the longitudinal study excess mortality from suicide and other external causes of death among women with cosmetic breast implants (2007), reported that women who sought breast implants are almost 3.0 times as likely to commit suicide as are women who have not sought breast implants. compared to the standard suicide-rate for women of the general populace, the suicide-rate for women with augmented breasts remained alike until 10-years post-implantation, yet it increased to 4.5 times greater at the 11-year mark, and so remained until the 19-year mark, when it increased to 6.0 times greater at 20-years post-implantation. moreover, additional to the suicide risk, women with breast implants also faced a trebled death risk from alcoholism and drugs abuse (prescription and recreational). although seven studies have statistically connected a woman's undergoing a breast augmentation procedure to a greater suicide rate, the research indicates that augmenation surgery does not increase the suicide rate; and that, in the first instance, it is the psychopathologically inclined woman who is likelier to undergo breast augmentation. moreover, the study effect of breast augmentation mammoplasty on self-esteem and sexuality: a quantitative analysis (2007), reported that the women attributed their improved self-esteem, self-image, and increased, satisfactory sexual functioning to having undergone breast augmentation; the cohort, aged 21–57 years, averaged post-operative self-esteem increases ranging from 20.7 to 24.9 points on the 30-point rosenberg self-esteem scale, which data supported the 78.6 percent increase in the woman's libido, relative to her pre-operative level of libido. therefore, before agreeing to any surgical procedure, the plastic surgeon evaluates and considers the woman's mental health to determine if breast implants can positively affect her self-esteem and sexual functioning. surgical procedures indications breast augmentation: the post-operative aspect of a right-breast cancer mastectomy; the woman is a candidate for a primary breast reconstruction with a breast implant. an augmentation mammoplasty for emplacing breast implants has three therapeutic purposes: primary reconstruction: to replace breast tissues damaged by trauma (blunt, penetrating, blast), disease (breast cancer), and failed anatomic development (tuberous breast deformity). revision and reconstruction: to revise (correct) the outcome of a previous breast reconstruction surgery. primary augmentation: to aesthetically augment the size, form, and feel of the breasts. the operating room time of post–mastectomy breast reconstruction, and of breast augmentation surgery is determined by the emplacement procedure employed, the type of incisional technique, the breast implant (type and materials), and the pectoral locale of the implant pocket. incision types the emplacement of a breast implant device is performed with five types of surgical incisions: inframammary: an incision made below the breast, in the inframammary fold (imf), which affords maximal access for precise dissection and emplacement of the breast implant devices. it is the preferred surgical technique for emplacing silicone-gel implants, because of the longer incisions required; yet, imf implantation can produce thicker, slightly more visible surgical scars. periareolar: an incision made along the areolar periphery (border), which provides an optimal approach when adjustments to the imf position are required, or when a mastopexy (breast lift) is included to the primary mammoplasty procedure. in the periareolar emplacement method, the incision is around the medial-half (inferior half) of the areola's circumference. silicone-gel implants can be difficult to emplace with this incision, because of the short, five-centimetre length (~ 5.0 cm.) of the required access-incision. aesthetically, because the scars are at the areola's border, they usually are less visible than the imf-incision scars of women with light-pigment areolae. furthermore, periareolar implantation produces a greater incidence of capsular contracture, severs the milk ducts and the nerves to the nipple, thus causes the most post-operative functional problems, e.g. impeded breastfeeding. transaxillary: an incision made to the axilla (armpit), from which the dissection tunnels medially, thus allows emplacing the implants without producing visible scars upon the breast proper; yet is likelier to produce inferior asymmetry of the implant-device position. therefore, surgical revision of transaxillary emplaced breast implants usually requires either an imf incision or a periareolar incision. transaxillary emplacement can be performed bluntly or with an endoscope (illuminated video microcamera). transumbilical: a trans-umbilical breast augmentation (tuba) is a less common implant-device insertion technique wherein the