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 (4th lateral intercostal) that provides feeling to the nipple. By using blunt finger dissection, it is possible to avoid cutting this nerve.
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 two manufacturers, Mentor® and Allergan®, 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." The breasts appear to run into each other, with inadequate separation, the opposite problem from the "bookend" look.
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" (See K.N. in Complications) 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.
Are there 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, that were treated by me, 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 from magazines to demonstrate what they have in mind. The pictures can be pretty entertaining, I must admit, coming from a variety of magazines, not all of which are People and Vogue. I encourage this. The pictures help me to know what size the patient has in mind. Sometimes, 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 five-year period of my practice, five patients returned to have larger implants inserted. None returned to have her implants replaced with a smaller size. All five elected to have larger implants.
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.
Breast Augmentation and Cup Size
I personally prefer a breast size in the full C range, but do not object to a D cup size. If a patient wants a B cup- that's okay and it is her call, 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 full C-cup. Generally, this size provides an excellent appearance, and is not so large that the breasts interfere with activities or give the appearance of being "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 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 (See D.A.) wishing to be larger. They have a new-found appreciation of their breasts and have lost some of their apprehension about having larger breasts.
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 have 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. The procedure is much more of an art than a science. There is no formula which 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.
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 presented in the Patient Photographs section, it is obvious that the preoperative breast size is as important as the implant size in determining the final breast size. (See examples: R.K.s breasts are larger than J.S.'s breasts, even though the implants were smaller.)
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 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 D cup size if desired.
Personally, I have not found it helpful to use implants tucked into patient's bras to gauge the size of the implant to be used at surgery. Nor have I found computer simulation helpful. Selection of implant size remains a judgment, a decision made intraoperatively, based on the patient's wishes, her anatomy, and my experience.
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. Sometimes 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. Each of these three approaches has relative advantages and disadvantages:
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, which it turns out is a little too low. 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 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. It is also important to make the pocket just the right size, and insert the implant with minimal trauma to reduce the risk of creases in the implant envelope that might lead to leakage later (leaks often occur at folds).
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 very well-hidden.
The Transaxillary Incision
This approach can be done with or without endoscopic assistance. While 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. However, for many plastic surgeons, it remains their most common approach.
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 technically difficult operation such as 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 are able to 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 - a result such that 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 Pamela Lee 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 crease") 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.
Breast Implants
Silicone Gel-filled vs. Saline-filled Implants
Both silicone gel-filled implants ("silicone gel" implants) and saline-filled implants ("saline" implants) both 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.
The "feel" advantage of silicone gel has to be tempered by the fact that a silicone gel implant has a higher rate of hardening of the lining that the body forms around the implant (called "capsular contracture"). If this complication occurs, the breast feels much firmer than a breast with a saline implant in place and no capsular contracture. So women with silicone gel implants who do not have a capsular contracture have a very soft, natural feel that is superior to a saline-filled implant. But those who are unlucky and develop a capsular contracture after having silicone gel implants will have an overly firm-feeling breast which is much inferior to a breast augmented with a saline implant.
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 are 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 less risk of wrinkling with silicone gel implants. In these thin patients, the risk-benefit ratio may be more in favor of 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.
Detection of Deflation
The FDA recommends an MRI scan three years after a breast augmentation using silicone gel implants and every two years after that. The reason for this recommendation 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. 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.
Silicone gel implants are about double the price of saline implants. This adds about $1000 to the cost of surgery. They 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.
Interestingly, silicone gel implants are much more commonly used just about everywhere in the world except the U.S., where their use was temporarily curtailed by the FDA. This is often cited as evidence of their superiority.
However, American surgeons have been forced to learn many of the advantages of saline implants. I prefer them for the majority of my patients, although I implant silicone gel implants in patients who make an informed decision to choose them after we discuss the pros and cons. Silicone gel implants can be the right choice for some patients.
Safety of Silicone Gel Implants
Most of us are aware of the concerns about silicone gel breast implants, which were impossible to miss in the media in the early 1990's. 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.
Thre was also a controversial report from Scandinavia that seemed to implicate breast implants in suicide risk. One of my patients, who did attempt suicide, was instructed to have her breast implants removed! Instead she divorced her abusive husband. Indeed, any relationship between implants and suicide attempts is likely to be an association and not a cause-and-effect relationship. Perhaps, there are factors in common between the two groups that account for this association.
Silicone Gel Implants: Leakage and Rupture
However, local problems from silicone gel-filled breast implants are well recognized. Silicone gel very gradually diffuses through the envelope of the breast implant. The original silicone envelope was made thin, so it would be soft and difficult to feel. But surgeons later discovered that this thin envelope eventually breaks down, releasing the silicone gel into the pocket which the body has formed around the implant. When these early silicone gel implants were removed after ten years in the body, they were usually found to be ruptured. Even "third-generation" silicone gel implants that are currently in use are projected to maintain integrity at a rate of only 83-85% after 10 years. This compares to a rate of 97-99% for saline implants at 10 years.
