Dr. Tholen's Comprehensive Guide to Breast Augmentation: Part 1


For each of the past ten years, breast enlargement (augmentation mammoplasty) has been the most common surgical cosmetic operation performed in the United States [American Society of Plastic Surgeons data].  Over 305,000 women requested this operation in 2015, up 202 percent from 1997 [American Society for Aesthetic Plastic Surgeons data].  Since 2004, breast enlargement has been the most frequently performed operation at Minneapolis Plastic Surgery, Ltd. In 2016, over four hundred women underwent this one-hour outpatient operation in our nationally-accredited (AAAASF) office surgical facility.  Superior anesthesia care, advanced surgical techniques, the care of my fantastic nursing and office staff, and over 29 years of experience allow my breast augmentation patients to return to everyday activities within 24 hours, and strenuous activities within several weeks.

If marketing hype and “snappy” trademarked names were important, perhaps we would call our procedure the “Overnight Recovery Augmentation,” the “24-hour Recovery Breast Enlargement,” or the “Flash Recovery Breast Augmentation,” as other doctors have done. Some of them have written articles in the plastic surgical literature about minimizing surgical trauma with careful surgery, and the resultant advantages of less pain and bruising, as well as improved healing and less complications. But for us, precise surgical technique and outstanding patient care leading to rapid and comfortable recovery is nothing new or something with a “special name”—this is the way we have been doing things all along.

We have chosen to elevate the care and technical details of elective breast enlargement surgery, rather than marketing or advertising a “brand-name” operation that tries to imply a “special” or unique secret that no other plastic surgeon has—some hidden talent that supposedly transforms patients into someone who has “more rapid” healing, “no” pain, and can return to all activity “magically” the next day!  This is pure marketing (baloney), and may be a cover for substandard surgical practices.

Careful tissue handling, meticulous hemostasis (control of bleeding capillaries), avoidance of rib or muscle injury, and skillful use of medications designed to keep discomfort and anesthesia side effects to an absolute minimum are what we concentrate our efforts on; this is what allows a safe, quick, and comfortable recovery, not a gimmicky procedure name.

Candidates for Breast Enlargement

Some women who choose breast enlargement do so to restore breast volume lost as a result of pregnancy, breastfeeding, weight loss, or aging.  Others request this outpatient operation to improve symmetry in breasts that have never matched in size, and many women simply seek the improvement in self-image or clothing fit that fuller breast size gives them.  Some women with more severe loss of breast volume causing sagging or nipple position below the inframammary crease or pointing downward may require one of several breast lifting operations (with or without implants); examination and measurements will immediately tell us if breast lifting is necessary, or if excellent results can be obtained with implants alone.

Implants do not lift breasts, but in some “borderline” cases, choosing an adequate implant size to fill out the deflated skin brassiere can provide good results without the scars and cost of breast lift surgery.

Whatever the reason for requesting information about breast augmentation, you must understand that this operation is appropriate for you if and only if:

  • You have realistic expectations regarding potential risks vs. benefits.
  • Your breast development is complete (for younger women).
  • Your nipple/areola complexes face forward and are at or above the level of the inframammary crease (IMC).
  • You have decided to undergo this operation to feel better about yourself, not to live up to the expectations of anyone else.
  • You are not pregnant or breastfeeding.

Basic Facts

  • Breast implants do not increase the risk of developing breast cancer.
  • Mammography and breast self-examination can be performed on augmented breasts.
  • Skillfully augmented breasts both look and feel normal in the majority of women.
  • Breast implants do not harden, nor do they automatically need replacement after ten years.
  • Nipple sensation and the ability to breast-feed are preserved in most patients.
  • Breast implants (both silicone gel and saline) do not cause or increase the risk of developing arthritis, lupus, scleroderma, or connective tissue diseases.
  • Saline implant leakage and deflation is uncommon and can be dealt with when it does occur.
  • Since 2006, silicone gel implants are FDA-approved for use in first-time cosmetic breast enlargement patients.  They are “cohesive” and cannot deflate.
  • Women age 18-22 can legally and ethically have silicone gel implants placed.

A complete medical and surgical history will be obtained from all patients, and should include information about allergies to any medications. You must inform your surgeon of all prescription or over-the-counter medications you take, including herbal, vitamin, nutritional supplements, and appetite suppressants. Some of these can interfere with proper blood clotting and increase the risk of bleeding after surgery. Breast enlargement patients must avoid aspirin or ibuprofen-containing products, Aleve™, additional vitamin E (the dose in a single daily multivitamin is acceptable), and any herbal remedies for a full two weeks before and after surgery.

Your Breast Augmentation Consultation

Any patient considering breast enlargement with implants must have a personal consultation, during which she will discuss her individual cosmetic goals and concerns with Dr. Tholen. Many of our patients who do not live within driving distance of the Minneapolis/St. Paul area pre-arrange for a consultation and surgical procedure during the same visit.  Our staff can help you with arrangements for local lodging, postoperative care and assistance, if desired, and follow-up appointments.  

A complete medical and surgical history will be obtained from all patients, and should include information about allergies to any medications. You must inform your surgeon of all prescription or over-the-counter medications you take, including herbal, vitamin, nutritional supplements, and appetite suppressants. Some of these can interfere with proper blood clotting and increase the risk of bleeding after surgery. Breast enlargement patients must avoid aspirin or ibuprofen-containing products, Aleve™, additional vitamin E (the dose in a single daily multivitamin is acceptable), and any herbal remedies for a full two weeks before and after surgery.

Do You Need a Breast Lift, or Implants Only?

Your pregnancy, breastfeeding, and mammographic history are important, as is physical examination of your breasts, nipple-areola position, measurements, and skin and muscle tone. Mild to moderate ptosis (breast droop) is often caused by loss of breast volume after weight loss, pregnancy, or breastfeeding, and low nipple-areola position can usually be corrected with implants alone (breast augmentation only).  This is because “filling-out” the loose skin of breasts that have lost volume can give the appearance of raising the nipple/areola position on the breast mound as the implants drop into position behind the breasts. Many women with flattened, deflated-looking breasts think (and are told elsewhere) they “need” breast lifting surgery, when in fact they can achieve beautiful results with restoration of breast volume (implants alone) in many of these borderline cases.

