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BEFORE AND AFTER PHOTOS

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HOW IT IS DONE

 

 

 

Where Is It Done?

 

Today breast augmentation is done primarily in ambulatory surgery center and in office operating suites. My patients have surgery at the Surgery Center of Leawood, an adjoining state-licensed ambulatory surgery center. All members of the American Society of Plastic Surgeons must use accredited facilities. This is an important safety consideration.

 

Anesthesia

 

You might have noticed that I place anesthesia right at the top of the list. Proper anesthesia is vital to patient safety. I prefer a total intravenous anesthetic. This is a form of anesthesia that provides, in my opinion, the ideal balance of patient comfort and safety. Patients are asleep for their surgery and wake up afterward with no recollection of the surgery. This type of general anesthesia differs from traditional general anesthesia in avoiding gas, intubation, paralysis, and mechanical ventilation. I call this type of anesthesia “SAFE” anesthesia. These letters stand for “Spontaneous breathing, Avoid gas, Face up, and Extremities mobile.” (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160.)

 

Implant Placement: Under the Muscle

 

Surgeons tend to have a preference regarding implant placement and use the same approach in almost all of their patients. Most plastic surgeons today favor the submuscular approach. Submuscular placement of the implant is achieved by developing a pocket between the pectoral muscle above (superficial) and the rib cage below (deep). The pocket is under the muscle, which is under the breast tissue. The muscle is not cut, but rather lifted off the chest wall, making a pocket underneath. Most of the dissection can be done with the surgeon’s fingers, which helps preserve a major nerve (lateral branch of the fourth intercostal) that provides feeling to the nipple. By using blunt finger dissection, it is possible to avoid cutting this nerve. Surgeons using other forms of dissection, such as cautery or a scalpel are theoretically more likely to damages these important sensory branches.

 

The creation of this pocket is the main source of variation from one surgeon to another. After all, the implant used by most plastic surgeons in the U.S. is likely to be similar. Only three manufacturers, Mentor, Allergan, and Sientra produce almost all the implants used by American plastic surgeons. The pectoral muscle is released just the right amount over the breastbone (“sternum”) to achieve cleavage.

 

With an inadequate release, the space between the breasts may be too wide, especially in thin women. Women often ask about this problem at their consultation. They’ve seen pictures in magazines showing a wide space between the breasts. There should not be a wide flat space between the breasts, contained by the inside borders of the breasts that appear to spring forward from the chest like bookends. Instead, the breasts should come together to provide a cleavage when a bra is worn. Without a bra, the breasts should settle apart naturally.

 

The pocket needs to be big enough to avoid wrinkling of the implant as it is filled, but not so big as to create an unnatural bridge between the breasts, due to overdissection of the pocket in the medially, in the area of the cleavage. This problem is called “synmastia” or “symmastia.” The breasts appear to run into each other, with inadequate separation, the opposite problem from the “bookend” look, and resembling buttocks.

 

The most important advantage of submuscular placement is a more natural appearance. Because most of the implant is covered by muscle, unnatural overly-defined borders of the breast are prevented. The “half grapefruit stuck to the chest look” is avoided. The test of a well-done breast augmentation is the appearance of the cleavage. The cleavage should be natural, without a distinct border to suggest the presence of an implant. Because implants placed deep to the muscle have an extra layer of muscle over them, they are more difficult to feel. This is particularly important in thin individuals, or older women who may have less fatty tissue to conceal the implants.

 

The risk of capsular contracture is reduced by submuscular placement. Mammograms are made slightly easier, because there is some separation between the breast tissue and the implant, except the lower outer corner, where the implant is not completely covered by muscle. Some surgeons call the submuscular placement a “dual-plane” technique, recognizing that the implant is submuscular only in the area covered by the pectoralis major. Therefore, it is partially under muscle and partially under breast tissue.

 

There are a few surgeons who have advocated “total” muscle cover of the implants. Although this would seem an appealing idea, the extra muscle dissection causes an unnatural blunting of the inframammary crease. It is not a popular technique for cosmetic breast augmentation. Some surgeons who use the term “total muscle cover” are in fact using the traditional submuscular or dual-plane approach.

 

Any Disadvantages of Submuscular Placement?

 

Yes, just one. The surgery is more painful than the above-muscle (also called “prepectoral” or “subglandular”) augmentation. In my experience, very few patients, on being informed of the merits of both techniques, elect to have an above-muscle augmentation. I use the submuscular placement in almost all of my patients. You may have noticed that all the patients featured in this section have submuscular implants. If a patient has existing implants above the muscle, her replacements are placed under the muscle.

