Does Cohesive Gel Even Ripple?

Rippling may occur with any saline or silicone gel implant, cohesive gel or not. It occurs more frequently with saline implants and depends on: individual anatomy,  thickness of breast and fatty tissue, the surface of the implant (textured may  ripple more than smooth), and placement of the implant. Subfascial is essentially subglandular and has a greater potential for showing rippling in a thin patient than submuscular placement.You should discuss the pros and cons of the procedures and
the various types of implants with your plastic surgeon who should be certified
by the American Board of Plastic Surgery and ideally a member of the American
Society for Aesthetic Plastic Surgery (ASAPS).



Robert Singer, MD
FACS
La Jolla, California

Any breast implant can ripple, even cohesive gel in a sub muscular plane.  For example, if very large implants are chosen the tissue layer can be stretched very thin and over time rippling can occur.

Cohesive gel implants (by any of the 3 USA companies)--Check! Good choice. BTW, MRI is NOT an appropriate recommendation since they cannot "leak" and would require a significant force (or manufacturer's defect) to rupture one. I've seen 4 in the past 15 years, two in one patient, and all 4 implants from the same manufacturing year (2002-2003) when they were hand-made. Now they are all machine-made and much more uniform and durable.Subfascial--not a bad choice, but if you are thin, have little of your own breast tissue, and are concerned at all about ripples, a better choice would be submuscular, which is still subfascial inferolaterally where the pec major muscle is not below the breast. The rest of the implants is covered by a much more thick and durable layer of tissue to isolate the edges, ripples, and bacteria from being issues.Plus, there is a higher chance of capsular contracture (CC) with above the muscle placement because of intraductal bacteria causing a biofilm on the surface of your implants. Sure, subfascial is theoretically a barrier to these bacteria, but I have seen very few, if any, women whose submammary fascia is able to be lifted as a uniform sheet without tiny pinhole, tear, or opening that could let breast ductal bacteria come into contact with the implant(s). No matter how skilled the surgeon, meticulous the dissection, and careful the retraction, there are bound to be one or more openings big enough to allow bacteria through. This is also partially true about submuscular placement (in the inferolateral area mentioned above) where there is no pec major muscle, and the plane is below the breast fascia (often why some surgeons call this single plane beneath two different structures a "dual-plane" technique) can still have the same issue I raise above. With submuscular placement there's just less area to "leak" bacteria, and less CC risk.To answer your question directly, yes, there is always a chance of visible implant edge or ripples, even with cohesive gel implants, but more commonly with thin patients, and with above the muscle (including subfascial) placement. Cohesive gel implants are far less likely to show ripples than saline implants, and teardrop-shaped implants even less so, as they are constructed with an even "stiffer" or firm cohesive gel. But then you have the disadvantage of texture adherence, rotational (position) asymmetry issues, lack of natural shape when reclining, plus no real movement (since they are textured and designed to adhere to the tissues). Not bad, just different. But, hey, you're asking about fine details here, so I think it counts.If you were my patient, I would ask you to consider round smooth cohesive silicone gel implants placed into a submuscular plane (subfascial inferolaterally) and do a proper fiber release inferomedially to minimize activation distortion and downward and outward displacement issues with muscular contraction. Again, a fine point, but something to consider. Subfascial sounds elegant and addresses the issues we have discussed above, but avoids the very real fact that keeping the fascial layer absolutely intact and bacteria-impervious is easy to promote, but hard (perhaps impossible?) to achieve in the operating room. I hope this helps your due diligence. Best wishes! Dr. Tholen