If breast size (volume) is adequate for your goals and body proportions, but your breasts are sagging or nipples are pointing downward, a breast lift is what you need. Only an ounce or ounce and a half of excess skin needs to be removed to create a new, uplifted breast appearance with nipples that are facing forward and in the proper positions on the breast mounds. While many surgeons may tell you that removal of “more” breast tissue will allow the placement of implants, and that this will produce “more upper pole fullness” or give a longer-lasting result, implants and breast tissue are designed to be similar in “feel” and removing some of one to add the other does NOT, in my opinion, enhance results, longevity, or give more fullness superiorly.

If you want or need a breast lift plus additional breast size, implants added to your breast lift surgery will be necessary. This can usually be done as one operation, not two.

Regardless of pre-existing breast size, if breast ptosis (sagging) is severe, or if nipples point downward or are below the inframammary creases, a breast lift (mastopexy) will likely be necessary. After examination, Dr. Tholen can determine the exact type of breast lift that is recommended and explain the additional incisions and resultant permanent scars that are involved.  Breast lift surgery (with or without  breast implants) requires additional operating time, incisions, and cost, but can correct more severe drooping or sagging of the breast skin, as well as raise nipple position.  This is done without removal of the nipple-areola complex (though there is a scar around the areola to reposition it higher on the chest), which can preserve both sensation and ability to breast feed in about 85% of patients undergoing breast lift surgery. 

Other conditions such as nipple inversion, tuberous breasts, significant asymmetry, Poland's syndrome, or problems from prior surgery, such as bottoming out, symmastia (uni-boob, “breadloafing,” or loss of cleavage), capsular contracture, or malposition can also be corrected or improved.

Choosing Your Breast Implants

The sheer number of implant variations available to patients and surgeons can lead to confusion. This confusion is added to by the advertising and marketing of the three USA implant manufacturers (each of which, by the way, make excellent and very similar implants), and individual surgeons who may promote one manufacturer’s products or a specific implant type. Contrary to what manufacturer’s marketing and some surgeons state or imply, outcome is determined much less by choice of implant than by choice of surgeon. Stated another way, an average (or poor) surgeon cannot guarantee a superior result simply by using a specific company’s implant. However, careful measurement, proper analysis of your anatomy, and experienced surgical decision-making, plus a skillfully-performed surgical procedure, can help give you the best cosmetic result possible, regardless of the implant company whose products are used.

Unfortunately, some choices are made on the basis of marketing, surgeon habit, a friend’s advice, or cost, rather than careful listening to the patient’s goals and concerns and utilizing the surgeon’s expertise to determine her best options.  Since breast enhancement is done so frequently at Minneapolis Plastic Surgery, Ltd., we maintain an extensive on-site inventory of breast implants in virtually every size and profile, in both silicone and saline types.  Your implants don’t have to be ordered in advance, you don’t have to worry about having the “right ones” in the operating room, and on-time delivery is not an issue—they are already here.

Types of Implants

Breast implants come in numerous sizes (100cc – 800cc, or about 3 to 27 ounces each), shapes (round, oval, or teardrop “anatomic”), surface characteristics (smooth or textured), and fill material.  Most breast implants are filled with saline or silicone gel, and occasionally other materials (though none of these “other materials” are FDA approved at the present time). Silicone gel implants presently come no larger than 800cc, but 800cc saline implants can be “overfilled” to volumes higher than this when requested in select patients. Saline implants are filled in the operating room; silicone gel implants are pre-filled (solid, cohesive gel) at the factory and come ready for insertion.

Since the material inside breast implants is what gives them their “feel,” choice of filler material has generated much controversy and media interest, not to mention scientific debate.  We can provide both the science and years of expertise to help you determine whether saline or silicone is best for you.

Until 2012, only two companies produced breast implants FDA-approved for use in the United States (Mentor Corp., now part of Johnson and Johnson; and Inamed Corp., previously McGhan Medical, now owned by Allergan, Inc.).  For the first time in 20 years in the United States, a third company (Silimed) received FDA approval on March 9th, 2012 to sell their Sientra brand of silicone breast implants, including textured anatomic silicone gel implants.

Prior to the FDA restrictions of 1991-1992, numerous companies produced breast implants with different designs, surfaces, and filler materials, including polyurethane-coated silicone gel implants, silicone-saline double-lumen implants (the Becker implant), and PVP hydrogel filled implants designed to pass mammography X-rays and have a feel more like silicone than saline (the Bioplasty Misti-Gold implant).  After the FDA restrictions, these implant options and companies were lost to USA patients, though some of these companies and options remain available in other countries.

In the United States, besides the presently-available Mentor, Allergan, and now Sientra implants, several companies have produced other types of implants such as Hutchison saline implants, Ideal saline implants, and others. As of January, 2016, the Ideal implant has received FDA approval, but other investigational implants are not yet FDA-approved and are being implanted only by plastic surgeons associated with the FDA investigation/approval study process.

Silicone or saline? (How about fat?)

At Minneapolis Plastic Surgery we offer both saline and silicone breast implants.

Nationally, 85% of women choose silicone. Some plastic surgeons still encourage the use of saline implants, though not because they have been proven to be safer or have some beneficial effect regarding connective tissue or autoimmune disorders (the science about that will be discussed below). More commonly it is because saline implants are less costly (higher profit), easier to insert (rolled up and then filled inside the body), can be used via armpit or belly button incisions, and leave slightly smaller scars—NOT because they are better or feel more natural!

With nearly 3 decades of experience with fat grafting, we do this procedure for many locations throughout the body, but do not recommend fat grafts for elective breast augmentation in normal breasts.

Saline identical to intravenous fluid was the most common type of breast implant filler material used in the United States from 1992 until November 2006, when the FDA re-approved the use of silicone gel-filled implants for primary elective breast augmentation.  Prior to the 1992 FDA restrictions, silicone gel implants were utilized in over 85% of all breast augmentations in this country, and remain the most commonly used implants worldwide. 