 

Breast Size

 

The question of how large to make the breasts is on every patient’s mind at the time of consultation. Sometimes, women bring pictures of models from magazines (or photos on their smartphones) to demonstrate what they have in mind. The pictures help me to know what size the patient has in mind. Occasionally, women say they want to be a C-cup size and show me pictures of women who clearly have D-cup size breasts. But, women don’t necessarily need to bring pictures because I have plenty of photographs of other patients with a variety of breast shapes and sizes that we can review together.

 

Most women already understand that their breasts will not look identical to one of the models in the magazine; they will retain many of their original breast characteristics such as general shape, nipple level and nipple position on the breast. Their breasts are simply filled out.

 

Women may have a certain volume in mind: “A girlfriend had 350 cc implants and she looks great!” Breast size is a highly personal decision. I try to help patients make this decision, based upon my own experience and judgment. It turns out though, that most women have similar desires—they want larger breasts, but not too big! Many women do not know for sure what size they want. This is uncharted territory and they don’t know yet how they are going to react. It is my job to listen to what they say and give them the benefit of my experience to help them reach the right decision.

 

No doubt there is surgeon bias. The implant sales representative tells me some surgeons consistently order larger implants and some consistently use smaller implants. Obviously, it is not because they are treating different types of patients. Presently, the most commonly ordered implants have maximum fill volume of 390 cc. This is the average fill volume among my patients. Over a 5-year period of my practice, five women returned to have larger implants inserted. None returned to have her implants replaced with a smaller size. (Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166.)

 

The surgeon needs to individualize according to the desires of the patient. If this is done, the vast majority of women are very happy with their breast size after surgery, and the likelihood that they will need another operation to adjust breast size is minimized. This is important, because a second operation roughly doubles the expense and risk of complications. It is also important to recognize that some women will inevitably change their minds about size after having implants and that is okay, too. The reoperation rate for a size change will never be zero.

 

Breast Augmentation and Cup Size

 

If a patient wants a B-cup, that’s okay and it is her choice, but I tell her she can move up slightly to a C-cup size and she will not regret it. The most commonly requested size is a size that sits on the cusp of a C and D-cup (some bras a C and some bras a D). Generally, this size provides an excellent appearance, and is not so large that the breasts interfere with activities or appear “top heavy.” Patients who desire a full cleavage should select a D-cup size. The B-cup will not allow for spontaneous cleavage, but cleavage may be obtained by wearing a push-up bra. Personally, I believe (and my patients tend to agree) that women should not have to wear a push-up bra or inserts in their bras after a breast augmentation. This is why I counsel patients who are thinking of a modest B-cup size to consider a C-cup. But the decision is theirs, and I respect that.

 

When patients of mine have insisted on a B-cup size, they have usually told me later they wished they had asked for a larger size. Some of my patients return with the intended C or full C-cup sizes and return later, sometimes years later, wishing to be larger. They have a newfound appreciation of their breasts and have lost some of their apprehension about having larger breasts.

 

Replacement of Implants With a Larger Size

 

D.A., Age 26, Dancer

Height: 5'1"

Weight: 105

Children: 1

Preop. Bra Size: A

Postop. Bra Size: C/D

Implant Type: First Implant: Mentor textured, round, saline-filled. Second Implant: Mentor smooth, round, saline

Placement: Submuscular

Approach: Inframammary

Implant Size: First Implants: 300 cc/Replacement Implants: 475 cc

 

Comments: This patient had a breast augmentation, augmenting her to a C-cup size. She returned 5 years later, wishing to be a full D-cup size, with a deep cleavage “like Pamela Lee Anderson.” She was pleased with the result.

 

Dr. Eric Swanson patient after photo-breast augmentation

Dr. Eric Swanson patient before and after photo-breast augmentation

Before, 5 years after, 7 years after

 

The vast majority of women in my practice are satisfied with their breast size after surgery and would not change it. If they were to change, it would usually be to a larger size. Patients almost never find that they are too big a month after surgery, when the swelling has gone down. If a patient is going to have second thoughts later about size, it is usually that she would like to be larger. If a patient is “on the fence” about a B or C size, or C versus full C size, I tell them to choose the slightly larger size. It is unlikely they will return saying they are too big. Tellingly, most women ask to have larger implants inserted if they have their existing implants replaced for a deflation.

 

Of course, the surgeon cannot guarantee a certain bra cup size after surgery and bras do tend to fit differently from one manufacturer to another. A patient may find she is a C-cup size in one bra and a D-cup in another.