incision is at the navel, and the dissection tunnels superiorly. this surgical approach enables emplacing the breast implants without producing visible scars upon the breast; but it makes appropriate dissection and device-emplacement more technically difficult. a tuba procedure is performed bluntly – without the endoscope's visual assistance – and is not appropriate for emplacing (pre-filled) silicone-gel implants, because of the great potential for damaging the elastomer silicone shell of the breast-implant device during its manual insertion through the short – two-centimetre (~2.0 cm.) – incision at the navel, and because pre-filled silicone-gel implants are incompressible, and cannot be inserted through so small an incision. transabdominal – as in the tuba procedure, in the transabdominoplasty breast augmentation (taba), the breast implants are tunneled superiorly from the abdominal incision into bluntly dissected implant pockets, while the patient simultaneously undergoes an abdominoplasty. implant pocket placement the four surgical approaches to emplacing a breast implant to the implant pocket are described in anatomical relation to the pectoralis major muscle. subglandular – the breast implant is emplaced to the retromammary space, between the breast tissue (the mammary gland) and the pectoralis major muscle (major muscle of the chest), which most approximates the plane of normal breast tissue, and affords the most aesthetic results. yet, in women with thin pectoral soft-tissue, the subglandular position is likelier to show the ripples and wrinkles of the underlying implant. moreover, the capsular contracture incidence rate is slightly greater with subglandular implantation. subfascial – the breast implant is emplaced beneath the fascia of the pectoralis major muscle; the subfascial position is a variant of the subglandular position for the breast implant. the technical advantages of the subfascial implant-pocket technique are debated; proponent surgeons report that the layer of fascial tissue provides greater implant coverage and better sustains its position. subpectoral (dual plane) – the breast implant is inserted beneath the pectoralis major muscle, after the surgeon releases the inferior muscular attachments, with or without partial dissection of the subglandular plane. resultantly, the upper half of the implant is partially beneath the pectoralis major muscle, while the lower half of the implant is in the subglandular plane. this implantation technique achieves maximal coverage of the upper half of the implant, while allowing the expansion of the implant's lower half; however, "animation deformity", the movement of the implants in the subpectoral plane can be excessive for some patients. submuscular – the breast implant is emplaced beneath the pectoralis major muscle, without releasing the inferior origin of the muscle proper. total muscular coverage of the implant can be achieved by releasing the lateral muscles of the chest wall – either the serratus muscle or the pectoralis minor muscle, or both – and suturing it, or them, to the pectoralis major muscle. in breast reconstruction surgery, the submuscular implantation approach effects maximal coverage of the breast implants. post-surgical recovery the surgical scars of a breast augmentation mammoplasty heal at 6-weeks post-operative, and fade within several months, according to the skin type of the woman. depending upon the daily physical activity the woman might require, the augmentation mammoplasty patient usually resumes her normal life activities at about 1-week post-operative. the woman who underwent submuscular implantation (beneath the pectoralis major muscles) usually has a longer post–operative convalescence, and experiences more pain, because of the healing of the deep-tissue cuts into the chest muscles for the breast augmentation. the patient usually does not exercise or engage in strenuous physical activities for about six weeks. moreover, during the initial convalescence, the patient is encouraged to regularly exercise (flex and move) her arms to alleviate pain and discomfort; and, as required, analgesic medication catheters for alleviating pain. medical complications the plastic surgical emplacement of breast-implant devices, either for breast reconstruction or for aesthetic purpose, presents the same health risks common to surgery, such as adverse reaction to anesthesia, hematoma (post-operative bleeding), seroma (fluid accumulation), incision-site breakdown (wound infection). complications specific to breast augmentation include breast pain, altered sensation, impeded breast-feeding function, visible wrinkling, asymmetry, thinning of the breast tissue, and symmastia, the "bread loafing" of the bust that interrupts the natural plane between the breasts. specific treatments for the complications of indwelling breast