i dont know whether to go big or medium, saline breast implants or silicone breast implants, under or over muscle. help!
Best Breast Implants
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The Best Breast Implants - The best surgeons provide the best outcomes
Over and over I hear patients remark, after reviewing some of our `before and after' photos, that they had no idea that a breast augmentation could look so natural. It can, and in my opinion it should. Having practiced plastic surgery in the 'breast augmentation capital of the world' (Los Angeles), and having performed hundreds of breast augmentations in North Carolina for patients who are seeking a breast enhancement that looks like it actually is a natural part of their body, I have developed some fairly strong opinions about this operation.
it is important to discuss the following with your plastic surgeon
*Cohesive silicone gel vs. saline breast implants
*How many cc's? - deciding on implant volume
*Incision locations - around areola or underarm incision
*Subpectoral vs prepectoral implant position
* Position of Implant nad creating appropriate pocket so implants are not too far apart or too close together
* Repositioning of inframammary fold - is this right for you?
*Breast augmentation after pregnancy
* Augmentation alone vs. Augmentation plus mastopexy (breast lift)
* Protecting Breast Implant position after breast augmentation surgery
*Special considerations: asymmetry, tuberous/constricted breasts, etc
*Recovery and downtime
*Avoiding capsular contracture
* Mammograms and breast implants
*Revisional breast augmentation surgery
IWomen considering breast augmentation now have the luxury of deciding between two kinds of breast implants: cohesive silicone gel (approved for cosmetic use by the FDA in 1996) and saline. There are a number of pros and cons to consider with each type of implant however the most important thing to know is that patient satisfaction is very high with both. You can't really go wrong with this decision - it is merely a matter of deciding which is best for you personally.
It is also very important to understand from the outset that a cohesive silicone gel implant is a very different (and vastly superior) medical device compared to the older liquid silicone gel implants that were available for cosmetic use in the 70's and 80's, but were not approved by the FDA for cosmetic use from 1991 to 2006 (although they still could be used for breast reconstruction). The new cohesive gel implants are manufactured so that the gel material is in a solid state which means that if the implant's outer shell fails, the gel material does not easily leak out of the implant as it would with the older liquid silicone gel implants. The design and manufacturing process for the outer shell has also improved a great deal, resulting in significantly lower implant failure rates. These improvements make gel implants much more appealing as long-term medical devices, and because of the major improvements the FDA cleared them for cosmetic use in 2006.
One very important issue to consider is implant palpability, i.e. whether you can feel the implant or not when you - or someone else - feels your breast. Both silicone gel and saline implants are soft and generally breast-like. Most surgeons and patients agree, however, that silicone gel breast implants tend to feel more natural than saline breast implants. Because saline is non-viscous, it tends to allow the edges of the implant to collapse and this makes the implant edges more easily palpable. This will be quite obvious to you when you examine samples of saline and silicone gel implants during your consultation.
The degree to which this difference is significant varies a great deal with regard to two factors: the amount of breast tissue that exists prior to augmentation, and the size of the implant that is used. A silicone gel implant's more natural feel will be much more important to patients who are slender and who fit in an A cup bra preoperatively, as they have less subcutaneous soft tissue and breast tissue to conceal the implant. In such a patient a saline implant is usually very easy to feel through the skin, and may even be visible externally - especially in the lateral aspect of the augmented breast where the tissue covering the implants is the thinnest. The difference in feel between saline and gel implants will be less noticeable to a patient who is more full-figured and whose pre-operative bra size is a full B or especially a C cup, and in some fuller-figured patients saline implants may be undetectable by palpation (meaning they feel completely natural). Saline implant palpability is primarily a matter, therefore, of how much natural tissue there is to disguise the implant.
Another important difference between gel and saline breast implants is what happens if the implant shell fails. If a saline implant ruptures, that breast will rapidly 'deflate' as the body absorbs the saline. Most patients have little tolerance for having just one augmented breast, of course, and a saline deflation thus requires a return to the operating room to replace that implant. When a gel implant fails, there is no change in the appearance or feel of the breast, as the gel material is inert and is not absorbed by the body (and with cohesive implants the vast majority of, if not all of the gel material, remains within the implant's outer shell).