 

Do You Make Measurements on My Breasts to Gauge Implant Size?

 

Size selection remains much more of an art than a science. There is no formula that will provide the correct size of implant. Plastic surgeons have published systems to calculate implant size based on chest measurements, but these measurements consistently produce modest volumes that most patients would consider too small. Although I have an idea beforehand of size, within a range of 100 cc or so, I usually make my final decision in the operating room. Although unscientific, this approach has a good track record in my practice.

 

Is It Helpful to Stuff My Bra with an Implant to Determine Size?

 

It is important to remember that an implant stuffed into a bra is different from an implant inserted behind the muscle in the breast. I do not find this method very helpful in size selection.

 

Breast Tissue + Implant Volume = Breast Size.

 

Final breast size depends not only on the implant size, but also on how much breast tissue is there to begin with. A woman who desires a full C-cup size and is presently a small B-cup will require a smaller implant than a woman starting from an A-cup size. In viewing the before and after pictures of the Breast Augmentation section, it is obvious that the preoperative breast size is as important as the implant size in determining the final breast size. The elasticity of the skin also makes a difference. A young woman with small breasts and no pregnancies will have tight skin and this can limit the size of the implants. A C-cup size or a small D-cup may be possible but not a full D-cup. On the other hand, a woman who has breasts that have been stretched out, usually after pregnancy, can easily accommodate a larger size and almost always can be augmented to a full D-cup size if desired.

 

Is 3-D Computer Simulation Useful?

 

Some surgeons use three-dimensional photographic systems in their office and computer simulations. It is important for women to know that these simulations are inaccurate because the software (at least as of 2016) is not based on measured changes in breast dimensions. At present, this technique remains a marketing strategy. Proponents claim that it increases their “conversion rate,” which is a marketing concern, not a scientific one.

 

The Incision

 

There are three common approaches to place the implant. An incision may be made in the crease under the breast, along the edge of the areola, or in the armpit. Occasionally I insert the implant through a trans-nipple incision, particularly when I am correcting an inverted or overly projecting nipple simultaneously. Few plastic surgeons use the umbilical approach because it is impossible to place the implant submuscularly using the trans-umbilical approach.

 

The Inframammary Incision

 

The most common approach for breast augmentation is the inframammary incision located on the lower part of the breast, just above the crease under the breast. This way, the scar is hidden even if the bikini top slides up slightly. Frequently I see women who have had past augmentations using an incision placed exactly in the crease under the breast. In this location, there may be some friction on the incision from the bra strap after surgery, and the scar may end up being more conspicuous. At least one NFL cheerleader has exposed such scars when lifting her arms above her head!

 

The properly-placed inframammary incision allows women to wear a bikini or evening gown with concealment of the scar. Importantly, this placement of the incision also allows the surgeon optimal exposure to create the pocket where the implant is to be inserted. This ease of approach is important because the shape of the breast and the quality of the cleavage are the most important criteria in getting an ideal result, even more important than the incision. A short scar in the crease under the breast is inconsequential.

 

Dr. Eric Swanson-Inframammary scar photo

Inframammary scar 3½ years after breast augmentation

 

Comments: These intraoperative photos show a smooth, round, saline-filled implant being inserted under the muscle using an inframammary approach. The implant is placed in the pocket and then filled with saline. The filling tube is pulled out when the desired volume is reached (the valve is self-sealing). A saline implant allows a short incision.

 

Dr. Eric Swanson-Breast augmentation intraoperative photo

 

The Periareolar Incision

 

The advantage of the periareolar incision is that it makes use of the natural border around the areola to hide the scar. It is a very acceptable alternative to the inframammary incision. However, it makes development of a submuscular pocket a little more difficult in that the surgeon has to dissect through breast tissue. There may be some numbness of the nipple because of the proximity of the incision. However, if the incision is kept short, numbness is unlikely to be of consequence and this problem may be over-rated. The scar may be more visible here along the edge of the areola, particularly if the patient happens to be a poor scar-former, than it would be tucked on the underside of the breast. Nevertheless, if a patient requests this incision, I am happy to oblige and the scar tends to be inconspicuous.