Unusual Filler Materials

Other types of filler material for breast enlargement have been evaluated over the years, and one or more problems are associated with each of these. Ivory balls, paraffin wax, sponges, and other unusual materials were used in historical efforts to surgically enlarge breasts; results were dismal until silicone came into use in the 1960’s.  More recently, with the FDA silicone restrictions of 1992-2006, soybean oil-filled implants were studied extensively, and were used in many patients in Europe, as well as a few US patients in FDA studies.  Breakdown of the oil, rancid smell, and other concerns ultimately led to withdrawal of this implant (Trilucent™) in the US and in Europe.  Fat as implant fill material has the same concern, and is not used. 

Fat Grafting for Breast Enlargement

Fat graft injections of a patient's own liposuction fat (directly into or beneath the breasts) have been performed by some physicians.  Among other names, this has been termed “natural breast augmentation” since enlargement is achieved by using a woman’s own fat tissue (but you also have to pay for the liposuction used to obtain the fat)!  Most doctors performing fat graft breast augmentation admit that they can achieve no more than ½ to one bra cup size enlargement (which interestingly, is the same size increase stated for Brava suction cup enlargement, which has now been “recycled” as a fat-grafting “preparation to increase vascularity” and boost “take”).  The American College of Surgeons and the American Society of Plastic Surgeons are not yet endorsing breast augmentation via fat grafting. One reason is that a portion of the transferred fat always dies (30-50%), and can cause microcalcifications and scar tissue lumps within the breast that can interfere with both breast examination and the mammographic detection of breast cancer. 

Though many radiologists state that they can tell the difference between dead-fat  microcalcifications  (from fat grafting) and dead-fat microcalcifications (from possible breast cancer), the majority of plastic surgeons (including Dr. Tholen) are not willing to risk your life for an unproven procedure, especially as 1 in 8 or 9 women will develop breast cancer in her lifetime. And also, since implants are still a superior choice lacking these mammographic concerns.

Scientific studies confirm that fat cells removed via “standard” liposuction are mostly destroyed and non-living; improper storage of the fat for later use (freezing) kills even more cells (ice crystals puncturing cell walls kill the fat cells), so this is worthless and potentially harmful.  The same goes for fat harvested with SmartLipo (laser destroys the living fat cells) or excessive ultrasonic liposuction (too-much ultrasonic energy ruptures the living fat cells). Dead fat cannot turn into living grafts that maintain volume.  Unless your surgeon uses appropriate fat harvest technique, and transplants the still-living fat globules in carefully-spaced tunnels with the tiny fat grafts surrounded by abundant healthy tissue for blood supply, the transplanted fat is not going to survive. Any breast enlargement thus achieved is gradually and ultimately lost as the dead fat is absorbed and carried away by the body—potentially leaving scars, lumps, and calcifications.

Breasts augmented with fat grafts that die, calcify, or become scarred nodules within the breast are far from “natural.” And as the dead cells are removed by the woman’s body, the once-larger breasts gradually lose size. Many former fat graft breast patients return for the implants they should have had in the first place.

The latest marketing “hype” around fat grafting for breast enlargement uses the term “stem cell breast augmentation.”  This is the same procedure as fat grafting, but with the possible addition of centrifugation or addition of blood plasma to “concentrate” or “enrich” the “stem cells.”  Until peer-reviewed scientific research validates fat grafting (or the even more “out-there” stem-cell breast enlargement), this should be considered experimental only!

Saline Implants

Between 1992 and 2006, FDA restrictions on the use of silicone gel implants for elective, first-time breast augmentation meant that most women received saline-filled silicone-shell implants. Minneapolis Plastic Surgery has many satisfied patients with saline-filled implants who underwent their breast augmentation during these years, and many are shown in our website photo gallery (go to mpsmn.com/gallery/breast-augmentation/ ). Because of our significant numbers of patients who received them during this period, we also became well-aware of the pros and cons of saline-filled implants.

Numerous scientific studies were performed during these years of implant controversy, and to date, there has not been one credible peer-reviewed study that shows cause-and-effect relationship between breast implants (silicone gel or saline) and any sort of auto-immune disease or illness. Saline implants can leak and deflate, particularly if they are not filled properly, and they have also been shown to have a higher visibility of rippling or wrinkling on the implant surface. This rippling is often unsightly and unnatural in appearance, and tends to be worse when bending over or when wearing swimsuits or cleavage-revealing clothing. Implant placement below the pectoralis major muscles reduces saline-implant ripples, and usually eliminates them when silicone gel implants are used.

Saline implants cost less, and can be inserted via a slightly shorter incision, though we continue to be surprised by the length and placement of breast augmentation incisions (both saline and silicone) in patients we see from other surgeons. Incision length is much less a factor of saline vs. silicone than choice of surgeon. We have also found that the cost differential between saline and silicone gel implants is not always passed on to the patient, making saline implants more profitable than silicone in some doctors’ offices, and perhaps skewing why they may make a certain implant recommendation.

Surgeons who tend to promote the use of saline implants may do so out of training, their own experiences, habit, or profit motive, but those who scare patients with (disproven) autoimmune illness association, or tell them of the (outdated) FDA recommendation for every-other-year MRI scans in silicone implant patients (unnecessary for the latest generation of cohesive silicone gel implants), only serve their own interests, not those of their patients. These are old, outdated, and inapplicable “concerns” that have been exhaustively studied and no longer apply. Strongly-held and science-based facts are fine; “scare tactics” designed to coerce thinking to a particular point of view (or implant) are not.

Leak and deflation of saline implants require surgical replacement (the implant manufacturers provide free lifetime implant replacement, and will cover a majority of the surgical costs for the first ten years after initial implantation). But another operation is needed, including time off from work or social activities, and restrictions during healing. When saline implant leak requires re-operation, a majority of my patients choose cohesive silicone gel implants to replace both of their saline ones, ensuring that leak and deflation can never again occur. Significant numbers of my patients who initially received saline breast implants have undergone a second procedure (whether they had a leak or not) to replace their saline implants with the latest generation of cohesive silicone gel implants. Rippling is eliminated or significantly reduced, softness and natural “feel” is enhanced, and leak or deflation is no longer a concern. Many also used this opportunity to choose a different (usually larger) size. Whatever the reason, and despite the fact that many happy saline implant patients remain without concerns and with excellent results, a majority of my patients now choose silicone gel implants.

