Implant Decisions

Decisions to Make before Breast Augmentation Surgery

Dr. Loftus considers each decision prior to breast augmentation to be important to success and satisfaction. On this page, she will walk you through an overview of each of these decisions. Be sure to visit the pages detailing each of the decisions (link is at bottom of each paragraph).

1. Position (under or over the muscle)

   By implant position, plastic surgeons are referring to whether the breast implant should be placed above or below the pectoralis muscle. Advantages for placing the breast implant above the muscle include less discomfort post-operatively, less swelling, and less chance that the breast will appear to move when you are exercising your upper body. This last issue has been one of great concern for many women, especially those who have full workout regimes. Simply put, if your breast implants are under the muscle, then when you flex your pectoralis muscles (as you often do during workouts), your breasts may appear to move. Sometimes (though not commonly) the breast motion will appear quite distorted. Now, to bring things into perspective, you should realize that many women who work out (and even some professional female athletes) have implants under the muscle and are very happy with their appearance. In other words, if you work out a lot, do not automatically assume that your breast implants need to go over the muscle. Advantages for placing the implants under the muscle include less interference with mammography and less rippling in the upper half of the breast. Generally, thin and small-breasted women should favor implant placement under the muscle. The advantages of less interference with mammography, less rippling of the upper half of the breast, and more cushion between the implant and the skin outweigh the drawbacks, many of which are temporary. Athletic women should consider placement of the implant above the muscle (as long as they have adequate breast tissue and body fat) to avoid breast distortion when the pectoral muscles are flexed. Thin, small-breasted, athletic women must weigh the options. In general, they are probably better off with implants under the muscle. Even though this can cause distortion of the breast while working out, this is not too much of a problem unless you work out in the nude. A more significant cosmetic problem for these women is rippling, which is less likely to occur in the upper half of the breast if the implants are placed under the muscle. Of course, this is your call. Be sure to discuss it carefully with your plastic surgeon. An alternative for these women is to have silicone breast implants. Read more about the under/over decision here: breast implant placement.
   
   

2. Breast Implant surface (textured or smooth)

   By implant surface, plastic surgeons are referring to whether the implant is smooth or textured. A smooth implant is just that – as smooth as the surface of a balloon. Textured implants are rough, somewhat like sandpaper. Once they are in placed under your breasts, it is impossible to tell whether you have smooth or textured implants. Textured implants were developed because plastic surgeons thought that they would be less likely to cause capsular contractures. Unfortunately, studies have not shown a consistent advantage of textured implants over smooth when it comes to capsular contractures. Also, textured implants are more likely to cause rippling, which can be a big problem for thin and small-breasted women. For these reasons, most plastic surgeons favor smooth implants for breast enlargement. Read more about implant surface here: breast implant surface.
   
   

3. Shape (round or teardrop)

   By this, plastic surgeons are referring to round or teardrop shape. Round implants are shaped like jelly donuts. Teardrop implants are shaped more like the breast. At first, you might be thinking that (of course) teardrop implants would be better. However, most plastic surgeons disagree: they think that teardrop implants tend to become round with the forces of healing and that the teardrop implants do not necessarily give a better result. Furthermore, they find that teardrop implants may rotate, giving an unnatural appearance, and they impose restrictions in that they must be textured. Round implants tend to acquire a teardrop shape when a woman is standing or sitting upright. Therefore, most plastic surgeons recommend round. Read more about shape here: breast implant shape.
   
   

4. Size

   This is the all-important size issue. Breast implants come in all sizes with the most common sizes ranging from 200-600 cc. This is equivalent to 7-20 ounces. Within that range, 300-500cc is the most common of the breast implant size. By the way, a cc (cubic centimeter) is the same as a ml (milliliter) – just in case you have visited other sites which refer to volumes in mls. The decision of size is highly personal and highly individualized. The best way to determine your size is by placing breast implant sizers (your plastic surgeon will hopefully have them) in your bra and then put a sweater, blouse, or t-shirt on (or, perhaps try all of them, as you will appear different in each). Do not allow your surgeon to dictate your size. You must have input in this decision. Read more about size selection here: breast size selection. Also, please check out this down-loadable pdf file: Implant Volume, Diameter, and Projection, which shows the specifications of all moderate and high profile implants (both saline and silicone) made by one of the major implant manufacturers. All implant manufacturers make similarly shaped implants with similar specifications.
   