 

Dr. Eric Swanson-Periareolar scar photo

Periareolar scar 2½ months after breast augmentation

 

Dr. Eric Swanson patient after photo-breast augmentation

 

The Transaxillary Incision

 

Although the armpit approach has the advantage of avoiding incisions on the breast, it does leave a scar in the armpit. Usually this scar heals well and is inconspicuous. However, it may be visible if the patient raises her arm while in a bathing suit or evening gown. A few patients have told me they knew their hairdresser had implants because they could see the armpit scar. It is more difficult to dissect the breast pocket because the incision is more removed from the area of dissection. If subsequent breast surgery is performed, for example, an open capsulotomy to release a capsular contracture, an inframammary incision is used, so now the patient has two scars on each side rather than one. There may be some disadvantage to a transaxillary approach if the patient needs lymph node sampling at a later time as part of breast cancer treatment. I find now that I use this approach only on the rare occasion when the patient specifically requests it.

 

Dr. Eric Swanson patient photo-Underarm scar after breast augmentation

Axillary scar 7 months after breast augmentation

 

 

Ideal Technique—Ideal Result

 

Like some other plastic surgery techniques, such as liposuction, a breast augmentation is an easy procedure to understand, and it is not the most technically demanding plastic surgical operation. The procedure is more forgiving than a rhinoplasty, where a millimeter one way or the other can make a difference. A so-so result after a breast augmentation may still be preferable to no breast augmentation at all. The procedure is so reliable, and the patient motivation so strong, that even with a less-than-ideal result, the patient is usually satisfied. I regularly see patients in consultation who have had a previous breast augmentation with a result that might be considered very average. I ask them if they are happy with their result and they often tell me they are pleased, “best thing I ever did.” Not surprisingly, plastic surgeons often direct their marketing efforts to this procedure that has a consistently high level of patient satisfaction.

 

The Importance of Skill and Experience

 

Of course, most plastic surgeons (who are not as a group ego-challenged) have their own idea about results and it is not enough that a patient merely be satisfied. What can separate an ideal breast augmentation from a merely acceptable one is the skill and experience of the surgeon in creating the pocket for the implant—how much to release the muscle, making the implant pocket the right size and the correct position. Other matters of a technical nature—the particular approach used, the type of implant selected, and postoperative preferences are less important than the surgeons’ skill in correctly creating the pocket.

 

Experienced and skilled surgeons consistently produce satisfying results by learning through experience (good and bad, but mainly bad). Their reoperation rate drops as they advance along the learning curve. They learn how to properly create the pocket to achieve the most natural-looking result. Others may wonder but not know if a woman has had implants—has she or hasn’t she?

 

It is vital to place the implants at the correct level. Otherwise, the breast mounds will be unnaturally high (the busting-out look), or too low, a common problem seen in nude centerfold models whose implants have settled too low, pushing down the natural crease under the breast (inframammary fold) so that the nipples appear to be riding high. In making the pocket, the experienced surgeon takes settling of the implants due to gravity into consideration. Implants that appear correctly positioned immediately after surgery will, in time, appear bottomed out. For this reason, it is important for patients and surgeons to look at their long-term results. Implants that are placed correctly may appear to be too high for the first few months after surgery, until they settle into their proper position. Patients are therefore cautioned to expect that their implants will look too high at first, a little too perky. Being a little overly perky at first does not pose a problem. The appearance is certainly not objectionable in clothing.

 

Silicone Gel-Filled vs. Saline-Filled Breast Implants

Both silicone gel-filled implants (“silicone gel” implants) and saline-filled implants (“saline” implants) have silicone envelopes. The envelopes are made of a hard (“polymerized”) form of silicone that has a firm consistency, like rubber. This material breaks down in our bodies in only very minute quantities, in fact less than our environmental exposure to silicone from such household products as antacids and deodorants. Implants in the body such as pacemakers, catheters, and artificial joints have been coated in this inert material for decades. It is a tried-and-true material that is safe. It is doubtful that anyone is allergic to it, or rejects it.

 

Silicone gel-filled implants contain the gel form of silicone. This material is gelatinous, with the consistency of jelly. It is soft and squishy. This characteristic is desirable and one reason that silicone gel was chosen as a filler for breast implants in the first place.

 

Saline-filled implants, on the other hand, have a similar envelope made of the hard form of silicone, but are filled with salt water (“saline”), which is known to be completely safe, with a salt concentration similar to our body fluids. But, the implant is not as squishy and soft. A saline-filled implant is firmer. It feels more like a water balloon. The softer feel of a silicone gel implant is its advantage.

 

Many patients find the safety of saline reassuring. They are concerned about having silicone gel implants in their bodies, with some degree of leakage of silicone into the tissues over time, however minimal, and the possibility of undetected implant rupture. This issue is more important to them than the advantage in consistency of silicone gel implants.