The actual size of a breast implant, measured in cc's, is really not very descriptive of what a breast augmentation will look like, or what the cup size will be. It is all relative to the size of the breast and the size of the patient preoperatively. A tall, broad-shouldered patient with small A-cup breasts may require 450cc implants to achieve a C-cup breast volume postoperatively, while a shorter patient with medium B-cup breasts may only need a 250cc implant to achieve a C-cup breast volume.
For any patient there is obviously a range of implant volumes that would be considered natural-appearing, and a volume at which the upper pole of the breast begins to look very unnatural. While one patient may seek an augmentation that is 'perfectly natural', another may be interested in a result that is more on 'the full side of natural', and many patients do ask that the largest implant volume be selected that does not produce an unnatural fullness in the upper pole. By using breast implant sizers intra-operatively to determine exactly what breast implant profile and volume produces the best breast appearance in the O.R., patients can be provided with the closest possible approximation of their preoperative goals, and can be assured of a natural-appearing result.
In many breast augmentation patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola. Ideally the implant should be centered directly behind the nipple-areola complex (NAC). In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that a breast implant sits below the skin. In addition, inadequate release of the inferior origin of the pectoralis major will allow the muscle to hold the implant in too high a position, and may even cause the implant to displace upwards (as high as the collar bone in some patients) when the muscle contracts. Patients with this problem require reoperation to release the inferior origin of the pec major and/or the inframammary fold.
Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance, and one that requires surgical correction: repair of the inframammary fold(s).
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. The result may (or may not) be tolerable in the upright standing or sitting position, but when the patient lays down in supine position (on one's back) the implants may fall far to the side and produce little to no anterior breast projection in this position. Patients with the problem almost always want it corrected, and the treatment once again is surgical: a lateral repair of the implant space, to restrain the implants from falling off to the side.
Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. It is lateral projection of the breasts beyond the lateral border of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure'. While one does not want to over dissect the lateral extent of an implant pocket, careful attention must also be paid to ensure that lateral breast projection is not inadequate.
Breast implant base diameter is also of crucial importance. The base diameter (the side-to-side dimension of the implant) must be ideal for the existing horizontal dimension of the breasts preoperatively, as well as the breadth of the anterior chest in general. Obviously, a given implant volume and base diameter that works well for a small-framed patient that is 5'3" will be completely inadequate for a broad-chested patient who is 5'10". One wants to increase cleavage area fullness and lateral breast projection in most cases, and an implant of inadequate base diameter may accomplish only one of those goals, while too wide an implant will be overprojecting in both directions.
Careful evaluation of all of these breast and implant dimension issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.
Options and Alternatives for Breast Implants and Incisions
Breast Augmentation now offers patients and surgeons alike a great deal of choices in terms of types of implants, location of incisions, and placement of implants above or below the muscle.
A number of factors influence the utility of these methods of placement of breast implants, and not every option is available to every patient. It is critical for the patient to choose a surgeon who has experience with all types of breast implants, who has the technical skill to place the implants through a variety of incisions, either above or below the muscle, and who possesses the familiarity with the multiple anatomic variations of women’s breasts.
The surgeon must possess the appropriate judgment as to which combination of implant, incision, and pocket will have the greatest likelihood of producing a natural result with the fewest possible risks or complications. Any surgeon who applies a “cookie-cutter” philosophy, who offers only one type of implant, or one surgical approach, cannot possibly create a pleasing breast except by chance.
Types of Breast Implants:
- Saline vs. Silicone
- Smooth vs. Textured
- Round vs. Shaped (Anatomic/Form Stable)
All breast implants share the common characteristic of an outer silicone rubber shell, which can be either smooth or textured. The implants then vary depending on the characteristic of the filling material inside the shell.
Saline Breast Implants are packaged empty, and are filled by the surgeon at the time of operation using sterile injectable IV saline (salt water) solution, through a small valve located on the surface of the implant. Saline implants became most widely used between 1992 and 2006, during the FDA moratorium on gel implants.
After a 15 year hiatus, during which their use was restricted to a limited number of patients meeting specific criteria, Silicone Gel Breast Implants were returned to full market availability in the U.S. in November 2006. The silicone gel is a polymer with a density similar to fat, and can be chemically altered by the manufacturer in a variety of ways to create different degrees of viscosity, from a consistency somewhat like honey or molasses, to that of a “gummy-bear”.
