This is a very good question, because it's a very common issue, and it's one that, as you can see, you will get lots of varying opinions about. I always try to be very "common sensical" about stuff like this and adhere to proven facts or things that make sense based upon logical reasoning and the preponderance of experience - mine and others. With those things in mind, I have a few general comments to make about this type of situation that will probably apply to your case. First, there is one immutable fact about placing breast implants: at the end result, the nipple has to be positioned appropriately on the breast mound, or the breasts will look odd. This means positioned properly in the up-and-down plane as well as the side-to-side plane. We can debate about what those specific positions are precisely, as many surgeons may have differing opinions on that, but for the purposes of this discussion, I think it's sufficient to talk in general terms. Having said that, it's just very simple geometry to recognize that if your "lower pole arc length" - the distance between your nipple and your existing inframammary fold - is short, you will either have to limit your selection of implants to those with a base diameter that will fit within the existing arc length of your breasts without adjustment, or you will have to increase that arc length to accommodate an implant of larger size, if you are to wind up with a properly positioned nipple. That's pretty much it. I accept that we can plan on a little bit of stretching of the tissues to slightly increase that arc length over time, and this helps, but it is also highly variable and depends upon many factors, some related to each patient's tissues and anatomy, and some to the type of implant being used. More about that issue in a minute. In any event, I think you get the idea that those surgeons who are vehemently opposed to lowering the inframammary fold at all costs will either be limiting their patients to a smaller size range of implants, thereby probably resulting in more unsatisfied patients who wish they could be bigger, or they will routinely place the implants too high in these ladies, leaving their folds (and thus arc lengths) intact, and relying on the very unpredictable and uncontrollable process of "settling" to obtain proper final position of the nipple. If that doesn't happen, which is frequently the case, they then wind up with nipples pointing downward over implants which are too high. Those are pretty much your options if you don't properly adjust the fold. Admittedly, adjusting the fold to any degree does present some chance that there will be a double contour, or "double bubble." However, if it is done properly, with proper release of internal tissues and proper stabilization of the new fold position, you can very reliably and predictably avoid double contour AND control the risk of "bottoming out " of the implants. I know this because I routinely adjust the folds with no problems. With regard to the type of implant used, I think this depends more on what you want your upper pole to look like, and less on the ability of round or anatomical implants to avoid double contour more. Both types of implants can result in double contour if used improperly or if the tissues and anatomy are too unfavorable. As you probably know, anatomical implants create less upper pole fullness and a more “natural look,” while round implants create more upper pole fullness and a more “obviously implanted look.” This is the most important feature and deciding factor between them, in my opinion. One subtle point that I can make here, though, is that there may be an argument to use anatomical implants over certain round implants in this setting. Anatomical implants are always textured, and they are all highly cohesive gel, or “gummy bear” type. This means they are solid and “form stable,” or they always want to hold their form. Thus, when highly cohesive gel implants are compressed, say by tight tissues, they always want to “push back” to regain their original form. Over time, they will often work like a tissue expander and slowly but surely stretch the tissues as their “memory” forces them back into their original shape. This can alleviate double contour better than an older less cohesive gel implant, which most round implants still are today. The one company that makes all of their round implants out of highly cohesive gel is Sientra, and for that reason, if I am going to use round implants, I will frequently use Sientra implants. Another fine point to make here is that all 3 US implant manufacturers have differences, subtle but still differences, in their gel “stiffness,” their dimensions - like projection height, width, and vertical height, and their texturing. I use these differences to my advantage. For instance, if I have a patient who has tight tissues and in whom I need to lower the fold significantly, I might use a higher projecting shaped implant style from a company whose gel is a bit stiffer than another in order to make the implant “work for me.” Textured implants, round or shaped, don’t slide around and move in the tissues, so it’s a whole different way to think of them. Again, you have to think more about tissue “stretching” and compliance as opposed to moving/settling/“bottoming out” of the implants. There are a couple of things that are frequently said about different implants by surgeons that I disagree with wholeheartedly. First, bottoming out is not common just because you lower the fold. As I said above, if the fold is controlled properly, and especially if you use a textured implant which stays in place better because of its friction on the