 

It is important to note that if a capsular contracture develops (a tightening of the capsule around the implant), both types of implants will feel overly firm.

 

Frequently, the difference in feel characteristics of the two types of implants is a moot point. Women with a moderate amount of breast tissue to start with, for example, a B-cup size, notice less difference in consistency between a saline implant and a silicone gel implant because there is proportionately more breast tissue to feel. Also, most of these women do not mind a little additional firmness because they feel their tissues are too loose to start with. Patients having a breast lift at the same time as implants are well-served with saline implants.

 

In women who are very thin or have virtually no breast tissue, the feel difference between the two implant styles is likely to be greater, because there is proportionately less natural breast tissue, so that the consistency of their breast is virtually the same as the consistency of the breast implant. Also, there is slightly less risk of wrinkling with silicone gel implants (but it can still happen). In these thin patients, the risk-benefit ratio may favor silicone gel implants. Silicone gel implants are more expensive than saline implants, a price difference of about $1000. They also require a longer incision and therefore a longer scar, because they come pre-filled.

 

Dr. Eric Swanson-Breast implant types-photo

(Above) Textured, saline implant. (Center) Smooth, saline implant. (Below) Silicone gel implant. Saline implants have valves on the front that allow them to be filled after insertion. Silicone gel implants come prefilled.

 

Detection of Implant Deflation

 

The detection of deflation is not a difficult diagnostic issue for saline implants. The breast volume deflates over a period of hours or days. Clinical detection is straightforward. The breast just seems to deflate. There is no harm because the saline fluid is absorbed by the body and is harmless. But the implant needed to be replaced to restore symmetry.

 

The FDA recommends an MRI scan 3 years after a breast augmentation using silicone gel implants and every 2 years after that.  Few women comply. The reason for this recommendation (one that is considered impractical by most patients) is that a leaky silicone gel implant is difficult or impossible to detect just by examining the breast. The breast does not simply deflate the way it does when a saline implant leaks and the water is absorbed by the body. Instead, the viscous silicone gel is held in its pocket by the capsule that forms around the implant. Obviously, an MRI is an expensive test and one that is not likely to be covered by insurance.

 

Silicone gel implants are more difficult to replace if they have disintegrated, with free silicone gel in the pocket, which makes surgical instruments slippery and requires numerous irrigations of the pocket because the silicone gel does not dissolve in saline. If there is extensive calcification of the capsule, this may necessitate partial or complete removal of the capsule as well. Today, the implant shells are more durable than they were in the past, so that this problem is less likely. Interestingly, silicone gel implants are much more commonly used just about everywhere in the world. Their use in the U.S. was curtailed from 1992 to 2006. This fact is often cited as evidence of their superiority. However, American surgeons have learned many of the advantages of saline implants. Most of my patients still choose saline implants, although I implant silicone gel implants in patients who choose them after we discuss the pros and cons. Silicone gel implants can be the right choice for some patients.

 

Breast Augmentation, Hispanic, Silicone Gel Implants

 

A.C., Age 24, Real Estate Agent

Height: 5'6"

Weight: 123

Children: 1

Placement: Submuscular

Approach: Inframammary

Implant Size: 400 cc

Implant Type: Mentor smooth, round, moderate-plus profile, silicone gel

Preop. Bra Size: A

Postop. Bra Size: Full C

 

Comments: This 24-year-old Hispanic woman wanted ideal feel characteristics and opted for silicone gel implants. Simultaneously, an old scar of the medial side of the left breast was revised. Her assessment 2 months after surgery was, “I could not be happier.”

 

Dr. Eric Swanson patient before and after photo-breast augmentation

Before, 7 months after

 

Safety of Silicone Gel Implants

 

Most of us (okay, maybe just those of a certain age) are aware of the concerns about silicone gel breast implants, which were impossible to miss in the media in the early 1990s. These reports highlighted “local” problems with breast implants that occur in the area of the breasts—mainly implant leakage and capsular contracture. There were also concerns that silicone may be causing health problems in other parts of the body. The debates were very emotionally-charged. Fortunately, evidence from large reputable studies, including one from the National Institute of Health, published in the reputable New England Journal of Medicine, showed that there is no increased risk of autoimmune diseases or breast cancer in women with breast implants. This is an important finding because some people had suspected that silicone from the implants might cause the body to start producing antibodies that might go on to attack normal tissues, such as the joints for example. Such autoimmune diseases as rheumatoid arthritis, lupus, and scleroderma do happen in women with breast implants. But these diseases also happen in women without implants. There is no evidence of one causing the other—scientists say there is no causal relationship. When these diseases occur in women with implants, it is a not-unexpected coincidence. Studies show the same is true for breast cancer.