Silicone Implants

The newest generation of cohesive silicone breast implants provides incredibly natural-looking and feeling results, and also a high level of safety. Previous versions of silicone gel implants had thin shells and liquid or oily silicone filler, were extremely soft, and were susceptible to rupture, leakage, or microscopic silicone “bleed.” The latest types of silicone gel breast implants (by any of the 3 USA implant manufacturers) have been used as part of the more general FDA study since 1992, and are soft, yet still a cohesive solid gel that cannot leak. These implants do not leak even if the shell is cut or punctured, and these implants can still be inserted via a 1½-inch incision. Slicing open one of this latest generation of breast implants is like cutting Jell-O—you get two solid intact parts and leakage does not occur. (These implants are often erroneously called “gummy bear” implants since they are cohesive, though the true first “gummy bear” implants were the Allergan style 410s.)

Allergan style 410 implants are made with a more firm (“highly cohesive”) silicone gel that is described as “form-stable,” meaning its teardrop shape is maintained in the body (even when reclining). Because proper orientation is critical for normal breast appearance (upside-down would look mighty strange, for example), the surface of this implant style is textured to adhere to the surrounding tissues. This highly-cohesive, firm silicone gel material led to the lay description “gummy bear” implant. Like all cohesive implants, this “highly-cohesive” implant retains its form and innate integrity even when its outer shell is punctured. This implant is more firm (like a “gummy bear” or silicone bathtub seal) than the softer, latest-generation, cohesive silicone gel implants, and requires a larger 2.5 inch incision for placement. (It’s also more costly.) This implant—Allergan (formerly McGhan) style 410—has now been FDA approved, but we feel this implant configuration (form-stable, highly cohesive, textured, teardrop-shaped) is usually more appropriate for reconstructive or “rescue” operations than for primary cosmetic breast augmentation.

Now that a third implant manufacturer (Silimed) is producing Sientra implants that are FDA-approved for use in this country, additional options exist for patient and surgeon choice. Sientra has decided to sell their products only to American Board of Plastic Surgery-certified plastic surgeons (a laudable position), whereas Mentor and Allergan will sell their implants to any licensed physician, regardless of specialty. (This is how Dermatologists, Family Practitioners, and doctors with little or no plastic surgical training can legally obtain breast implants, and insert them into unwitting patients who think that their “cosmetic surgeons” have the same training and certification as ABPS-certified plastic surgeons.) Whether or not Sientra’s “plastic surgeons-only” policy will confer better statistics, outcome studies, or lower complication rates than the other companies’ practices remains to be seen. I’d bet on it; and I’d also bet that the company will use that data to sell more implants. But what that anticipated data will really tell us is that implants placed by American Board of Plastic Surgery-certified plastic surgeons are going to have a far lower complication rate than implants placed by non-plastic surgeons.

Sientra also was the first company to receive FDA approval for their own brand of “high-strength” cohesive, textured-surface, teardrop-shaped (form stable) silicone gel implants, as their approval pre-dated Allergan’s style 410 FDA approval. They also began marketing all of their cohesive implants as “gummy bear implants.” This confused individuals who used the “gummy bear” moniker to describe the Allergan Style 410 textured cohesive teardrop-shaped implants. For this reason, I personally believe that although the term “gummy bear” is descriptive and “catchy” to use, it has now become confusing, since each implant manufacturer has its own version of textured-surface, shaped, cohesive, “high-strength,” or “highly cohesive” silicone gel implants. Plus, the “regular” smooth round silicone implants are also cohesive. So they’re ALL “gummy bears” and they’re NOT all “gummy bears,” depending on how you define the term.

Bottom line: all silicone gel implants by all implant manufacturers are cohesive, whether they are round or shaped, textured-surface or smooth, so none can “leak.” Rupture, though possible, is extremely rare unless the implant is damaged during insertion. This is why I feel MRI is not useful as a screening tool.

With silicone gel or saline implants, microscopic silicone molecules can still enter a patient's body, just as liquid silicone does in the patient who has an injection with a needle lubricated with liquid silicone. No scientific study to date has provided credible evidence that silicone has any cause-and-effect relationship with autoimmune diseases or conditions such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant illnesses."  With these studies in mind, silicone gel breast implants were FDA-approved in November 2006 for elective first-time cosmetic breast enlargement in women over the age of 22.  Use of silicone gel implants in women under age 22 is considered “off-label” use and is perfectly legal.  I support the right of properly-informed women between the ages of 18 and 22 to consent and request the implants of their choice, including silicone gel implants.

The present generation of cohesive silicone gel implants made by Allergan Corporation are called Natrelle implants, and we now offer the newest Natrelle Inspira cohesive silicone gel implants. These are identical to the previous Natrelle implants, but with additional gel “fill” in the silicone shell, about 95% vs. 85%. I believe these implants have the same degree of softness but with even less potential for visible rippling in extremely thin patients with very little breast tissue to “cover and conceal” any implant edge or ripple. I now use the Inspira implants in the majority of my patients who request silicone implants.

Allergan has just introduced another Natrelle Inspira "Cohesive" implant collection that utilizes the style 410 highly cohesive silicone gel inside smooth round implants. These more expensive and slightly less soft implants offer the least potential for persistent rippling in women who still have this concern.

Is an MRI really necessary every two years with silicone implants?

If your silicone implants were produced before the FDA restrictions of 1992, they were previous-generation devices that had a thinner shell and a less-cohesive gel filler. In other words, if an implant was damaged or defective, the silicone gel could indeed “leak” into surrounding tissues, eventually causing scar formation and capsular contracture. MRI studies proved to be more effective at detecting these kinds of implant damage and leak than physician exam, leading to this “recommendation” from the FDA.