implants – capsular contracture and capsular rupture – are periodic mri monitoring and physical examinations. furthermore, complications and re-operations related to the implantation surgery, and to tissue expanders (implant placeholders during surgery) can cause unfavorable scarring in approximately 6–7% of the patients. statistically, 20% of women who underwent cosmetic implantation, and 50% of women who underwent breast reconstruction implantation, required their explantation at the 10-year mark. in 2019, a direct link was identified between allergan biocell textured breast implants of allergan and the breast implant-associated anaplastic large cell lymphoma (bia-alcl), a cancer of the immune system. fda recalled all allergan biocell implants. implant rupture because a breast implant is a class iii medical device of limited product-life, the principal rupture-rate factors are its age and design; nonetheless, a breast implant device can retain its mechanical integrity for decades in a woman's body. when a saline breast implant ruptures, leaks, and empties, it quickly deflates, and thus can be readily explanted (surgically removed). the follow-up report, natrelle saline-filled breast implants: a prospective 10-year study (2009) indicated rupture-deflation rates of 3–5 percent at 3-years post-implantation, and 7–10 percent rupture-deflation rates at 10-years post-implantation. in a study of his 4761 augmentation mammaplasty patients, eisenberg reported that overfilling saline breast implants 10-13% significantly reduced the rupture-deflation rate to 1.83% at 8-years post-implantation. breast-implant failure: the parts of a surgically explanted breast-implant are the red, fibrous capsule (left), the ruptured silicone implant (center), and the transparent filler-gel that leaked to the woman's pectoral tissues (right). when a silicone breast implant ruptures it usually does not deflate, yet the filler gel does leak from it, which can migrate to the implant pocket; therefore, an intracapsular rupture (in-capsule leak) can become an extracapsular rupture (out-of-capsule leak), and each occurrence is resolved by explantation. although the leaked silicone filler-gel can migrate from the chest tissues to elsewhere in the woman's body, most clinical complications are limited to the breast and armpit areas, usually manifested as granulomas (inflammatory nodules) and axillary lymphadenopathy (enlarged lymph glands in the armpit area). the suspected mechanisms of breast implant rupture damage during implantation damage during (other) surgical procedures chemical degradation of the breast implant shell trauma (blunt trauma, penetrating trauma or blast trauma) mechanical pressure of traditional mammographic breast examination silicone implant rupture can be evaluated using magnetic resonance imaging; from the long-term mri data for single-lumen breast implants, the european literature about second generation silicone-gel breast implants (1970s design), reported silent device-rupture rates of 8–15 percent at 10-years post-implantation (15–30% of the patients). the study safety and effectiveness of mentor's memorygel implants at 6 years (2009), which was a branch study of the u.s. fda's core clinical trials for primary breast augmentation surgery patients, reported low device-rupture rates of 1.1 percent at 6-years post-implantation. the first series of mri evaluations of the silicone breast implants with thick filler-gel reported a device-rupture rate of 1.0 percent, or less, at the median 6-year device-age. statistically, the manual examination (palpation) of the woman is inadequate for accurately evaluating if a breast implant has ruptured. the study, the diagnosis of silicone breast-implant rupture: clinical findings compared with findings at magnetic resonance imaging (2005), reported that, in asymptomatic patients, only 30 percent of the ruptured breast implants is accurately palpated and detected by an experienced plastic surgeon, whereas mri examinations accurately detected 86 percent of breast-implant ruptures. therefore, the u.s. fda recommended scheduled mri examinations, as silent-rupture screenings, beginning at the 3-year-mark post-implantation, and then every two years, thereafter. nonetheless, beyond the u.s., the medical establishments of other nations have not endorsed routine mri screening, and, in its stead, proposed that such a radiologic examination be reserved for two purposes: (i) for the woman with a suspected breast-implant rupture; and (ii) for the confirmation of mammographic and ultrasonic studies that indicate the presence of a ruptured breast implant. furthermore, the effect of study design biases on the diagnostic accuracy of magnetic resonance imaging for detecting silicone breast implant ruptures: a meta-analysis (2011) reported that the breast-screening mris of asymptomatic women