Implant shells can be created from molds in either a round, disk-like form, or in a shaped form (crescent, tear-drop, etc.) in both saline and silicone formats. The “anatomic” or “form-stable” implants are generally filled with a higher-viscosity (“cohesive”) silicone gel, and are intended to hold their form at all times, whereas round implants are intended to flow with the breast as the position of the patient changes, since the saline or silicone gel flows according to the laws of gravity in a round implant.
Generally speaking, saline implants can be placed through smaller incisions, and “form-stable” or large gel implants require larger incisions.
Breast implants can be placed via a number of surgical approaches, either above or below the pectoralis muscle which lies under the breast itself. With any approach, there is a risk of bleeding, infection, or loss of sensation. There is generally no impairment of breast function with any incision approach.
The Trans-Axillary approach involves placing an incision near the apex of the armpit in the natural skin crease. A pocket is then created either behind the breast itself, or behind the pectoralis muscle and the breast, for placement of the implant. An endoscope (lighted surgical camera-telescope with images viewed on a TV monitor) can be used to assist in the dissection of the pocket, or the procedure can be done blindly.
Advantages of this incision include no visible scar on or near the breast. Disadvantages include potential numbness in the upper inner arm area, potential difficulty with proper implant positioning, and inability to re-use the incision in some cases of later breast revision surgery.
The Peri-Areolar approach involves placing the incision around the border of the areola where it meets the lighter skin of the breast, usually around the lower semi-circle of the areola from 3:00 to 9:00. The incision is carried through the breast tissue until the space behind the breast tissue is reached, or alternatively lifting the pectoralis muscle as well to create a space under the breast and muscle.
Advantages of the peri-areolar incision include the fact that the incision is hidden under all types of clothing; the scar is generally acceptable and can be re-used in the event that future implant revision surgery is needed. Disadvantages include variable and transient loss of nipple sensation.
The Inframammary approach involves placement of the incision in the natural fold below the breast, or in the position where the fold is desired after placement of the implants. The pocket can be created above or below the muscle.
Advantages of the inframammary incision are that the breast tissue is not disrupted, and the incision can be re-used for future breast implant revisions. Disadvantages include potential unsightly visible scars.
The Trans-Umbilical (“TUBA”) procedure involves placement of the implant through a remote incision at the upper border of the belly button. A variation involves placement of implants from below, during an abdominoplasty (“tummy tuck”). The procedure is generally done “blindly”, developing the space either above or below the muscle.
Advantages include a scar remote from the breast. Disadvantages include difficulty with accurate implant placement, difficulty controlling potential bleeding, and inability to re-use the incision for implant revisions. Usually, saline implants are placed, since larger gel implants cannot be placed from such a remote and small incision.
Through any of the potential incisions, a space for the implants can be created immediately behind the breast tissue and above the muscle (Sub-Glandular), or behind both the breast tissue and the pectoralis major muscle (Sub-Pectoral / Sub-Muscular / Dual-Plane).
In general terms, women with more native breast tissue, or women who have some degree of sagginess of their existing breasts, are better candidates for sub-glandular implant placement. Advantages of sub-glandular implant placement include less immediate post-operative pain. Disadvantages include greater potential ability to feel the implant, or to see rippling or wrinkling of the implant with the breast in certain positions, and slightly greater interference with mammography.
Women with smaller breasts, without droopiness, are generally better candidates for sub-muscular implant placement. In this situation, the majority of the implant lies beneath the muscle, while the lower and outer portions of the implant lie in contact with the breast tissue itself (hence the term “dual-plane”). Advantages include less ability to feel or see implant ripples or wrinkles, and less ability to see the contours of the implant, and less interference with mammography. Disadvantages include greater immediate post-operative pain, slightly greater difficulty achieving good cleavage, and mild distortion of the breast with contraction of the chest wall muscles.
Making the Choice
Your surgeon should carefully examine your breasts for masses, make note of your breast dimensions relative to the chest wall and your body build, and analyze the individual characteristics of your breasts. After listening to your desires and goals for the surgery, your surgeon should be able to articulate to you a specific treatment plan that will meet your goals, including the best type of implant, incision, and pocket location for your specific case.
Remember, one size of breast implant does not fit everyone, and one tool or surgical approach cannot do every job or properly treat every situation.
