How do I choose the best breast implant for me?

The choice between saline-filled vs. silicone gel-filled implants obviously requires the consideration of a wide range of issues. Many patients that I meet in consultation have decided on a type of implant in advance of the appointment, while some are still deciding in the interval between the consultation appointment and the date of surgery. It is a significant decision, but I do not think it should be turned into or thought of as a ‘make or break’ decision in terms of a pateint’s long-term happiness with breast augmentation. In most cases, it is impossible to tell by outward appearance whether a patient has saline or silicone gel implants. And in no case have I had a patient express regret regarding the type of implant they selected.

If you are certain that you do not want an implant that requires radiologic follow-up to determine whether or not it is intact and may need to be replaced, and you are comfortable with the possibility that the edge of the implant may be palpable to some degree in a limited area of the breast, then saline implants are an appropriate choice. Once you have recovered from saline implant breast augmentation there is no long-term implant monitoring that is required. And there is no reason to have the implants changed at a later date just because a given number of years have passed. Deflation is the only likely reason you might have the implants changed at some point.

On the other hand, if you cannot tolerate the idea of the implant edges potentially being palpable in some areas, and are comfortable with the idea of postoperative monitoring (i.e. breast MRI scans) to screen for implant rupture, then silicone gel implants are an appropriate choice. You may be particularly more inclined to choose silicone gel implants if you are slender and your natural breast volume is an A to small B cup, as the surgical result is likely to look and feel much more natural with gel implants. Another instance in which silicone gel implants are strongly preferable is if you prefer sub-mammary instead of sub-pectoral implant placement. Submammary placement works well with gel implants in many patients, while saline implants are most commonly placed in a sub-pectoral position (unless the starting breast volume is fairly full).

At your consultation appointment all of these issues can be reviewed in detail. Your personal feelings about the concepts presented above, combined with my recommendations based on breast examination, make it fairly easy in most cases to arrive at a decision with which each patient is very comfortable. Again, patient satisfaction with both types of implants is extremely high in this practice. An important part of achieving high patient satisfaction is ensuring that patients fully understand what to expect from each type of implant, so please give all of the issues presented above some serious consideration as you are making your decision.

Breast Augmentation now offers patients and surgeons alike a great deal of choices in terms of types of implants, location of incisions, and placement of implants above or below the muscle.

A number of factors influence the utility of these methods of placement of breast implants, and not every option is available to every patient. It is critical for the patient to choose a surgeon who has experience with all types of breast implants, who has the technical skill to place the implants through a variety of incisions, either above or below the muscle, and who possesses the familiarity with the multiple anatomic variations of women’s breasts.

The surgeon must possess the appropriate judgment as to which combination of implant, incision, and pocket will have the greatest likelihood of producing a natural result with the fewest possible risks or complications. Any surgeon who applies a “cookie-cutter” philosophy, who offers only one type of implant, or one surgical approach, cannot possibly create a pleasing breast except by chance.

Types of Breast Implants:

• Saline vs. Silicone
• Smooth vs. Textured
• Round vs. Shaped (Anatomic/Form Stable)

All breast implants share the common characteristic of an outer silicone rubber shell, which can be either smooth or textured. The implants then vary depending on the characteristic of the filling material inside the shell.

Saline Breast Implants are packaged empty, and are filled by the surgeon at the time of operation using sterile injectable IV saline (salt water) solution, through a small valve located on the surface of the implant. Saline implants became most widely used between 1992 and 2006, during the FDA moratorium on gel implants.

After a 15 year hiatus, during which their use was restricted to a limited number of patients meeting specific criteria, Silicone Gel Breast Implants were returned to full market availability in the U.S. in November 2006. The silicone gel is a polymer with a density similar to fat, and can be chemically altered by the manufacturer in a variety of ways to create different degrees of viscosity, from a consistency somewhat like honey or molasses, to that of a “gummy-bear”.

Implant shells can be created from molds in either a round, disk-like form, or in a shaped form (crescent, tear-drop, etc.) in both saline and silicone formats. The “anatomic” or “form-stable” implants are generally filled with a higher-viscosity (“cohesive”) silicone gel, and are intended to hold their form at all times, whereas round implants are intended to flow with the breast as the position of the patient changes, since the saline or silicone gel flows according to the laws of gravity in a round implant.

Generally speaking, saline implants can be placed through smaller incisions, and “form-stable” or large gel implants require larger incisions.

Incision Locations:

• Trans-Axillary
• Peri-Areolar
• Inframammary
• Trans-Umbilical

Breast implants can be placed via a number of surgical approaches, either above or below the pectoralis muscle which lies under the breast itself. With any approach, there is a risk of bleeding, infection, or loss of sensation. There is generally no impairment of breast function with any incision approach.

The Trans-Axillary approach involves placing an incision near the apex of the armpit in the natural skin crease. A pocket is then created either behind the breast itself, or behind the pectoralis muscle and the breast, for placement of the implant. An endoscope (lighted surgical camera-telescope with images viewed on a TV monitor) can be used to assist in the dissection of the pocket, or the procedure can be done blindly.