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. MRI's are more reliable for detecting implant rupture.
Cohesive Gel Implants
There is a newer type of breast implant which is presently available outside the United States and likely to be introduced to the market here soon, called a cohesive gel implant or "gummy bear" implant. "Cohesive" is a relative term, referring to the viscosity of the silicone gel. The silicone material in these new implants is tightly contained to reduce the amount of silicone gel that escapes into the tissues. In fact, you can slice it like a piece of pie without having silicone ooze out. More cohesive 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. If the implant is at all firm, it has lost its most important advantage over saline implants. However, this implant is popular where it has been available outside the United States.
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 significant possibility of rupture if they have been in over ten 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, usually with new saline implants. This also renews the warranty.
Often, women with old silicone gel implants do 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.
On several occasions, I have taken patients to the O.R. to perform other cosmetic procedures, such as liposuction, and noticed that they had capsular contractures while I'm in surgery operating on other areas. This would have been an ideal opportunity to perform capsulotomies, release the capsules and replace the implants. There is a quality of life improvement to be achieved by softening the breasts. I try to determine this preoperatively of course, but patients are sometimes modest and do not bring this problem to my attention (and I usually allow them to keep their bras on if they are seeing me in consultation for liposuction).
When I replace silicone gel implants, I usually replace them with saline implants. This way, the patient never needs to be concerned about silicone gel leakage again. But she does need to know that saline implants are firmer in consistency (but softer than silicone gel implants with contractures).
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.
Although anecdotal and therefore not scientific, I have had reports from dozens of women whose ruptured implants I have removed that they feel better after surgery. They may have experienced a malaise, headaches, or discomfort that is now gone. Is this a physical relief, related to the removal of the silicone material from the pocket, or is it psychological? I don't know, but either way, the patient feels better.
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.
Someday there may be a more ideal filler material which will give 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 an inch and a half (four centimeters) instead of two inches (six centimeters) 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 (within a range of 25-50 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 this is less convenient; surgeons are more likely to use implants of the same size, to keep equal-volume pairs of implants in their inventory, and tolerate small volume differences.
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 350 cc. implant has a minimum fill volume of 350 cc. and a maximum fill volume of 420cc. 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 on implants, wrinkles can be a problem. But we don't want to inflate it 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 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. We do not have a perfect implant.
Adjustable Size Implants
Patients sometimes ask about the adjustable size implants. These implants come with a separate injection port connected to the implant with a short tube under the skin. The surgeon is able to fill the implant gradually at the time of postoperative visits. The advantage is that this technique allows for change in breast size without another operation, and breast size may be adjusted depending on the occasion or later changes in patient weight or desired breast size. But, the size range between minimum fill volume and maximum fill volume is small, almost negligible (remember, the envelope is not very elastic). Disadvantages include the presence of a separate injection port, which may be felt under the skin (it is removed surgically later) and a higher complication rate. Subsequent injections do carry a risk of infection. I am not convinced that most patients would find it an advantage to change their breast size after surgery, particularly within such a small size range. I have not used this implant, but I think there would be very few women who would benefit from it. It is a curiosity that has not gained popular use.
Smooth versus 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? A recent study showed no difference in the incidence of capsular contracture between smooth and textured implants. 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.
Plastic surgeons have observed a lower rate of capsular contracture among women treated with saline implants than silicone gel implants. 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.
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.
Why not use textured implants anyway and take advantage of the textured surface whether it really is helpful or not? For a few reasons that have become apparent now that textured implants have been in use long enough to study the long-term results. Smooth implants are less likely to leak. The risk of leaking or rupture of the textured implants was found to be one percent per year per patient. This means that if a woman has textured implants for ten years, she has a ten per cent 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.
Almost as importantly, 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.
Contoured 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 1990's 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.
Infact, contoured implants may produce less pleasing breast shapes, too vertical with one type and too wide horizontally with another.
An excellent result is possible with both round and contoured implant styles, so patients should not be too concerned about this point. 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. When I look at photographs of my own patients, I cannot tell without checking the operative note.
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 patient 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. Mentor Corporation introduced a MemoryGelTM"Moderate Plus" implant in 2005, and subsequently, most of my patients have had moderate-plus profile implants. 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. However, I use high-profile implants judiciously to avoid producing too much of a good thing and giving a "torpedo" appearance to the breasts.
How Long Do They 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.
Recent studies have shown that in fact most women who have a breast augmentation will return for a future procedure on their breasts and 13% will undergo reoperation within three years. 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 which 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 one to three percent at ten years. It was reassuring to patients and surgeons alike when Mentor Corporation increased its warranty from five years to ten years in 2006, likely influenced by the low deflation rate of their implants.