However, since all 3 USA breast implant manufacturers now make cohesive or highly cohesive silicone gel implants, “leakage” does not occur, and since the shells are thicker and much more durable, implant rupture from manufacturers’ defect is extremely rare, and surgeon damage during insertion is the most common cause of implant “rupture.” Use of the Keller Funnel decreases forces on implants during insertion, and taking care to avoid contact with needles, instruments, or other sources of implant damage can virtually eliminate rupture. Since present-day solid cohesive silicone gel implants (from all 3 manufacturers) cannot “leak,” many plastic surgeons, including myself, do not believe there is any value in MRI evaluation of asymptomatic breast implant patients. In fact, there is also a “false positive” rate of 21%, where absolutely normal intact implants are erroneously read as “ruptured” by MRI. I do not recommend MRI on asymptomatic patients whose breasts are soft and implants move normally.

How long do implants last? 

This is a common and appropriate question, since it takes an operation to replace them for any reason, including request for different size. The latest cohesive silicone gel implants (by any of the three USA manufacturers) are not intended to be lifetime devices. That being said, barring complications regarding size, position, contracture, or infection, I believe that these devices will last much longer than the majority of their human recipients. They cannot “leak,” rarely have a manufacturer’s defect or rupture (requiring extreme injuring force or surgeon damage during insertion), and if kept from becoming bacterially contaminated at the time of surgery or subsequent dental work, they do NOT require “replacement” after ten years, or usually ever. I certainly have a significantly lower re-operation rate than the 47% in 7 years quoted in some of the implant manufacturer data. But then again, that data includes doctors of any type who decide they want to place implants, even without training and certification by the American Board of Plastic Surgery—hence, the higher numbers.

Smooth or textured? Above or below the muscle?

The surface of breast implants can be smooth or textured, regardless of the filler material—silicone gel or saline. When silicone gel implants were used prior to the FDA restrictions of 1992, placement above the muscle was also the preferred implant position for many plastic surgeons. Texturing the surface of the silicone gel implant reduced the incidence of capsular contracture in this position (above the muscle and just below the breast tissue).

However, after the 1992 FDA restriction on silicone gel implants and the switch to saline-filled implants, placement above the muscle led to unacceptable wrinkling that could sometimes be felt or seen. This led to most surgeons switching to placement of saline breast implants below the muscle to increase tissue coverage and reduce visible rippling. Even placement of saline-filled implants below the muscle will not always eliminate implant wrinkles or ripples, particularly in thin patients and/or patients with very little overlying breast tissue. Now that silicone gel implants are again available, more patients will be able to avoid the “water-balloon” feel and visible or palpable rippling seen in some saline implant patients.

However, going below the muscle did reduce the incidence of capsular contracture, regardless of textured or smooth (making texture below the muscle unnecessary, whereas above, in the presence of all those ductal bacteria, it was an advantage.)

Based on the choice of saline or silicone, textured or smooth, and the patient's unique body type, appropriate surgical placement will be determined.  Using textured breast implants below the muscle can cause unnatural adherence to the chest and restricted natural movement of the breast, and is not recommended, though this practice is more common in Europe and South America.

In textured saline implants, the lack of gel to act as a lubricant inside the implant (saline is a poor lubricant) can allow flexing and creasing of the implant shell surface with each movement or breath of the patient. This can ultimately leading to a higher risk of failure at one of the low spots in the textured surface, with leakage and deflation of the saline implant. The textured implant shell is also thicker and more palpable. Submuscular placement already reduces the incidence of capsular contracture, so smooth breast implants in this location are preferable to adherent textured-surface implants. The smooth-shell saline-filled implant placed below the muscle is soft, less palpable, and less likely to deflate (if properly filled), and has low rates of capsular contracture formation. It also moves with the patient's position and is therefore more natural and breast-like.

However, smooth-shell silicone-gel-filled implants are even more homogeneous with breast tissue and provide the softest, most breast-like, and most natural “feel” of any implant.  Since the newest generation of silicone gel implants is also cohesive, they cannot leak. While the vast majority of patients are again choosing submuscular silicone implants for their breast enhancement surgery, I believe that the best and most experienced breast surgeons offer their patients a choice of either silicone or saline breast implants.  With careful evaluation of the patient’s individual requests and needs, and detailed discussion of the pros and cons of the three surface textures available, we can help you choose not only the implant but the location and proper profile for your anatomy.

Anatomic (teardrop-shaped) or Round Breast Implants?

Breast implants come in round or teardrop ("anatomic") shapes. While some plastic surgeons prefer the teardrop-shaped implants in some situations, smooth round implants are generally the softest, most natural in appearance (upright and lying down), least likely to be felt externally, and (for saline implants) least likely to leak. They also cost less than teardrop-shaped textured implants.

Textured surface implants have a thicker shell, are more likely to be felt externally, and have a somewhat higher leak rate (saline implants) because of the thinner or weaker areas in the tiny peaks and valleys of the shell surface. Since teardrop-shaped implants must have proper positioning and must stay in that position (sloped part up, rounded part down) to take advantage of their innate shape, by necessity they are textured so that the body's tissues can adhere to and maintain the proper position of the implants. (Upside-down teardrop implants really would look weird.) Even less major malposition asymmetries are “stuck” and remain a bit “off” in appearance. This adherence also makes initial positioning critical—textured implants do not settle or drop over time. Post-op tissue swelling and tightness diminish, giving a softer feel, but position (by definition) is determined by the initial placement and adherence.

Loss of adherence with trauma or activity can allow rotation and distortion of appearance, and this is something noted only with shaped implants, since they are designed to remain in a given position. Loss of that intended positioning can be difficult to correct, as the adherence is now lost, and the implant can freely rotate in its pocket. Round implants do not have this rotational concern, since they look the same in any position.

Teardrop, “anatomic,” or “gummy-bear” implants cannot and do not move very much at all as the patient changes from a standing to a reclining position. Teardrop implants remain teardrop-shaped when the patient is lying down, whereas the natural breast flattens out and assumes a round appearance.  Teardrop, “anatomic,” or “gummy-bear” implants are also more costly than round smooth implants. The smooth round implant does just what a natural breast does: it is teardrop-shaped when the patient is upright, and flattens and drops slightly to the side when the patient reclines. Thus, the round implant is actually more anatomically realistic than the teardrop, “gummy-bear,” or so-called “anatomic implant.”

