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


For all but two of the last 10 years, breast enlargement (augmentation mammoplasty) has been the most common surgical cosmetic operation performed in the United States—over 285,000 women requested this operation in 2014, up 183 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. 

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. But for us, this is nothing new—precise surgical technique and outstanding patient care leading to rapid and comfortable recovery 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 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 can fill out the deflated skin brassiere and 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.

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 or sagging of the skin caused by loss of breast volume after weight loss, pregnancy, or breastfeeding, and normal to slightly low nipple-areola position) can usually be corrected with implants alone (standard breast augmentation). 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 and restore fullness. 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 plus breast lift will be necessary.

If the ptosis is more severe, or if nipple position is below the inframammary crease, a breast lift (mastopexy) procedure 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
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 ordering the “right
ones,” 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), configurations or 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.

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
investigational implants that 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

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.

Filler Materials

Other types of filler material have been
evaluated over the years, and one or more problems are associated with these.
Paraffin, sponges, and other unusual materials were used in early efforts to surgically
enlarge breasts; results were dismal until silicone came into use in the
1960’s.More recently, 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” using one’s own fat tissue (and 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 because 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.

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

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


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 (mpsmn.com). 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
silicone gel or saline implants 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 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


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 can 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 recently been FDA
approved, but we feel this implant configuration is usually more appropriate
for reconstructive or “rescue” operations than for primary cosmetic breast

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 this will confer better
statistics, outcome studies, or lower complication rates than the other
companies’ practices remains to be seen.

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.

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.

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 really 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


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.

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

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.

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

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.

Since Sientra implants also come
in many different shapes and sizes, including smooth, textured, round, and
teardrop-shaped styles, many more options exist 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 moderate 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

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
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

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 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 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.

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 50 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.

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 1½cup 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.

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

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).

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.”

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.

Atno 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

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

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 re-operation (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!


Implants and Breast Cancer; Mammography

Numerous scientific studies have shown that augmentation mammoplasty does not increase the risk of developing breast cancer.  Even without a family history of breast cancer, a woman has an 11% risk of developing a breast cancer in her lifetime.  If there is a family history of breast cancer, these risks are higher.  It is important to realize that while breast enlargement does not increase the risk of developing breast cancer, it also does not reduce the risk, so every woman must continue breast self-examination, physician examination, and mammography, regardless of whether or not she has breast implants.  If you have any concern whatsoever regarding your breasts, I would be happy to perform breast examination and answer any questions; there is never a charge for consultation or recheck for any reason.

In early 2011, the FDA requested that health care professionals report confirmed cases of anaplastic large cell lymphoma (ALCL) in women who have breast implants.  This FDA request was part of an investigation of a possible association between breast implants (saline and silicone) and ALCL. The FDA reported that the scientific literature from January 1997 through May 2010 showed 34 unique cases of anaplastic large cell lymphoma (ALCL) in up to an estimated 10 million women with saline and silicone breast implants.  This equates to 1 case per 294,118 women (over 13.3 years), or 0.00033%. These cases were most common in patients undergoing revision for late onset, persistent seroma for which treatment may consist of implant and adjacent capsule removal.

ALCL is lymphoma, NOT breast cancer, and some researchers have suggested that breast implant-associated ALCL may represent a new clinical entity with less aggressive behavior (Li, 2010; Miranda et al, 2009; Thompson et al, 2010). Because of the extremely small number of cases and short median duration of follow-up, the FDA states that it is premature to draw conclusions regarding prognosis of ALCL in women with breast implants.

The FDA also states that because the risk of ALCL appears very small, the totality of evidence continues to support a reasonable assurance that FDA-approved breast implants are safe and effective when used as labeled.  The FDA further states that "There is no need for women with breast implants to change their routine medical care and follow-up."

Mammography can still be done successfully in women who have undergone breast enlargement surgery.  Most radiologists feel that they can adequately view 99% of a woman's breast tissue even with implants in place, though special techniques and additional views may be necessary to accomplish this.

Although there is a slight chance that mammography might cause leak or rupture of a saline breast implant, this is less likely with a soft, non-contracted breast, with smooth implants, and with submuscular placement.  (The present generation of silicone implants is cohesive and cannot leak.)  Improperly-performed mammograms can forcibly compress and rupture the scar capsule around any kind of breast implant, so it is important to let the radiologist and technician know that you have breast implants.  A radiographic method called the Ecklund technique (also known as the displacement technique) compresses the breast tissue in front of the implant, and not only increases the visibility of breast tissue in the mammogram, but also reduces pressure on the implant.  I do recommend a baseline mammogram one year after augmentation, so that any scar tissue or calcium deposits within the breast are documented and available for comparison with any subsequent mammogram.


Timing of Surgery

Many women wonder if they should wait until their
family is complete before undergoing breast augmentation.Certainly, pregnancy and breast-feeding
change the breast skin, shape, and size; these are common reasons many women
choose to have this surgery.Should a woman
who has never had a child (and plans to in the future), or a woman who wishes
to have more children later, undergo augmentation mammoplasty?

your breast development is complete and you have had breast enlargement surgery,
and then later become pregnant and breast-feed, your breasts will indeed change
in appearance, just as in a woman who has larger breasts naturally, becomes
pregnant, and nurses her baby. Since
breast implants are in most cases placed beneath the chest (pectoralis major)
muscle, and in all cases beneath the breast itself, the presence of implants does not interfere with the function of the
breasts.Whatever breast tissue a
woman has prior to breast enlargement surgery will swell and respond to the
normal hormonal changes of pregnancy and later breast-feeding.The degree of enlargement, skin stretch, and
later droop or sagging is as individual as each woman.A patient who had breast augmentation prior
to pregnancy may choose to undergo a breast lift when her family is complete, just
as the woman without breast implants.Others may simply choose a slightly larger implant to further fill the
stretched skin brassiere.Or, you can
indeed wait until your family is complete, and then undergo augmentation to
obtain desired breast size, or augmentation plus mastopexy if a lift is needed
in addition to restoring volume.

What you need to know is that it is safe and
appropriate to choose either way, whichever is best for you.

augmentation does not generally affect the ability to breast feed.One study
shows that about 54% of women without implants reported problems nursing.93% of breast augmentation patients had their
children before undergoing the procedure, so nursing was not an issue. Of the
7% who had children and nursed them after augmentation, 50% reported problems,
essentially the same number as those without implants.

Article by
Minneapolis Plastic Surgeon