How do I choose the best implant for me?
One of the things I find most interesting is the amount of misinformation the average patient must sift through when researching breast augmentation surgery. In particular, I think that many patients become overwhelmed with implant choices and the abundance of information about these options available on the Web.
This is complicated once they contact a surgeon or two for information about the implants, and which is most likely to give them the result they desire. Somewhere along the way, opinions expressed by a surgeon are perceived as fact by a prospective patient (because of the surgeon's reputation or the apparent strength of his/her opinion), who then becomes more confused when she hears a differing opinion.
This leads to ridiculously technical questions being posted on sites like RealSelf and others, such as:
"I am 5'5", 125 lbs, my measurements are 34, 22, 36. I have had 3 babies, all by C-section, and I breast fed two of them. My breasts sag a little, but not as much as some women I have seen. I want to have a full C-cup breast. Should I get 325 cc Allergan 410 style implants, or Mentor 350 cc Moderate profile implants. Projection is more important to me than a natural shape..."
Every time I get one of these over-thought questions, I always think the same thing... ???????
Let's take a big step back from the trees here and take a look at the forrest in front of us, shall we?
Fundamentally, the reason any woman seeks breast augmentation is because she wants to achieve a certain appearance, right? Let's repeat that- to achieve a certain appearance. NOT a certain bra size, or a certain implant volume, or even a certain implant type. When you first stared to think you might want an augmentation, you didn't think, "I would like it if I could have 350cc implants"... You probably thought, "I would love to look like that (after admiring another woman's breasts)..."
So if we can agree that what you are really after is an appearance you would be happier with (as I always tell my patients), let's make the desired appearance the focus of our communications...Let us both ignore bra sizes (which are not standardized and the choice of which is very arbitrary) and implant types/sizes (for now)... Let's first understand what you want to look like. I think you would agree that if we are able to make you look the way you wanted to look, the letter on your bra and the number on your implant is lees important, right? Help me understand what you want to look like, and I can give you a very accurate recommendation of options for achieving that appearance -- provided a careful physical examination has also occurred.
Why is the exam so critical? After all, can't we just put small implants in women who want small breasts and larger implants into those who want larger ones?
The exam is critical, because for any one particular woman, there are only a few good choices of implants available, regardless of her goals, and these options are arrived at by taking careful stock of her breast tissue, skin, and frame. In other words, your anatomy will, to a large extent, help us understand the implant options that would make you look the best. This is the "One Right Result" concept. The taking of these measurements is so important, I do it myself every time, and based on these measurements and my patient's goals, then make recommendations regarding the implant options available to her (as these options would be different for different women).
While (as with any aesthetic procedure) no guarantee of outcome can be given, you are much more likely to achieve your desired outcome if you focus on communicating your desired appearance successfully with a skilled and experienced, Board Certified Plastic Surgeon than by over-researching the implants and micro-managing the details of the surgery. In fact, I can think of no better way for you to increase the odds of you ending up dissatisfied.
So don't over-think it. Think carefully about the appearance you want, communicate it carefully to your surgeon (using photos if possible), and make sure that the implant choice arrived at by the two of you together is based on both your anatomy and your goal. You'll be happier and the process will be less stressful!
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Best Breast Implants-Choose the Best Experienced Plastic Surgeon
Thank you for your great question.
The best Breast Implants are the ones that look the best on you, are soft and natural looking and feeling, and are placed with minimal discomfort and recovery without complications.
The most important decision you make will be the choice of your Board Certified Plastic Surgeon.
The Best Breast Implant Result is not based on the type of implant but on your surgeons skill in helping you decide the best implant, location of implant and scar, and performing a careful expert Breast Augmentation.
It is not the device-implant-but the skill of the doctor that will determine your result.
That said there are a few generalities:
- Under the Muscle is preferred by most plastic surgeons if possible - eg. normal breast position without sag
- Most patients today prefer Silicone Gel Breast Implants because of their natural feel and less tenancy to create visible folds
- Incision under the breast is most common-better visibility and accuracy for the surgeon fewer revisions necessary
- If you have Ptosis-breast sag- a Breast Lift is best but in some cases a Sub Glandular-over the muscle-Breast Implant will work.
I wish you a happy result.
