Does Cohesive Gel Even Ripple?

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

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

All breast implants have the potential to have rippling. But cohesive gel silicone implants have the least likelihood that they will and even if they do it is not usually visible.

There is a chance that they can ripple, however under the muscle and under a good volume of breast tissue is very beneficial in making this a essentially non-issue. They do maintain better shape, feel much more natural and have less problems. Under the muscle also has a lower incidence of capsular contracture.Good LuckStephen M. Davis, MD, FACSGreen Hills Plastic Surgery

All implants, cohesive or not, have a chance for rippling.  The more breast tissue you have and the more you cover it under the muscle, the less chance you have for rippling.The fascia is about 1 mm thick.  In my opinion, subfascial placement is no different than subglandular placement. The final location of the implant and the type of implant is a decision strictly between you and your surgeon, so the more experienced your surgeon is, the better chance you have of a good result. Review many, many before/after photos, ask many questions.  Together with your surgeon you will then have the best chance of making a good choice.Best wishes.  Below is a patient with silicone breast implants in a ubmuscular dual plane.

Both saline and silicone breast implants have the potential to ripple.  The amount of soft tissue coverage (breast tissue, fat, muscle) between the skin and the implant will play a role in your individual risk of rippling.  As time goes on, the tissue thickness between the skin and the implant will decrease, making rippling more likely.  A physical examination of your breasts would be needed to further define your risk of rippling, but I would suggest a placement of the implant under the muscle to help decrease the risk of rippling if this is your primary concern.  I hope this helps.  Good luck!

There is no single gel which is THE cohesive gel.  Each manufacturer of implants has its own proprietary gel formulations, and while they may all be described as "cohesive," meaning that they behave like a solid and don't leak or run like a liquid and they hold their shape in most or all positions, there are some "cohesive gels" that are firmer, or more cohesive than others.  The one thing that I think can be said accurately is that all gels classified as "cohesive" will retain their shape better and demonstrate less palpability, including rippling, than saline or even the less cohesive types of gel. If your tissues are thin enough though, all implants will be palpable to some degree.  That doesn't mean that you will feel or see actual ripples or folds, the same that you might with saline, but you might be able to feel some of the texture of the implant.  I think that the less tissue you have covering an implant, whether you are talking about natural fat and breast tissue, muscle, or fascia, the more likely it is that you will appreciate some texture of the implant.  Fascia being thinner than muscle, I would have to say that a subfascial placement, in most cases, would likely have a greater chance of palpability than submuscular.  Having said all of that, I can tell you that the cohesive gel implants made by all 3 manufacturers in the US are the state-of-the-art, at least in our country, and they are the best that we have to offer.   And they are pretty darn good, as they give excellent results in the vast majority of patients, and from the standpoint of rippling and palpability they are a huge improvement over the implants previously used, especially saline.

"Cohesive gel" is a loosely applied term, describing both the gels that all the manufacturers use for their "standard" round implants and for their shaped implants, which for most of the companies involves a more cohesive gel. Ripples are still possible with silicone, although less likely than with saline. Position above and below the muscle or in subfascial plane each has pros and cons.  Ripples are least likely to be seen with under the muscle placement.  That advantage is more important with saline than with silicone, and least important with shaped silicone implants. Hope that helps some.  All the best. 

All implants have the potential to ripple.Cohesive gel decreases the chance for rippling to occur. Anatomic implants have an even higher cohesion of the gel to reduce the rippling.Placement can also influence the chance to ripple.