Some implant manufacturers and plastic surgeons have suggested that the “anatomic” or teardrop-shaped breast implant has a more natural look than a round implant, and much advertising and marketing has been used to promote “anatomic” implants to the public. These implants are perfectly good devices, but are more expensive than smooth, round implants, and whether or not they are truly more "anatomic" is questionable (see above).

A recent study compared actual women with smooth, round implants to women with textured, teardrop-shaped implants. Mammograms were performed in upright and supine (lying-down) positions, and digital tracings computerized and compared. Both the round and teardrop-shaped implants had a sloped, teardrop shape when the women were upright. In fact, in upright patients, teardrop and round implants were indistinguishable on X-ray. But when a woman is lying down, the natural non-augmented breast flattens, drops to the side of the chest, and assumes a round shape, as does the round smooth implant. The teardrop-shaped implant stays teardrop-shaped in the lying-down position, which makes this unusual appearance actually less anatomic than the round implant! Still, in rare situations, the textured or teardrop-shaped implant may be an appropriate choice.

Moderate, moderate plus, or high profile? (and now there’s ultra-high!)

Both saline and silicone gel breast implants come in three standard profiles: moderate “classic,” moderate plus, and high profile. For example, a 400cc (Mentor style 7000) moderate profile silicone gel implant has a base diameter of 14.5cm and a projection (height) of 3.2cm. The 400cc (Mentor style 1000) moderate plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.0cm. The 400cc (Mentor style 4000) high profile silicone gel implant has a base diameter of 12.2cm and a projection of 5.0cm. Mentor now also makes an ultra high profile (style 5000) implant with a base of 10.6cm and projection of 5.4cm for the 400cc size. Thus, various dimensions are available to help best match the desired size of implant to the patient’s breast dimensions.

Allergan Natrelle® implants also come in a total of four silicone gel profiles: moderate, moderate plus, high, and extra-high profiles. To use similar examples, a 390cc (Natrelle style 10) moderate profile silicone gel implant has a base diameter of 13.6cm and projection (height) of 3.8cm. The 397cc (Natrelle style 15) moderate-plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.2cm. The 400cc (Natrelle style 20) high profile silicone gel implant has a base diameter of 11.9cm and a projection of 5.0cm. As you can see by comparing these two manufacturers’ implant dimensions, near-equal volumes and profile implants from each company have nearly identical measurements. Allergan also makes an extra-high profile silicone gel implant (Natrelle style 45) with an 11.2cm base and 5.1cm projection for the 400cc size.

The newest Allergan Natrelle® Inspira implants come in five profiles: low, low plus, moderate, full, and extra full. This allows even more surgical options for every woman’s anatomy and goals.

Since Sientra implants also come in many different shapes and sizes, including smooth, textured, round, and teardrop-shaped styles, each implant manufacturer provides many options for patient and surgeon choice.

I believe it is important to first measure the patient’s breast dimensions, including base diameter, nipple to crease distance, nipple-to-nipple distance (cleavage diameter) and overall chest circumference, determine what final breast size she wants to achieve, and then see if a properly-chosen implant volume and profile can be surgically combined with her own breast tissues and skin brassiere to yield the desired results.  Most of the time it can! In other cases, there may need to be compromises to achieve a good result, or additional skin shaping and tailoring (via breast lift) may be necessary.

A surgeon who “always uses” high-profile implants, for example, “because I like the look of those the best” or “because they give better upper pole fullness” is selling some of his or her patients short. A narrow-chest small-frame petite woman who wants large breasts (but has virtually no breast tissue of her own), may require high profile breast implants to achieve the look she wants.  But a tall, wide-breast base, large frame woman who only wants a modest enlargement (or has a fair amount of her own breast tissue), will not be served well by high profile implants—she needs low profile implants to get as much base diameter as possible for the small(er) size she has selected, in order to accurately fill her own breast base.  Otherwise, she would have a narrow-diameter implant “sliding around” in a large-diameter breast pocket, not to mention very wide, unnatural-appearing cleavage.

Patients are often told (by some plastic surgeons, and often in on-line forums) that “High profile implants give more upper pole fullness.” Until implants drop over the 6-12 months needed for complete healing and “final” position, this is indeed true. But since smooth round HP implants have narrow widths (and more projection), they also have a less-tall height (vertical diameter) that leads to LESS upper pole fullness when the implants reach their proper position at the creases. Choose the widest (lowest) implant profile that fits the breast base diameter for the most upper pole fullness.

Thus, implant profile is based on each individual patient’s anatomy, pre-operative breast measurements, and requests, not on a particular surgeon’s “habit” or “routine.”  It is, in my opinion, not the surgeon’s job to decide what a patient should have, but rather to listen to the patient’s requests, examine and carefully measure the patient’s individual anatomy, and then use our experience and expertise to determine how to best achieve her goals, or at least come as close as the anatomy and details allow. One profile does NOT fit all!

What is the Right Size for You?

Choosing breast implant size can be done in a number of ways; using as many of them as possible only increases the information I utilize to most accurately achieve the “look” each patient desires.

Of course, patients often have input from friends who have undergone this operation, have a "great result," and have ____cc implants. "Get those!" she tells you. But you probably don’t know what proportion of her present size is her natural breast tissue, and how much is implant. Unless your breasts exactly match your friend's pre-operative breast size (doubtful), and the rest of your chest wall, breast base, and anatomy are the same (impossible, unless she is your identical twin sister), you will probably need different implants added to your own tissue to get similar results.

Determining what size is best for you is even more difficult if you rely on friends (frenemies?) who advise to “not go too large” or you will “look fat,” be top-heavy, or have a "porn-star look." Compared to whom? Or is she just a bit jealous? I have seen entertainers, models, and everyday women with breasts of all sizes and shapes--many of whom ask me to give them something different: bigger, smaller, higher, or with an improved shape. What is best for one is definitely not best for all.