Individualized Breast Implant Options
Choosing the right implant/prosthese is a personal decision, but be sure your surgeon can guide you.
There are a lot of posibilities (size, measurements, implantation place, shape, incisión), but not every option is available to every patient. Patient's desired options followed by a thorough breast examination is a major part in choosing the correct surgical procedure and implant option.
In Spain (Europe) there is a long tradition in breast augmentation surgeries. It’s not good to generalize, but usually, anatomical shaped prostheses, submuscularly placed will result in a very natural and “unoperated” look. Each woman need individualized valuation and very likely a different implant.
SO MUCH TO KNOW!
Hello 'Best Breast Implants',
It is a daunting task to figure out all the variables available to you regarding breast augmentation. I would like to guide you to Dr. Cambre's excellent answer to your question, if you haven't already read it. It is unbiased, complete, and factual. I would like to emphasize a few points though, and give you my particular bias as well!
Regarding implant material, there really is no compelling reason to chose a saline filled implant. They are more palpable, and less durable than silicone gel filled implants. Enless money is really holding you back, silicone should be seriously considered. They are more natural to the touch, more durable, equally safe, and it is not an immediate problem if they infact rupture, like saline.
Implants that are smooth and round give an equally natural result as 'shaped' implants with less risk of secondary problems associated with them: more rippling and rotational issues. If you are looking for a natural result, than it is the size of the implant that is most important when chosing your implant.
Implants really should be placed under the muscle, where there is the lowest risk of capsular contracture. Additionally, long term affects of subglandularly placed implants are usually unsatisfactory: visible implant contour in the central chest area, visible and palpable ripping along the implants boarder, and more severe ptosis or drooping of the breast gland away from the implant. A fuller, slightly saggy breast would do much better with subpectoral implants and a breast lift than subglandular implants and no lift, and that person will likely be dissatisfied in a few years and require a lift anyway. Regarding discomfort after breast augmentation: when the surgeon adheres to the principles of meticulous surgical techniques as discribed by Dr John Tebbits, post operative pain is mild and doesn't require narcotics, and most patients are back to their usual activities in 48 to 72 hours.
Best of luck to you!
Personalize your implants - you be you
Many of my patients have the same questions you do. After a consultation, hopefully we can answer all of them and help you reach an informed decision about what is right for you. Choosing the right implant is a personal decision and I have always felt that the most important job your plastic surgeon has during your initial consultation is to understand where you are coming from and what your goals really are for breast augmentation. Then, using their expertise, they can help you make the decisions that are right for you. If your plastic surgeon doesn't hear where you are coming from, get another opinion.
There are a lot of different factors including lifestyle, budget and what you want your breast to look like after surgery that will drive this decision. Make sure to talk through all of these things with your surgeon before making a final decision.
For the vast majority of patients, round, smooth walled...
For the vast majority of patients, round, smooth walled implants are best. "Anatomical" shaped, textured implants have been heavily promoted but:
- "Anatomical" implants are associated with a higher incidence of palpable and visible rippling.
- "Anatomical" implants are not associated with less hardness or capsular contracture.
- "Anatomical" implants can rotate 180 degrees and produce a deformity.
- A good study has shown that "anatomical" implants do not improve the shape of the breast.
The Best Implant for You
The answers are individual and unique to you and will become clear during a consultation.
There are many articles on this website (and others) about:
- silicone vs. saline?
- over- or under-the-muscle (prepectoral vs. subpectoral)?
- low-, medium- or high-profile?
- textured- or smooth-surface implants?
- best incision site: breast crease, armpit, areola, navel?
The Internet is great for gathering information, but not necessarily for helping you decide.
The knowledge you have gained from your Internet reading and research is a valuable basis for your consultation with your plastic surgeon who can then integrate your goals with your physical attributes and anatomy to advise you how to best proceed.
Your plastic surgeon's professional judgment, founded in knowledge and experience are invaluable resources to you in choosing the best implant for you.
Breast implant size is the first choice you have to make
You first need to decide what size you want. Size with your surgeon, research photographs, be pretty sure about what you want. Once you decide on approximate size, your surgeon will help you with the other choices. These are individualized based on your shape, size, amount of soft tissue coverage etc. I could generalize what my preferences are but that isn't very useful for your particular circumstance. Get a couple of opinions so you go into it having done your due diligence.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.