Category Archives: Augmentation Decision

Alternatives to Breast Implants: Lifts and Fat Transfers


When considering cosmetic breast augmentation, women typically consider implants as their main option. However, there are several other procedures to change how your breasts look that may have fewer risks and complications compared to breast implants. These alternatives include breast lifts and fat transfers.

Breast Lifts

Breast lifts, clinically called a “mastopexy,” raise and reshape the breasts. Surgeons remove extra skin and tighten surrounding tissue. In addition to reshaping the breasts, a lift can reposition the nipple and reduce the size of the areola if it has become enlarged over time. Many women choose to get breast lifts to improve the stretching or sagging of their breasts that could have been caused by pregnancy, weight fluctuations, and simple gravity. A breast lift alone cannot make breasts larger, but breasts will look fuller and more perky after the procedure. 1

There are four types of breast lift techniques, which depend on breast and areola size and shape, degree of sagging, amount of skin that must be removed, and the elasticity of skin. For women who have smaller breasts or minor sagging, a crescent or donut technique can be used to create small incisions around the areola. For women who have larger breasts and more severe sagging, surgeons will need to create multiple incisions, either around the areola and vertically down the middle of the breast (a lollipop technique) or including a horizontal incision along the breast crease (an anchor technique). 2

Swelling and bruising will last for about two weeks, and numbness may last up to six weeks. Final results of breast lifts will appear over the months following the procedure as the breasts settle into their new shape and position. Results of a breast lift procedure are long-lasting, especially with a healthy lifestyle. Women with smaller breasts will likely have results that last longer than women with larger breasts. It is also important to note that the cosmetic appearance of the breasts can change due to pregnancy, breast feeding, and significant weight changes that occur after surgery. Therefore, women should consider whether they are planning a pregnancy in the near future before having a breast lift. 3

Risks of Breast Lifts 

When considering a breast lift, it is important to consider the risks of the procedures in addition to the benefits. For breast lift procedures, the most common risks include changes in nipple or breast sensation, asymmetrical breast shape, and partial or total loss of the areola.1 Less common risks that some patients experience are bleeding or hematoma formation, infection, poor incision healing, fat necrosis (fatty tissue around skin may die), and fluid accumulation. Although patients will have scars from a breast lift procedure, many notice that some scarring is hidden in natural contours of the breasts and that scars improve over time, typically within one year.3 As with any cosmetic procedure, some patients may be unhappy with the final result. Your chances of getting the results you want will be better if you choose a board certified plastic surgeon with a lot of experience doing breast lifts without breast implants.

Some plastic surgeons recommend getting both a breast lift and implants to get the best cosmetic result. However, that means patients will face the risks of the lift and the additional risks of the implants. While the breast lift procedure alone is safer than getting implants, there is still a lack of safety data and research on breast lifts to know how often complications occur in the solo procedure. The skill and experience of the plastic surgeon makes a big difference.

Fat Transfer

Fat transfers may be a good option for women who want to have more natural looking, fuller breasts without implants. Fat transfers use liposuction to remove fat from other parts of the body and insert it into the breasts. Fat for liposuction is typically taken from areas such as the back, thighs, abdomen, and buttocks. 4 Next, the fat cells are processed into a liquid so they can be injected into the breast area. 5 The surgeon will slowly inject the fat liquid to multiple areas of the breast until the desired breast size is achieved. Since the procedure uses body fat from the patient, thin women may not be good candidates for this procedure. Because the injected fat does not contain its own blood supply, only a small amount of fat can be injected at a time. Patients should not expect to gain more than one cup size. 

Patients typically notice improvement right after the procedure, but the final results will appear one year after surgery when swelling has gone down. Multiple follow-up fat transfer procedures may be necessary to maintain the shape of the breasts. In many cases, fat that has been injected into the breasts may be reabsorbed by the body over time, move to other parts of the body, or die, causing breasts to lose volume.5 Therefore, surgeons may recommend follow-up sessions to repeat the procedure, which may be expensive and is an important factor to consider.

Risks of Fat Transfers

High patient and surgeon satisfaction as well as low complication rates have been reported for fat transfer procedures, but outcomes vary greatly based on the surgeon as the procedure is not yet standardized. 6, 7 The most common complications from fat transfers include development of cysts (lumps) or fat necrosis, which is when the transferred fat dies and is reabsorbed by the body. 8 Fat necrosis is more common when a large amount of fat is injected. This usually does not need to be treated, as the body takes care of the dead cells on its own. 

Other less common complications can include infection and calcification of the fat.8 Like fat necrosis, these complications are more common when a large amount of fat is injected. Because the injected fat does not have its own blood supply, too much injected fat may lead to microcalcifications, which is when the fat hardens. These calcifications are usually harmless, but they may look like breast cancer on a mammogram, resulting in stressful and expensive breast biopsies.