Advantages of this incision include no visible scar on or near the breast. Disadvantages include potential numbness in the upper inner arm area, potential difficulty with proper implant positioning, and inability to re-use the incision in some cases of later breast revision surgery.

The Peri-Areolar approach involves placing the incision around the border of the areola where it meets the lighter skin of the breast, usually around the lower semi-circle of the areola from 3:00 to 9:00. The incision is carried through the breast tissue until the space behind the breast tissue is reached, or alternatively lifting the pectoralis muscle as well to create a space under the breast and muscle.

Advantages of the peri-areolar incision include the fact that the incision is hidden under all types of clothing; the scar is generally acceptable and can be re-used in the event that future implant revision surgery is needed. Disadvantages include variable and transient loss of nipple sensation.

The Inframammary approach involves placement of the incision in the natural fold below the breast, or in the position where the fold is desired after placement of the implants. The pocket can be created above or below the muscle.

Advantages of the inframammary incision are that the breast tissue is not disrupted, and the incision can be re-used for future breast implant revisions. Disadvantages include potential unsightly visible scars.

The Trans-Umbilical (“TUBA”) procedure involves placement of the implant through a remote incision at the upper border of the belly button. A variation involves placement of implants from below, during an abdominoplasty (“tummy tuck”). The procedure is generally done “blindly”, developing the space either above or below the muscle.

Advantages include a scar remote from the breast. Disadvantages include difficulty with accurate implant placement, difficulty controlling potential bleeding, and inability to re-use the incision for implant revisions. Usually, saline implants are placed, since larger gel implants cannot be placed from such a remote and small incision.

Pocket Locations:

• Sub-Glandular
• Sub-Pectoral

Through any of the potential incisions, a space for the implants can be created immediately behind the breast tissue and above the muscle (Sub-Glandular), or behind both the breast tissue and the pectoralis major muscle (Sub-Pectoral / Sub-Muscular / Dual-Plane).

In general terms, women with more native breast tissue, or women who have some degree of sagginess of their existing breasts, are better candidates for sub-glandular implant placement. Advantages of sub-glandular implant placement include less immediate post-operative pain. Disadvantages include greater potential ability to feel the implant, or to see rippling or wrinkling of the implant with the breast in certain positions, and slightly greater interference with mammography.

Women with smaller breasts, without droopiness, are generally better candidates for sub-muscular implant placement. In this situation, the majority of the implant lies beneath the muscle, while the lower and outer portions of the implant lie in contact with the breast tissue itself (hence the term “dual-plane”). Advantages include less ability to feel or see implant ripples or wrinkles, and less ability to see the contours of the implant, and less interference with mammography. Disadvantages include greater immediate post-operative pain, slightly greater difficulty achieving good cleavage, and mild distortion of the breast with contraction of the chest wall muscles.

Making the Choice
Your surgeon should carefully examine your breasts for masses, make note of your breast dimensions relative to the chest wall and your body build, and analyze the individual characteristics of your breasts. After listening to your desires and goals for the surgery, your surgeon should be able to articulate to you a specific treatment plan that will meet your goals, including the best type of implant, incision, and pocket location for your specific case.

Remember, one size of breast implant does not fit everyone, and one tool or surgical approach cannot do every job or properly treat every situation.

I feel that it is essential to incorporate my patients in the decision-making process. It is important that they understand why I recommend a specific size, shape, and texture for them and want them to feel that they are playing an active role in their care.

I currently use smooth round implants and avoid the use of textured and/or shaped implants. My personal feeling is that the smooth round implants are an excellent choice and that pre-existing breast shape contributes the most to postoperative appearance.

I have all of my patients try on various implants following their initial consultation to help both them and myself identify an appropriate implant volume. I also take a number of chest wall measurements at this initial consultation which help me choose an implant based on desired fill volume and pre-existing breast base width.

It is important to remember that no one operation, type of implant or technique fits every patient. It is essential to work out the best plan for surgery with you to ensure you get the best possible result. This involves measuring your chest shape and size and choosing an implant volume and shape that will fit you perfectly. At the same time the technique must be adapted to best suit your breast type. I call this “the made to measure breast augmentation”.

It is important to consider the size of the implants and breasts and how slim you are.

The placement of the implants, which can be either...

• under the breast only
• under the muscle
• or a combination of both, i.e. a dual plane

...depends on how droopy the breasts are and how much tissue is left in them. Sometimes the implants are best combined with a lift, if the breasts are very droopy.

The implant type, either round or anatomical/teardrop, depends on where the woman would like most projection and her type of breasts.

Finally, the size of the implants is a joint decision between patient and surgeon.

Breast implants come in a variety of shapes and sizes. Shaped, or teardrop, implants are usually used for reconstructive patients. I prefer the smooth round implants because they look and feel the most natural when placed in the body. The profile, or height, of the implant can be discussed with your surgeon to obtain your desired size and appearance.

The most important factor to achieve is choosing an implant that will fit your chest anatomy; or an implant that is not too large or too small for your chest wall or breast pocket.