Which Implants Are Right for Someone Who is Already a 36D Naturally? (photo)

31 Yo RN; 165 #, 5 Foot 6 Inches. Goals: 1) "fill out" upper pole 2) perking up (or at least not droop/sag) 3) better shape/rounded breasts Consulted 3 surgeons thus far; their recommendations: 1) lift with Sub Musc silicone 2) Sub musc saline (550 mod or moderamod+) no lift 3) No lift; above muscle silicone 400ccs Above or below muscle? Silicone/saline? Profile? Lift or no lift?

Doctor Answers 12

Augmentation of the Larger Breast

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Hello Hall1,

I am frequently surprised by my colleagues responses to some questions, and this time is no exception.  I take a very simplified approach to all primary breast enhancement questions.  Although there are so many variables like lift or no lift, silicone or saline, above or below muscle, fat graft or not, and any number of combinations of these variables, what it should boil down to is performing a procedure that gives the safest, most durable, most reliable, and prettiest result possible, with the least risk of either short or long term complications.

Let me first address the two variables that really shouldn't be variables. The location of the placement of the implant is best under the muscle: lower risk of capsular contraction, lower risk of anterior and medial rippling, improved upper pole appearance, and improved mammogram screening.  Implants placed over the muscle or in the 'subfacial' position lack all those benefits, and deliver increased pressure directly on the breast gland, increasing the risk of long term atrophy and stretch of the breast tissue.

The other 'non-variable' is fat grafting for primary breast augmentation.  Whether alone or in combination with an implant, it is in the preliminary stages of development.   In it's current state, it is costly (longer surgical time, may require re-injections in near future), inconvenient (the need for pre-surgical vacuum bra system for two weeks), increases risk of complications at both donor site (irregularities of skin) and recipient site (fat necrosis, cyst formation, infection), and is arguably unnecessary with the current state of the art in breast implants.

The only 'real' variables then are implant selection and breast lift. The decision to use saline or silicone should not be affected by the current appearance of your breasts, the way you want your breasts to look after, or concerns of perceived safety of one over the other (they are truly equally safe). The decision to use saline or silicone should be based on many factors that differentiate them from one another: cost, quality of the feel/rippling, ability to detect rupture, long term effects on the breast tissue envelope, and risk of complications.  It goes beyond the scope of this conversation, so it is important you speak to your surgeon about all of these issues rather than having him pick one. I will say that for most surgeons that perform primary and revision breast surgery on a regular basis, our preference is silicone gel.  I might add that given your desire for upper pole fullness, then a highly cohesive, shaped implant would be ideal.

Finally, to lift or not to lift.  This decision depends to a great extent on your desired result.  If you don't mind persistent sagging, asymmetries between right and left breasts, or low lying nipple/areolar complexes, then a lift is not necessary and you can proceed forward to have a breast augmentation alone.  However, if you want all those good things to happen to your breasts but cannot tolerate scars, then you should not proceed with any operation; there are no good alternatives to not performing a lift, when one is necessary to achieve a particular goal appearance.   Larger, subglandular/subfacial, and high profile implants will not give you the improvement you are looking for, and will only cause you post operative problems in both the near and distant future.

I hope this has been helpful.  You should be able to get a great result!

Best of luck!

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 100 reviews

Which Implants Are Right for Someone Who is Already a 36D Naturally?

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No to much, you have volume, it is necessary to elevate both areola, more left side.


Spanish translation provided by doctor:

No demasiado, usted tiene volumen, es necesario elevar las areolas, mas dl lado izquierdo. 

Maria Cristina Picon, MD
Argentina Plastic Surgeon

Which Implants Are Right for Someone Who is Already a 36D Naturally?

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In my opinion based on the internet photos posted and your statements I recommend a "Composite Augmentation" of Dr Del Vecchio (Boston). using HP silicones sub muscular plus Fat grafts. 

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Breast augmentation choices

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From your frontal view it does appear that you would benefit from a lift. In those cases I always place the prostheses sub muscular .  I have not found significant long term differences with either silicone or saline particularly when utilizing a small prostheses .  From the side your nipple areola is above the crease and if confirmed at examination a dual plane augmentation would be possible without a lift.  In those cases I recommend silicone, less chance of palpation. The best way to determine size would be external sizers  and measurements. As you can see the actual exam is most important in your case.

Implants +/- lift

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It is hard to say exactly from your photos. I prefer in general to place implants belowe the muscle to provide more coverage.  A lift may not be necessary and if anything probably a circumareola alone.  Best to be evaluated in person.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Lift or no lift?

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Thank you for providing photos. It would be helpful to see the other lateral view. You appear to have some asymmetry with your left nipple being a bit lower than your right. The right nipple clearly is positioned above the inframammary fold, thus suggesting that if you desire a volume change in the range of 400-550 cc, you would not need a lift.  However, the position of the lower nipple (your left side) will help make the final determination. I would start by deciding how much of a volume change you desire. Then a determination could be made whether your skin envelope is appropriate for that volume on both sides. The one advantage to a lift in your case is that it would allow for correction of your asymmetry, which will not be possible with implants alone. I wish you well.

Tamir Mosharrafa, MD
Phoenix Plastic Surgeon
5.0 out of 5 stars 7 reviews

In person consultation

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You have done your homework and seems very knowledgeable about implants and surgery. It would better for in person consultation and examination. I would recommend that you try few more consultations before making your decision. You may get better result with shaped implants. 

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 153 reviews

Lift vs No Lift; Saline vs Silicone; Above vs Below the Muscle

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Thank you for your photos.  First you have good natural breast volume so a 400 cc implant is excessive.  Without an exam and measurements I would say that a lift and a small textured saline implant above the muscle would give you the result you desire. 

Dr. ES

To lift of not to lift, that is the question.

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Sorry to confuse you even further but there is a reason why you have many different opinions. You have some inherent breast tissue with a small amount of ptosis (droop). In my practice I would recommend and I think you'd get a great result with an anatomical round based Sientra gel implant. Alternatively, you seem to be a good candidate for autologous fat transfer if you want a modest improvement in size. Breast of luck. 

Kevin Tehrani, MD, FACS
New York Plastic Surgeon
4.7 out of 5 stars 112 reviews

Breast augmentation with vs. without a lift

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Judging by the side view photo you do not need a lift. You may need some adjunctive procedure on the left to improve symmetry as just putting in implants may increase your asymmetry. Your frontal photo is inadequate because the arm position distorts the breast and may be doing so more on one side than the other. If you are a 36D at baseline and only want to change breast shape with more upper pole filling why do you need a 500+cc implant? You could easily do some minor fat grafting around the edges to change the shape.


My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

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.