Bottom Line

Despite risks, lifts and fat transfers appear to be safer than breast implants. Breast implants are not lifetime devices, and women should expect additional surgery to replace them every 10-15 years if not more often. Health insurance often does not pay for removal or complications for augmentation patients and never pays for replacement of cosmetic implants. The high cost of these additional surgeries, as well as the common complications from implants, make lifts and transfers a safer option for many patients.

While breast lifts and fat transfers provide alternatives to breast implants for cosmetic breast enhancement, patients must consider the risks of both procedures before choosing to undergo surgery. More long-term research is needed to confirm the safety and effectiveness of both procedures.

When deciding whether or not to undergo cosmetic breast augmentation, it is important to weigh the risks and benefits of each procedure with a highly skilled, experienced surgeon who is board certified in plastic surgery, so you can make a decision that is right for you. 

The Breast Implant Working Group’s Breast Implant Black Box Warning and Patient Checklist

The Working Group consists of Dr. Diana Zuckerman, Dr. Scot Glasberg, Dr, Alan Matarasso, Jamee Cook, Raylene Hollrah, and Karuna Jaggar.  We are urging the FDA to include a black box warning about the risks of cancer and other serious health problems for women considering breast implants.  We are also urging the FDA to require a Checklist to be read and signed by all patients, to make sure they are aware of the many risks of breast implants.

See the checklist here or below:

BLACK BOX WARNING: Breast implants can cause a type of cancer of the immune system called BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma).  People with silicone or saline breast implants have developed this rare disease, which can be deadly if not treated early. Almost all women who have developed BIA-ALCL have had textured breast implants or expanders at some point.

Several studies also suggest that women with breast implants have a small but significant increase in their chances of developing certain autoimmune or connective tissue diseases. Women with silicone gel or saline breast implants have reported symptoms that are sometimes serious, such as joint or muscle pain, fibromyalgia, mental confusion, and painful skin conditions.  Many of these symptoms improve partially or completely when their breast implants are removed and not replaced.

BREAST IMPLANT PATIENT/DOCTOR CHECKLIST 

The purpose of this checklist is to provide information for patients considering breast implants for augmentation or reconstruction, so that they can carefully weigh the risks and benefits of breast implants and make the decision that is right for them. The risks in this checklist are in addition to common surgical risks such as infection, necrosis (skin death), or problems with anesthesia.

After reviewing the Patient Information Booklet, please read and discuss the items in this checklist with your surgeon. You should not initial or sign the document, and should not undergo the procedure, if you do not understand each of the issues listed below.

How long do breast implants last? I understand that breast implants are not expected to last for the rest of my life.  Implants may rupture or leak at any time, and that is more likely the longer you have them.  In addition, it is likely that I will need other surgeries related to my breast implants over the course of my life.  If I am a cosmetic surgery patient, my health insurance policy may refuse to cover these surgeries. These additional surgeries and procedures can include implant removal with or without replacement, muscle and tissue repair, scar revisions, MRI diagnostic exams, or other procedures. I understand that undergoing multiple surgeries may increase my chances of permanent breast deformity.

Patient Initials____________

Who shouldn’t get breast implants?  I understand that the safety of breast implants was never studied for people who have autoimmune symptoms or diseases, or a family history of those diseases. Breast implants may be more likely to cause serious health problems and symptoms for these people.  In addition, breast implants may not be safe for anyone with a weakened immune system or certain genetic risk factors that have not yet been identified.

Patient Initials____________

Chemicals and Metals in Breast Implants:  I understand that all breast implants contain chemicals and small amounts of heavy metals that may cause health problems. I understand that most of these chemicals are confined to the shell of the implant or stay inside the shell.  However, small quantities have been found to diffuse (bleed) from or through the implant shell, even if the implant is intact and not ruptured.

Patient Initials____________

Rupture and Leakage:  I understand that the longer my breast implants are in place, the more likely they are to rupture, especially after the first few years. When a saline implant ruptures, it usually deflates quickly. When a silicone gel implant ruptures, I may not notice any changes and the rupture may not be detected by my doctor or by mammogram, MRI, or sonogram. I understand that an MRI is recommended for silicone gel breast implants 3 years following surgery and every 2 years after that to check for silent rupture, and that these MRIs often are not covered by health insurance. I understand that silicone may migrate from the implant into nearby tissues such as the chest wall, lymph nodes, upper abdominal wall, and into organs such as the liver or lungs where it cannot be removed. Since migrated silicone can cause health problems, it is currently recommended that any ruptured silicone implant should be removed as soon as possible. I understand that, if needed, treatment of these conditions may be at my own expense and not covered by insurance or a manufacturer warranty.