tissues, bottoming out, or at the very least, uncontrolled and undesirable migration of the implants is not a problem at all. I think smooth implants are always more likely to become displaced or bottomed out, and I personally like the control that textured implants offer, especially when I have to do a lot of manipulations of the position or dimensions of the breast mound. Second, placed properly, shaped implants do not rotate or have displacement problems. I use a ton of shaped implants, and I have yet to have any problems with rotation. Can it possibly happen? Sure, but I’ll bet in the VAST majority of times when it has, it was there at the time the surgeon closed the wounds and wasn’t recognized or addressed then. It very rarely happens after the surgery. The studies all show this. Third, most round implants DO NOT take on a truly teardrop shape after surgery. Just look at the majority of round implant results out there compared to the shaped implant results and convince yourself of this. Differences in tissue compliance of different patients may have some small bearing on the gel mobility within the implant postoperatively, but in general, round implants still remain more or less round, compared to a true anatomically shaped form-stable implant. There is no question that if you hold a (4th generation, older cohesive gel) round implant up just by pinching it with your thumb and finger, it will drape into a teardrop shape. This isn’t reality in the body though, as the tissues support the implant all around, and they preserve much of the round upper pole fullness compared to shaped implants. Now, you can make any implant - round or shaped - have a fuller or less full upper or lower pole just by how you position it up or down; that ’s not what I’m talking about. I’m talking about those guys who say that all round implants take on a teardrop shape, implying that there’s no difference ultimately between round and shaped implant results. I disagree based upon hundreds of examples of each. As you can see, this can actually wind up being quite an undertaking in some ladies, if we are to really strive for precision and optimal results; it’s much more than simply making a pocket and sticking an implant in it. I know I’ve touched on a lot of technical details that might make your eyes glaze over, and I didn’t necessarily expect you to memorize all of this or understand it fully, rather I wanted to impress upon you how technical this operation has become and how many different things there are to consider if you are to consistently get excellent results. For this reason I think it’s very important for you to visit with board certified plastic surgeons who have lots of experience with different techniques of breast augmentation, as well as using all different types of implants. This way you will be sure to learn about all possible options available to you and be guided to select the options that are most likely to produce the results that you are looking for. In addition to being certified by the American Board of Plastic Surgery, the only generally recognized organization which certifies true plastic surgeons and has the term “Plastic Surgery” in its title, your surgeon should also participate in the Maintenance of Certification program administered by that board. This program requires that surgeons who participate continue to update their credentials and professional standing regularly, as opposed to practicing on a single lifetime certificate like those plastic surgeons who elect not to participate. To find further information about this program and any surgeons you might consider for your surgery, I suggest visiting these sites: abplsurg.org and abms.org. Good luck.
The type of implant probably won't effect the risk of the "double bubble" contour irregularity. A breast implant will increase the distance from the fold under the breast to the nipple. Unfortunately, when the muscle in the lower portion of your breast is still attached to the breast tissue, it will create a crease or "double bubble" deformity. In your case separating the muscle from the breast tissue, as in a dual plane procedure, or placing the implant on top of the muscle would reduce the risk of the double bubble contour deformity.
Thank you for your question and photographs. In cases of a short nipple to fold distance I am not in favor of lowering a woman's breast crease due to bottoming out, but I would recommend appropriate muscle release so that the weight/volume of the implant will round out the lower portion of the breast with time. Hope this helps.
The double bubble is a technical related issue so can occur with either implant. I have personally never felt the contoured implant offered that much advantage since a round implant looks essentially like a contoured implant in the vertical position but holds that shape regardless of rotational orientation. At the end of the day, the answer is whichever implant your surgeon feels wills give you the best most predictable result in their hands.
In the face of a short nipple to IMF distance such as I see in your photographs, with either shaped or round implants being used, there will be some necessity to lower your fold. In my experience, anatomically shaped implants, especially the full height variants, tend to put a more downward pressure on the IMF leading to bottoming out more readily than a similarly sized round implant. My recommendation for you based on what I see in your photograph, would be a round smooth implant. Hope this is helpful.
If your surgeon doesn't lower your fold under the breast and uses an appropriate sized implant either a round or a contoured implant will work well.