Breast augmentation is a personal choice, and while a friend’s input can be helpful, you should choose a size that makes you feel good about yourself. For MOST women, the size you choose is not only possible, but perfect for you! Remember, you should never have surgery to please someone else, or to try to conform to someone else's opinion.

Plastic surgeons that perform lots of breast enlargements have extensive experience in helping our patients choose implant sizes that are compatible with individual anatomy. Every one of us does this slightly differently, and some surgeons even decide for their patient. But what about the patient's wishes?  Every patient has a "perfect size" in her mind's eye, and all we need to do is figure out what that size is, and whether or not it will match appropriately with the patient's chest and breast base dimensions, skin and muscle capacity, position of the nipple-areola complex, as well as a host of individual anatomic factors. I start with breast examination, careful measurements (everyone is asymmetrical), and ask you what your goals are. Based on these factors, I can determine if your requests can be achieved. For most patients, the answer is YES! If not, I will tell you, and we try to figure out what CAN work, and how to best get close to your ideals.

Some surgeons suggest rice bags or water-filled baggies to estimate ideal breast size at home. While many women find this cumbersome and do not wish to utilize these methods, there is certainly nothing wrong with either of these ways of estimating desired size.

One of the best techniques for choosing implant size is for the patient to bring photographs of models with the desired (final) breast size to their consultation, or at the time of surgery. The proper size implant to most closely achieve this goal photo appearance is then chosen in the operating room.  (Since we stock all sizes and profiles of saline and silicone gel breast implants in our surgical center, we do not have to “order in advance” and can change based on your choices right up to the time of surgery).  “Wish photos” have proven to be much more accurate than the patient requesting a letter cup size, or trying to find a similar person via internet search whose anatomy and/or results approximate your goals.  Don't try to match your height, weight, or preoperative breast appearance to the photos, and don't use a stated implant size as a guideline for choosing your implant size—just find an “AFTER” photo you like.

Also, if your breast sizes don’t match (most women have some degree of asymmetry), we can choose different implant sizes and/or profiles to achieve as much symmetry as possible. In more severe cases, we can recommend appropriate procedures (such as breast reduction, breast lift, or other surgical options) to optimize size, shape, and position between more mismatched breasts. Implant choices can be made to help camouflage chest wall or other skeletal asymmetries caused by scoliosis, pectus excavatum, tuberous breasts, Poland’s syndrome, or other genetic syndromes.

Trying on implants in a brassiere and stretchy top is another excellent way to provide some idea of desired final breast size and the implant volume needed to achieve that size; however, it is essential not to become overly attached to a specific bra cup size (B, C, D, etc.) or implant volume (400cc, etc.), since the implant size you like in a bra or top will always look smaller when it is under your own breast tissues and chest muscle.  Typically, a woman who chooses a specific cc volume implant that she feels looks good in her bra will be disappointed (too small) after surgery if that exact volume implant is used in her body.  This is because submuscular compression of the implants makes them look slightly smaller than when sizing in a bra. A good general rule of thumb is to add 30 to 100cc (10-20%) to the implant volume you feel looks good if you choose to size in a brassiere.  In other words, if you like how a 400cc implant looks in a bra, it will take somewhere near a 440-480cc implant to look about the same size in your body. Final size and profile are chosen in the operating room where your surgeon can actually identify specific characteristics of your skin and muscle tone, chest wall (ribcage) configuration, and accurately measure your pocket diameter, not relying just on estimations of breast base width measured pre-operatively.

Minneapolis Plastic Surgery features a comfortable, discreet, implant sizing room where you can try on actual silicone implants in a stretchy top. Comfortable chairs and plenty of mirrors allow you and a spouse, friend, or confidant choose what makes you feel the best about yourself. We then take this information, goal photographs, and any other input from you to help us provide you with the best outcome possible.

In general, for an “average” height and weight woman, 250cc equals about one bra cup size. A 12 ounce can of soda = 360cc. Most patients cannot even see a difference of 50cc (3 tablespoons and 1 teaspoon). Thus, 400cc implants will cause an increase of about 1½  cup sizes to whatever breast volume the patient started with!

Since what this surgery accomplishes is volume increase, your own skin brassiere (pre-surgery breast shape) will determine your final breast shape after implants increase your breast size.  Size and implant profile will also determine just how much breast mass extends to the side of the chest (“side-boob”), or into the cleavage region, since proper implant positioning is determined by the position of your nipple areola complex.


For instance, a woman with widely spaced nipples will need to have her breast implants positioned more laterally (towards the armpit area), since the implant pocket and final breast mound must be properly centered beneath the nipple areola complex.  If the implants were simply placed close together in the center to give the full cleavage look, each nipple areola complex would then be positioned too far laterally, giving a "wall-eyed" appearance. Wider-profile implants may therefore be necessary to give a normal cleavage as well as position.

Similarly, a woman who has more medial nipple position would have a "cross-eyed" appearance if she requested lateral fullness and her implants were placed towards the armpits without taking into account the nipple position atop the new breast mound. 

Clearly, not only size, but also the profile and exact position of your breast implants, is critical to your final result. Your own anatomy determines shape (unless you also need a breast lift, where incisions are made to lift or otherwise shape your breast skin, or reposition too-low nipple/areola complexes).

Most breast implant patients will notice that implant position tends to drop as time goes by after surgery. If you look “perfect” in the first few days after surgery, I believe that even wearing a surgical bra 24/7 may not prevent implant position from dropping to an unattractive “too-low” appearance (“bottoming out”) in a majority of patients after several months. (This also makes the scar position too high above the crease.) I endeavor to take this into account surgically, placing the implant position slightly higher than I anticipate the desired final position to be. I will have you use an elastic bandeau at night, and go braless during the day (when upright), to allow the implants to settle, drop, and soften as time goes by. The elastic bandeau also helps me adjust any differences between breasts, since each side will swell, bruise, scar, and heal slightly differently, and drop into position at its own individual rate! I firmly believe that looking a bit “high and tight” right after surgery ensures a better final result, and a lower likelihood of re-operation to adjust position. In those few patients that do not drop into “perfect” position, it is a much more simple (and successful) re-operation to open the pocket slightly lower than to try to raise the crease and keep it “high enough.” This is especially true if we are successful at creating a thin, soft, pliable capsule around your implants; to try to raise the pocket we must sew to that capsule and get our sutures to remain secure and not “tear through.”