Patient Initials____________

BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma):  I understand that there is a small risk for me to develop BIA-ALCL, a cancer of the immune system. BIA-ALCL is a type of lymphoma that develops on or around the scar capsule that surrounds the breast implant. I understand that the symptoms of BIA-ALCL include breast swelling, lumps, pain, and asymmetry that develop after surgical incisions are completely healed, usually years after implant surgery.

Treatment for BIA-ALCL includes removal of the implant and scar capsule, and, if not treated early, may include chemotherapy and radiation. This diagnosis and treatment may be at my own expense and is not always covered by insurance.

Patient Initials________________

Symptoms of “Breast Implant Illness:” I understand that because of the lack of long-term safety data, we are still learning about the health problems that result from breast implants.  To date, thousands of women have reported to the FDA or to researchers that they have experienced serious health problems that several studies have linked to their breast implants. This may occur either immediately after getting implants or years later. These often include symptoms such as: joint and muscle pain or weakness, memory and concentration problems, chronic pain, depression, fatigue, chronic flu-like symptoms, migraines, or rashes and skin problems.

Several studies of women with breast implants have shown that they are significantly more likely to be diagnosed with one or more of the following diseases compared to other women: • Chronic Fatigue Syndrome • Multiple Sclerosis (MS) • Rheumatoid Arthritis (RA) • Sjögren’s syndrome  • Systemic Sclerosis/Scleroderma

Although women who develop these symptoms or diseases can’t be certain that they were caused by breast implants, several studies indicate that most symptoms improve partially or completely after having their implants and capsules removed.

Patient Initials____________

Capsular Contracture:  I understand that one of the most common complications of breast implants is when the scar tissue capsule that forms around the implant hardens. In some cases, this can be quite painful, distort the shape of the breast, and can make mammography more painful and less accurate. Removing the implant and capsule without replacing the implant is the only recommended way to guarantee that this problem is corrected.

Patient Initials____________

Breast Cancer:  I understand that all breast implants can interfere with mammography and breast exams, possibly delaying the diagnosis of breast cancer. I understand that if I get breast implants, I should inform the mammography technologist about the implants and ask for additional views to improve the accuracy. I understand that mammography can also cause the breast implant to rupture or leak.

Patient Initials____________

Interference with Breastfeeding:  I understand that breast implants and breast surgery may interfere with my ability to successfully breastfeed.  No long-term research has been conducted to determine the possible transmission of chemicals and heavy metals in the breast milk of women with implants.

Patient Initials____________

Loss of Sensation to Breast or Nipple(s): I understand that breast implants and breast surgery may cause the nipple or breast to be painful, or to have decreased sensation. These changes may be temporary or permanent, and may affect sexual response or the ability to nurse a baby.

Patient Initials____________

Cosmetic Complications:  Asymmetry, Implant Displacement, Ptosis I understand that if my breasts had slightly different shapes before surgery, they may remain slightly different after surgery. I understand that the implants may cause the breasts to look slightly different in size or shape. I understand that the implant may move from the original placement location and that may result in asymmetry or other cosmetic problems. Breast implants can cause the breasts to sag over time due to the weight of the implants. I understand that if I am not happy with the results, I may need future surgeries to improve the appearance of my breasts.

Patient Initials____________

CONFIRMATION OF DISCUSSION OF RISKS 

Patient: I acknowledge that I have received and read the Breast Implant Patient Information Booklet and this checklist. I have had time to discuss the information in both with my doctor, and understand the benefits and risks of the implants and surgery.

______________________________________________Patient Signature & Date

Physician: I acknowledge that I have discussed the benefits and risks of breast implants as described in the Breast Implant Patient Information Booklet and this checklist. I have encouraged the patient to ask questions, and answered all questions accurately.

____________________________________________Physician Signature & Date

Making Your Decision


Deciding whether to get breast implants is a big decision. Before going forward, you should know as much as you can about the types of implants available, how much they will cost you in the short-term and long-term, and immediate and future health considerations.

Breast Implant Types

There are two types of implants: saline-filled and silicone gel-filled. Saline implants consist of a smooth or textured silicone envelope filled with saline (salt water). Silicone gel implants consist of a smooth or textured silicone envelope filled with silicone gel (a synthetic material). Breast implants also come in different shapes and sizes.  There are different reasons why some individuals prefer certain implants over others. You can read more about the different types of implants here.

Implant Costs

In 2016, the all-inclusive cost for initial implant surgery was between $5,000 and $8,000. Silicone gel implants usually cost about $1,000 more than saline implants.

