Aesthetic Primary and Secondary Breast Augmentation: Proposed Algorithm for Optimal Cosmetic Outcomes While Minimizing Complications
Authors: Troell Robert J. 
Published: February 2025

Introduction: The American Academy of Cosmetic Surgery does not have published guidelines on cosmetic primary and secondary breast surgery. Since augmentation-mastopexy is a common source of litigation, a guiding algorithm would be of benefit. Materials and methods: PubMed literature search was performed on each topic of cosmetic primary and secondary breast surgery. Articles were assessed for clinical relevance and the author referenced those deemed most representative of each topic area. In addition, the author’s clinical experience is presented. Results: Level of scientific evidence in clinical studies guide treatment recommendations, however, the quality of the cumulative clinical data less commonly reach a strong recommendation. The Aesthetic Society of Plastic Surgery publishes practice parameters, practice guidelines, policy statements, and performance measurement sets regarding breast augmentation and augmentation-mastopexy, many are not updated. Comparing these statements and different breast study results with their authors conclusions, identifies multiple points of view and controversies regarding virtually every aspect of the cosmetic breast surgical conundrum. Discussion: The cosmetic breast surgical plan starts with the initial patient request for breast enhancement, the breast and chest wall physical examination, and a detailed aesthetic consultation, which reviews all the variables to achieve the patient’s goals and guides the treatment plan regarding all clinical decisions. Dealing with breast augmentation variables: Size and projection determination, silicone gel cohesiveness, plane of implant placement, incision site, technique of placement, and when to use scaffolds, is presented in different clinical situations of those presenting for primary or secondary breast augmentation. Presented breast fat grafting techniques incorporates much of the current knowledge of harvesting, processing, enrichment, and administration that has yielded superior adipocyte survival and more consistent breast enhancement results. Mastopexy caveats, techniques, risk avoidance strategies, and use of adjuvant procedures are presented. Optimizing the overall breast cosmetic outcome, while minimizing complications requires a detailed anatomic breast and body examination, insightful and though planning, comprehensive patient consultation and consent regarding the alternative options, use of adjuvant devices (funnels, scaffolding, energy-based systems), regimented surgical procedure steps, and close postoperative surveillance. Conclusions: This review uses a surgeon’s personal experience and published studies to construct a logical primary and secondary breast augmentation algorithm to guide cosmetic surgeons in preparing a surgical plan, performing a preoperative risk assessment, and establishing perioperative risk avoidance strategies. The ultimate judgment regarding the care of a particular patient must be made by an individual surgeon jointly with the patient, taking into consideration their preferences and desired aesthetic outcome.