I also make the surgical pockets larger than your chosen implants, and will show you how to do implant movement exercises, often inaccurately called implant massage, to keep the pockets open and larger than the implants so that the final breasts are soft, natural, and drop slightly to the side when you recline (which is what naturally larger breasts do), rather than remaining hard and immobile on your chest.

Most women requesting this surgery emphasize that they do not wish to be "too large" after augmentation.  There is a natural hesitancy to make a change that is so dramatic that "everyone will know" or that might embarrass you at the health club, swimming pool, relative's home, or church meeting.  Most patients have these concerns, and many verbalize this.  However, 6-12 months after surgery, when these concerns evaporate, and the social settings where "someone might notice" are successfully overcome, a surprisingly large number of patients admit they now wish they had chosen larger implants.  Some even undergo another operation to place new, larger implants.  Fortunately, when size change is requested, the surgical pocket for the implant is already healed, and recovery is easier.  Although size choice is entirely up to each individual patient (with some anatomic limitations), choosing just slightly larger than what you consider to be optimal pre-operatively will help you to avoid re-operation for size change, including the cost of new implants, operating room, and anesthesia.         

Are Silicone Breast Implants Safe?  A Brief History

The modern era in breast augmentation began with the development and surgical implantation of silicone gel breast implants in a woman in 1963. In the first 30 years that followed, plastic surgeons worldwide used silicone-gel-filled breast implants for both breast reconstruction and elective breast enlargement in well over one million women. Saline-filled breast implants were also used during this time, but in only about 15% of all patients receiving implants.

Breast implants were developed and utilized for more than a decade before the FDA began regulating medical devices in 1976; the safe and effective use of silicone in these and other medical products such as pacemaker insulation, lubrication for insulin needles, chemotherapy tubing, and artificial joints was well-established before the FDA could evaluate all of them. Because silicone breast implants and many other silicone medical devices were already in use prior to 1976, the ongoing use of these products was “grandfathered” by the FDA without formal evaluation and approval. None of these other silicone medical devices has been made unavailable to patients, but lack of formal FDA evaluation and approval of breast implants came into public awareness in the early 1990s.

The lay media has been responsible for spreading a great deal of information and misinformation regarding breast enlargement in the past twenty-five years. Many women remember tabloid and TV talk shows' focus on the supposed problems claimed to be associated with silicone gel implants. Despite a lack of scientific data supporting these concerns, in 1992 the FDA restricted the use of silicone gel breast implants in women requesting elective breast augmentation.

At  no point have silicone gel implants ever been “taken off the market,” but between 1992 and November 2006 their use required enrollment in the FDA study that allowed only eligible patients and plastic surgeons access to them under strict guidelines. Since the FDA restrictions in 1992, numerous scientific studies (over 30 in the subsequent decade) have continued to show NO cause-and-effect relationship between silicone gel breast implants and autoimmune-type illnesses (such as rheumatoid arthritis, lupus, scleroderma, or so-called "human adjuvant" diseases). Since 1992, silicone gel implants have been used by plastic surgeons (including Dr. Tholen) involved in FDA-approved studies for patients undergoing breast reconstruction, breast augmentation revision (in certain patients), breast lift, and for those patients with congenital breast deformities.

After exhaustive review of the previous nearly four decades of use, the FDA approved the use of saline-filled implants in May 2000.

Late in 2003, the FDA reviewed all of the available scientific data about silicone gel implants, including very detailed information from implant patients over the past decade, and heard testimony from patients, physicians, and researchers. The expert physician advisory panel to the FDA voted to recommend that the FDA approve the use of silicone breast implants for primary elective breast augmentation. However, the FDA deferred its decision, requesting “additional information” before granting approval.

In spring 2005, the FDA again revisited the request by both of the existing implant manufacturers for approval of general use of silicone gel implants; the expert physician advisory panel recommended approval for Mentor Corporation’s gel implants. Late in 2005, Both Mentor and INAMED® (now Allergan) received letters of “[gel implant] product approvable” from the FDA.

On November 17, 2006 the FDA approved the use of silicone gel implants from both companies in patients over the age of 22, with certain restrictions, including involvement in the FDA study that has been ongoing for the past several years.

Opponents of silicone gel implants continue to claim that they cause autoimmune illness or are unsafe, but peer-reviewed scientific studies by many researchers and institutions have shown them to be safe and effective for their intended use. The controversy about silicone gel implants has made them one of the most intensely studied products in the entire medical marketplace.

As part of the 2006 FDA reapproval of silicone gel implant use, each company has an informed consent booklet that you will be asked to read (and sign) prior to breast enhancement surgery.  The FDA has made a controversial recommendation that patients with silicone gel implants undergo a MRI (magnetic resonance imaging, a non-X-ray study similar to a CAT scan) every two to three years to evaluate their implants (for leakage or rupture).  Studies have shown that MRI evaluation of silicone implants has 79% effectiveness in detecting implant rupture or “leak.”  Thus, if you have no identifiable problem or concern with your implants and choose to follow this recommendation, you will require an unnecessary reoperation (for entirely normal non-ruptured) implants 21% of the time!  The FDA makes this recommendation because physician examination has been shown to be unreliable in detecting silicone implant rupture. 

Yet, since present silicone implants are cohesive and cannot “leak,” this is a nonsensical recommendation, in my opinion.  If you are not having any kind of problem or concern with your implants, it is ridiculous to perform a costly (may not be covered by your insurance) and often-inaccurate test that would require an operation (erroneously) over 20% of the time.  Rather, I believe that if you have any issue at all with your implants (size, shape, position, firmness, or concern about possible rupture), return to our office for evaluation.  I can then do whatever corrective surgery is needed, where I will be able to examine, and replace (if necessary) your implants under direct vision.  I can offer better than 79% accuracy with direct implant examination!

continued in Articles: Part 2

Article by
Minneapolis Plastic Surgeon