 

What Happens When a Silicone Gel Implant Leaks?

 

Most of the time, the patient notices no change. There may or may not be a change in shape or size of the breast. Why not? Because the gel, which is a gelatinous material like Jell-O, is walled off by the capsule that the body forms around any artificial device that is inserted in the body. The silicone gel tends to stay in this pocket, so it is usually impossible to tell by examining the breast whether or not the implant is still intact. It is even difficult to tell on a mammogram, because silicone gel looks the same whether it is inside or outside the envelope, which it too thin to see on the mammogram. MRIs are more reliable for detecting implant rupture.

 

“Gummy Bear” Implants

 

There is a type of breast implant, which has been available in Europe and Canada for a few decades and was introduced to the market in the United States several years ago, called a highly cohesive gel implant or “gummy bear” implant. “Cohesive” is a relative term, referring to the viscosity (firmness) of the silicone gel. The silicone material in these new implants is tightly cross-linked to reduce the amount of silicone gel that escapes into the tissues if the shell ruptures. In fact, you can slice it like a piece of pie without having silicone ooze out (many women have seen this advertised image). These implants are called “form stable” because they are firm enough to maintain their form when in the body, rather than settling into a shape influenced by gravity. But there is a flip-side for this form preservation— these implants do not feel as soft as the original silicone gel-filled implants. The whole point of using silicone is because of its softness, and a jiggle is a desirable quality. They are also much pricier than the usual round silicone gel implants. This firmer implant style has not been widely adopted by American women. Many of my Canadian colleagues (it was available in Canada before the U.S.) who used one such implant, the Allergan 410, have stopped using it.

 

Are Shaped Implants Better?

 

A controversy exists among plastic surgeons regarding the claimed advantages of shaped implants. These implants tend to be firmer and are textured in an effort to avoid rotation. They provide more lower pole projection and less upper pole projection in an effort to simulate a natural (but not necessarily ideal) breast shape. However there are disadvantages to more firmness. Texturing (particularly Biocell implants) may be linked to double capsules, seromas (fluid collections) and even a rare form of cancer, ALCL. A shaped implant may also rotate and require repositioning. The whole concept of providing more lower pole fullness may be wrong because surveyed women prefer an idealized breast emphasizing fullness of the upper poles (which is why women wear bras). Financial conflict of interest is becoming a hot topic in plastic surgery and medicine in general. The profit margin for manufacturers is much higher for silicone gel implants and higher still for shaped form-stable or “gummy bear” implants. Many plastic surgeons who publish studies have financial ties to the manufacturers and this conflict no doubt creates a bias favoring shaped implants. I do not use them. Women are well-served with smooth, round implants.

 

Should Old Silicone Gel-Filled Implants Be Removed?

 

Should silicone gel implants come out if they’ve been in for a long time? It depends. If the patient is happy with the appearance and softness of her breasts (and thousands of women are), she may leave them alone, even if there is a good chance one or both have ruptured. There is a greater likelihood of rupture if they have been in over 10 years. But it’s hard to make a compelling case to remove implants if the breasts are soft, the patient is happy with her appearance, and she is free of any local symptoms, such as capsular contracture.

 

However, if she is concerned about a change in shape or size, discomfort, or if she is having other cosmetic surgery at the same time anyway, particularly on the breasts, she may decide to have the old implants removed and replaced. Almost any time I reoperate on the breasts, I remove old silicone gel implants, whether ruptured or not, and replace them. This also renews the warranty for silicone gel implants.

 

Often, women with old (earlier generation) silicone gel implants have varying degrees of capsular contracture. They have gotten used to the excessive firmness of their breasts, even though this can be a problem for them in such social situations as hugging. They may find that they avoid hugging because of their unnaturally firm breasts. They don’t want to advertise the fact that they have had a breast augmentation. This may even make them seem aloof among friends. The problem is not trivial.

 

An alternative is to remove implants and not replace them, but this is usually not a good option because the breast tissue and skin has been stretched and thinned out for years. She has gotten used to her breasts and will not like the empty, saggy look of her breasts without implants. So I remove the old implants and replace them or remove the old implants and perform a breast lift to take care of the extra slack breast tissue simultaneously. However, a breast lift procedure cannot duplicate the upper pole fullness provided by breast implants. Because this fullness is desirable in women of all ages, I commonly use implants at the time of a breast lift.