Complications, such as infection, rupture, pain, or asymmetry, are very common. You can read more about breast implant complications here. Breast implants are not lifetime devices. You should expect to need additional surgery at some point, which can cost as much, if not more, than the initial surgery. Additional surgery can be needed because of health issues or cosmetic problems, and is rare during the first year but becomes more likely every year after that.  Some women have reported developing autoimmune problems or connective tissue disorder after receiving their implants. In addition, breast implants can cause Anaplastic Large Cell Lymphoma (ALCL), a rare cancer of the immune system.

All breast implants eventually break and leak, which requires removal and/or replacement.  Leakage is more obvious with saline implants, which usually deflate quickly.  The FDA recommends breast magnetic resonance imaging (MRI) for silicone gel breast implants 3 years after surgery, and every two years after that, to check for a slow leak.  Breast MRIs to check for implant leakage cost about $2,000 and are not usually covered by health insurance, so that is a substantial expense to be aware of.

Health Considerations

Saline Implants

  • All breast implants interfere with mammography, making mammograms less accurate.
  • The silicone envelope of the implant will tear or fall apart over time. This can cause the implant to leak and deflate, which is usually noticeable.
  • If the implant ruptures, the saline solution is usually not dangerous, but after being in the body it may contain bacteria or mold that can sometimes cause infections
  • Textured implants are more likely than smooth implants to cause Anaplastic Large Cell Lymphoma (ALCL), a type of cancer of the immune system.

Silicone Implants

  • All breast implants interfere with mammography, making mammograms less accurate.
  • The silicone envelope of the implant will tear or fall apart over time, causing the implant to leak.
  • Leaks aren’t usually obvious, so silicone gel can travel to other parts of your body for years before the leak is detected. Silicone gel can be impossible to remove once it travels to breast tissue or other organs, such as the lungs or liver.
    • To avoid the health risks of leaking silicone gel, women with silicone gel implants need regular breast MRIs to check for silicone gel leaks. The FDA recommends having a breast MRI three years after getting breast implants and every two years after that.
    • Leaking silicone gel can cause pain or swelling. It could cause allergic and/or autoimmune reactions.
  • Textured implants are more likely than smooth implants to cause Anaplastic Large Cell Lymphoma (ALCL), a type of cancer of the immune system.

If you have a family history or a diagnosis of an autoimmune or connective tissue disease, you should know that implants have not been tested for safety in women with those conditions because of health concerns. You can read more about autoimmune reactions here.

What to Ask Your Plastic Surgeon if You’re Considering Implants


When you’re considering breast implants, it is often hard to know what questions to ask and who to ask. For many plastic surgeons, breast augmentation is a large part of their practice and their salary. Keep in mind that you may not receive completely objective responses, but here’s a good place to start:

Before you go in, make sure the plastic surgeon is very experienced in breast augmentation. Any physicians or dentists may call themselves cosmetic surgeons even if they aren’t well trained in surgery. That’s perfectly legal, but their patients are taking a risk.

Ideally, you will want to see a plastic surgeon who is board certified in plastic surgery (not in some other medical specialty), because that will help assure you that they received the appropriate training to perform breast augmentation. You can find out if a doctor is board-certified by the American Board of Plastic Surgery online.

However, not all board certified plastic surgeons are skilled at implanting or removing breast implants. Check online for complaints about any plastic surgeons that you are considering. If there are serious complaints about patients who were harmed by the surgeon, look for a plastic surgeon with better ratings.

Once you decide to see a surgeon, here are some questions to ask during your appointment:

  • Ask about all your options for breast enhancement. Some women may be satisfied with the results from a breast lift alone, and may not need implants to achieve the look they desire. You can also ask your surgeon about a fat transfer as an alternative to implants.
  • Ask to see before and after photographs of your plastic surgeon’s patients. Some doctors use photographs of patients whose surgery was done by other surgeons. If the doctor says that the photos are of his/her patients, ask when those patients had surgery. If it was a long time ago, ask to see more recent photos.
  • Ask to see photographs of her or his patients that were taken at least three years after the surgery. Many patients look good immediately after surgical scars have healed but their breasts look different years later.
  • Ask your doctor for a patient booklet or other written information that includes the risks of breast implants and read that information at least one week before surgery so you have time to ask questions and gather more information.
  • Ask for a copy of the informed consent form at least one week before surgery.
  • Ask whether there is a warranty on the implants and, if so, what is and isn’t included.
  • Ask whether the doctor will remove your implants for free if you have serious problems. If so, will the surgical center services also be free? What if you want them removed, but the doctor doesn’t think it is necessary?

If you’re still unsure about getting breast implants, seek advice from someone that has gone through breast implant surgery at least 5 -10 years ago. They may be able to help you make the decision that is best for you. Click here to read some personal stories from women who had breast implants.

All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.