Upper Pole Fullness in Breast Augmentation: The Role of Cohesive Round Implants
One very common request from breast augmentation patients is for more cleavage and upper pole fullness. This look is characterized by fullness/roundness in the upper chest, cleavage, and an implant which appears to sit higher on the chest. Achieving this look requires careful attention to detail and choosing the correct size and type of breast implant.
Surgeons should be very careful and meticulous in dissecting the "pocket" or space where the implant will be placed. For upper pole fullness, a submuscular pocket generally is preferred and will support the implant better in the upper pole. The pocket should be carefully designed to be only as large as the circumference of the implant and no bigger. The pocket should fit the implant like a glove leaving no room for the implant to move around in the pocket space. Great care should be taken to make space for the implant in the upper and inner part of the breast and to avoid making space on the side near the armpit (anterior axillary line). The will allow the implant to create breast volume in the upper and middle/inner part of the breast where fullness is desired. Finally, great care should be taken not to dissect or violate the breast crease (inframammary crease) under the breast. Leaving the breast crease in tact will hold the implant up and not allow the implant to fall down over time. In most cases, I will support the breast crease with internally placed sutures to hold the breast crease in place and prevent the implant from migrating down over time (bottoming out).
Saline implants are filled with liquid which will not hold it's shape in response to gravity. In the upright position, the liquid inside saline implants will migrate down creating a bottom heavy implant with no fullness in the upper part where it is needed.
Silicone implants come in several different varieties depending on how form stable the gel matrix inside the implant is. Form stable gel has been used for year in anatomic or breast shaped implants. These implants were designed to mimic the shape of the breast thereby creating a more natural look. Ironically, these anatomic implants utilized the form stable gel to lessen the fullness in the upper pole. Due to increased patient demand for upper pole fullness, implant manufacturers utilized the form stable properties of ultra cohesive gel in a round implant. The newest generation round implant place the form stable gel into the round implant which allows the implant to hold it's upper pole fullness against gravitational forces. The result is that in the upright position, the implant will remain full at the top of the implant creating breast volume in the upper and inner part of the breast where it is needed. This implant is manufactured by Allergan and is called "Inspira Cohesive." The Inspira Cohesive implant has a higher gel fill ratio, rounder shape, and form stable gel which holds its shape in the upper pole.
Implant profile: Implant profile is an important consideration in achieving the desire breast outcome. Implant manufacturers generally produce implants in 3 or more categories: low, moderate, and high profiles. The profile determines how far the implant will project outward from the chest. In the Inspira implant line, the profiles are low, low-plus, moderate, full, and extra-full profile. Patients who desire a rounder, fuller breast shape with upper pole fullness and cleavage should choose a higher profile implant (full or extra-full). By definition, the higher profile creates more upper pole full, more roundness, and more cleavage.
Implant texture: Implants come with either smooth or textured outer shells. Smooth implants are very "slick" and do not allow the body to adhere to their shell. Over time, these implants will drop further and have a higher incidence of "bottoming out." In the subglandular plane, smooth implants also have a higher incidence of capsular contracture. Textured implants have a rougher surface which allows the body to adhere to the implant surface. This prevents the implant from moving around in the pocket and allow the implant to better stay where it was initially placed. Over time, in response to gravity, textured implants won't drop as much as smooth implants and will maintain their intended position in the upper pole. Textured implants also have a lower incidence of capsular contracture in the subglandular plane.
Implant size: Until recently, implant size was determined by arbitrary factors such as implant sizers or other methods to estimate size such as rice filled zip locked bags. These methods were not only inaccurate but lead to confusion as to what size would be best. Recent technology has evolved to allow the surgeon to photograph the patient and create real time 3D images where implants can be placed using virtual reality software programming. The patient can see exactly what size, shape, and profile of implant will look like before undergoing the procedure. This eliminates all guesswork surrounding the procedure and gives the surgeon and patient much needed peace of mind knowing how the implant will look before the procedure.
In summary, achieving upper pole fullness and cleavage can be achieved with careful surgical technique and the correct choice of implant type, size, and texture.
1. Make the pocket the exact size with room in the upper and middle part of the breast
2. Do not violate the breast crease and reinforce the breast crease with internal sutures
3. Choose a textured, round, high profile implant, with form stable gel (Inspira Cohesive)
4. Use 3D imaging to choose the desired implant
Dr. John L. Burns, MD
Board Certified Plastic Surgeon