 

Saline Breast Implants

 

Saline-filled implants have been available almost as long as silicone gel implants. These implants consist of an envelope made of hard silicone (not the soft silicone gel that can ooze into tissues), a self-sealing valve, and are filled with saline—which is simply salt water. There is no evidence of any health risk associated with these implants.

 

I counsel patients that breast implants are not perfect. They do not feel exactly like breast tissue, which is pliable and easy to squish between the fingers. And saline implants are not quite as soft and squishy as silicone gel implants (although the difference when they are in the body is less obvious).

 

Someday there may be a more ideal filler material that will provide a truer breast feel, but there are no filler materials presently available with this quality today. Fortunately, for most women this difference in feel is minimal, particularly if the implants are below the muscle and they have some breast tissue of their own over their implants to make them feel softer.

 

Scarring and Sizing Advantages of Saline Implants

 

One slight advantage of saline implants over silicone gel implants is that the scar is shorter—about 1½ inches (3–4 cm) instead of 2 inches (5 cm) or more for silicone gel implants. The reason for the shorter incision that the saline-filled implant is introduced into its pocket empty, folded up to allow it to fit through a small opening, and then filled with saline using a filling tube, which is withdrawn as the valve on the implant seals itself, a remarkable piece of engineering in itself. Silicone gel implants, on the other hand, come already filled, so a longer incision is needed to insert them, which is why patients who have had breast augmentations with silicone gel implants have longer scars. Another advantage of the saline-filled implants is that small volume adjustments (< 30 cc) can be made during surgery, helping to reduce small breast size discrepancies, which are common. Silicone gel implants of differing sizes may be used too, but the implant sizes come in about 30 cc increments, so that smaller adjustments are not possible (but this is a minor point from a practical standpoint).

 

Implants are not one-size-fits-all like balloons. They are stretchable only within small ranges and are not very elastic, more like a beach ball than a balloon. Not enough volume and the envelope collapses into folds. Too much and the implant becomes hard. Not only may the implant become firm, but the edge may form a scalloped contour, so that wrinkles may still be present despite overfilling. The implants come in different sizes, with different base diameters and heights, and therefore different volumes. For example, a 360 cc implant has a minimum fill volume of 360 cc and a maximum fill volume of 390 cc. Most of the time, surgeons inflate the implant close to or at its maximum fill volume to minimize the risk of folds causing wrinkles.

 

Saline Implants and the Disadvantage of Wrinkling

 

Even with appropriate maximum filling of implants, wrinkles can be a problem. But we don’t want to inflate the implant too much because of excessive firmness that this would cause. The volumes listed for patients in this section represent the final fill volumes, in all cases close to or at the maximum fill volume of the implants. It would be nice if the envelope were elastic enough to accommodate a wide range of sizes without getting too tight, or forming wrinkles, but the manufacturer needs to balance elasticity with durability. We don’t want nice stretchy implants that leak. Unfortunately, we do not have a perfect implant.

 

Smooth vs. Textured Implants

 

The textured implant has a rough surface as opposed to a smooth implant, which has a smooth surface. The theory was that this type of surface would help to prevent the capsule that the body forms around the implant from getting excessively tight, making the breast feel overly firm—the notorious capsular contracture that has long bedeviled plastic surgeons. Does texturing work? There appears to be no difference in the incidence of capsular contracture between smooth and textured implants when the implants are placed below the muscle. So texturing is probably more of a theoretical benefit than a practical one. Anecdotally, I stopped using textured round implants in 1999 and have seen no increase in the frequency of capsular contracture in my patients. However, I have observed a significant reduction in deflations and fewer problems with wrinkling since I started using smooth implants exclusively. Today, most American plastic surgeons no longer routinely use textured breast implants.

 

In recent years problems have been identified with textured implants. These implants can sometimes cause “double capsules” and late seromas (fluid collections), and even ALCL, a rare form of cancer. This problem appears to be linked to aggressive texturing, particularly the Biocell textured implants.

 

Historically, plastic surgeons have observed a lower rate of capsular contracture among women treated with saline implants than silicone gel implants. With newer silicone gel implants there may no longer be a difference. We also know that putting the implant under the muscle reduces the risk of capsular contracture. The surface characteristics—smooth versus textured—does not seem to matter much regarding capsular contracture when the implant is placed under the muscle.

 

The textured surface adheres to the surrounding tissue, in contrast to a smooth implant, which can rotate freely in its pocket, never attaching to the surrounding capsule. The ability of textured implants to adhere to surrounding tissue is used to help anchor contoured implants, so they stay in position and maintain their correct orientation. Of course, orientation does not matter for round implants, which look the same if they spin.

