for symmetry and placement of the implants.  If the amount of saline is correct the fill tubes are removed by a gentle but firm tug of the tubes and the implant valve is then sealed.  If not, more saline is injected to create a symmetrical appearance.  All patients have a degree of asymmetry although some may have more pronounced imbalances than others. The diagrams depict a anterior-valved (the valve on the front, being up under the nipple area) breast prosthesis.

Your surgeon and his operating room staff will then perform an instrument and sponge check to determine all items are accounted for and the incision line is then sutured closed.  Some surgeons may insert a small latex or silicone drain or tube which may drain onto a thick gauze dressing.  Some surgeons may even use large "maxi pads" as drip pads.  Sometimes the drain is left in for 1 to 3 days and will be removed at your first post-operative check up.  

You are then possibly dressed in post-operative gear such as surgical bras and possibly further wrapped in an ace bandage.  Some patients may not be dressed in these garments for reasons such as in very small-breasted patients which may need gravity assistance for proper settling of the implants.  Some surgeons utilize waist wraps for further assurance of abdominal skin adhesion.  

Sometime towards the end of the surgery, and usually before you have been placed in your support garments the anesthesiologist will cease intravenous feed of the anesthetics or give you medications to reverse their affects and you are gently woken up and brought to the recovery area.  Please visit our recovery section for what to expect during the healing phase.




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(Updated on 02/23/10)
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