 

Smooth implants are less likely to leak. The risk of leaking or rupture of the textured implants was found to be 1% per year. This means that if a woman has textured implants for 10 years, she has a 10% chance of leakage! With smooth implants, the risk appears to be much less, on the order of 1–3% at 10 years. This lower leak rate is probably due to fewer problems with leaks developing at folds in the implants because the smooth surface is less likely to form these folds.

 

The risk of wrinkling is reduced with smooth implants. This problem did occur with regularity in textured implants, even when maximally filled, and in fact has been the most common complication seen with textured implants. Wrinkling happens less frequently with smooth implants, although it can still present a problem, particularly in very thin patients, in whom wrinkling may be visible.

 

“Teardrop” Shaped Implants

 

Sometimes, patients request a contoured or tear drop style implant. They may have done some research and concluded that this will give the most natural look. Contoured implants were popular in the early 1990s and the idea of a less rounded, more natural shape had obvious appeal. However, with experience, plastic surgeons learned that the majority of women do just as well with round implants. Round implants push forward on patients’ natural breast tissue, so they maintain naturally-contoured breasts. In fact, contoured implants may produce less pleasing breast shapes, too vertical with one type and too wide horizontally with another.

 

An excellent result is still possible using both round and contoured implant styles. In fact, it is usually impossible for me to determine whether a patient has been augmented with round or contoured implants simply by examining her. At a national plastic surgery meeting in 2014, plastic surgeons in the audience were polled to see if they could tell which patients had shaped implants and which had round. The audience was wrong 55% of the time!

 

Contoured implants are textured to help them stick to the surrounding tissues and maintain their orientation. Today, we prefer smooth implants. Occasionally, contoured implants can rotate (“spin”), causing asymmetry and requiring reoperation. Also, they are more expensive than round implants. Smooth, round implants are generally the better choice. Today, few patients request contoured implants.

 

Implant Profile

 

The implant profile is a measure of how much the implant projects for a given base diameter. Women desire increased projection and upper pole fullness, so low-profile implants are not used anymore. Most of the implants presented in this website are of the moderate profile style. High profile implants are used in women with narrow chests, wanting D-cup sizes, in whom a wide base diameter may be too much for their narrow chest to accommodate. And some women simply request high profile implants.

 

How Long Do Implants Last?

 

This question is virtually synonymous with “Will I need to have my breast implants replaced?” Certainly, today’s implants are more durable than thinner-walled implants used in the past. But they cannot be regarded as lifetime devices.

 

Many women who see me in consultation believe that implants last 10 years and then they need to be replaced. This is actually not true. Probably the 10 years figure comes from the length of the warranty. In my own experience, > 90% of women will not need their implants replaced within 10 years. They may last 15 or 20 years, or even more.

 

Nevertheless, any woman having a breast augmentation should be prepared to have them replaced at a future date. No doubt improvements in design and filling materials will be made in the future. However, the implants available today contain saline, a filler that is undeniably safe, even if is not as squishy as silicone gel, do not pose a health risk, and may be easily removed later. So it is safe to take advantage of existing technology and not difficult to “upgrade” later. Recent studies show that leak rates for saline implants are substantially less than they were in the past, now 1–3% at 10 years.

 

When is a patient thin? When you can see the lower ribs. You can see the ribs because there is very little tissue between the skin and the ribs. You can imagine that an implant placed under a small breast would also have very little tissue over it. The only tissue covering it would be the stretched-out breast tissue and a tiny layer of fat. That is why we make sure to place the implant under the muscle in these women, so that there is as much tissue as possible between the implant and the skin. This way the edges of the implant are not as easily seen and the cleavage looks more natural. However, in very thin women, a natural look may be impossible because there is simply very little cover tissue available. And large, perky breasts on a thin woman is rare. But these patients are very happy, even if they have an “augmented” look. In fact, I sometimes see patients who tell me “I want to look fake,” or “I want the Baywatch look.”

 

 

 

 

 

 

Dr. Eric Swanson patient after photo-breast augmentation

Dr. Eric Swanson patient before and after photo-breast augmentation

Dr. Eric Swanson-Inframammary scar photo

Dr. Eric Swanson-Breast augmentation intraoperative photo

Dr. Eric Swanson-Periareolar scar photo

Dr. Eric Swanson patient after photo-breast augmentation

Dr. Eric Swanson patient photo-Underarm scar after breast augmentation

Dr. Eric Swanson patient before and after photo-breast augmentation