   

5. Breast Implant projection (standard vs. high profile)

   Breast implants are designed so that, as volume increases, so does diameter (the footprint of the implant) and projection (the amount it sticks out, away from your body). Standard implants are designed so that MOST women who choose a given volume will be able to accommodate the breast implant’s diameter beneath her breasts. This is so because women with narrower breast diameters often have smaller bodies and tend to choose smaller breast implants; women with wider breast diameters often have larger body frames and tend to choose larger breast implants. In other words, women tend naturally to choose an implant volume that is in proportion with body size and breast diameter, and the breast implants were designed in anticipation of that. BUT, what if a woman wants the breast implant size to be that which has a larger volume than would be considered proportionate (by breast implant manufacturer standards) for her breast diameter, chest wall size, and body frame? In that case, placing a standard implant would risk an unnatural result, because it would be too wide for her body frame and would likely also extend too high and too low on her chest wall. In these cases, a High Profile implant is recommended. With a high profile implant, the volume is the same, but the diameter (footprint) is narrower and the projection (the amount that it sticks out away from your body) is greater. Most women (over 95%) are best suited to standard implants. The way to tell if you should have standard implants or high-profile is as follows: First, your surgeon should measure your breast diameter. Next, you should choose the implant volume that you want. Finally, your surgeon should compare the diameter of the desired implant size (standard implant) to the measured diameter of your breast. If the diameter of the breast implant size you selected is about the same or smaller than your measured breast diameter, then a standard implant is appropriate. If the diameter of the desired breast implant is larger than you breast diameter, then you should consider high profile breast implants. Read more about the decision of implant profile and projection here: implant profile and projection
   
   

6. Saline Vs. Silicone Gel

   On 11/17/06, the FDA approved silicone gel breast implants for use in primary breast augmentation for any woman over the age of 21. The FDA did this after considering a significant amount of data supporting the safety of silicone breast implants.
   
   Silicone breast implants provide a more natural look and feel, which is particularly important to women who have a modest amount of breast tissue. Although all women want a natural look and feel, women with larger breasts can often achieve this with saline implants. Women with smaller breasts typically cannot. The main disadvantage of silicone gel breast implants is that they might have a higher rate of capsular contracture, the incision is slightly longer, and the cost is higher than saline breast implants. Read more about saline vs. silicone implants here: saline implants or silicone gel implants.
   
   

7. Fill (This Pertains only to Saline Implants, as Silicone implants are Pre-filled by the Manufacturers)

   Saline implants come in increments of about one ounce, which is 30 cc. Allergan implants are made in 30cc increments (180cc, 210cc, 240cc, 270cc, 300cc, etc.). Mentor Implants are made in increments of 25cc (200cc, 225cc, 250cc, 275cc, etc.). Each saline breast implant can be and SHOULD BE overfilled by an additional 25-30 cc. This is because the implants were meant to be overfilled, and the implant manufacturers not only stand by their products when they are overfilled, but they encourage plastic surgeons to overfill them. Here’s why: overfilling reduces deflation, rippling, and sloshing. Underfilling has no advantages and significant disadvantages (rippling, sloshing, and deflation). So, after you select your desired final volume, your plastic surgeon should select an implant that is one size smaller, and then overfill it to your desired volume. Read more about implant fill here: breast implant fill.
   
   

8. Site of Incision

   The options for site of incision are under your breast, around your nipple, in your armpit, or through your belly button. An incision under the breast is placed within or near the natural crease beneath your breast. This incision has the advantage of having the scar hidden in the shadow of the crease under the breast. It also heals well. It also is the incision you would likely acquire if you require revision surgery later in life. Most plastic surgeons use this incision. Incisions around the nipple can give a good result in some women, but is riskier because it is at the focal point of the breast, so any irregularities in the scar will make it far more obvious. It also imposes a higher risk of nipple numbness and inability to breastfeed. Incisions under the arm are an option and have the advantage of being hidden in the armpit. Although many of these scars heal favorably, some armpit (axillary) incisions can be unsightly. Also, implant revision surgery, if needed, might not be possible through the existing armpit scar, so an additional scar would be necessary. Finally, the incision for your breast augmentation can be made through the belly button. This is called TUBA, or Trans-Umbilical Breast Augmentation. The advantage is that the incision is hidden inside the belly button. The disadvantages are that the implant must be placed in the sub-glandular plane (over the muscle), the surgeon may not be able to correct certain breast asymmetries, the deflation rate may be higher, and revision surgery through the original scar is not possible, so an additional scar would be necessary (around the nipple or under the breast). For all of these reasons, few surgeons perform this incision when placing breast implants. Read more about incision options here: scars and site of incision.
   
   

9. Breasts of Different Sizes

   Most women have breasts that are different from one another in size, shape, and position. But, what are the options if the breasts are more than just a little different? Read about breast asymmetry here: breast asymmetry.
   
   

10. To Lift or Not to Lift…. That is the Question

    Whereas a breast augmentation will increase breast size, it will not affect nipple position and will not raise a droopy breast. Simply put, implants will make you bigger but will not raise your nipples. A breast lift will raise your nipples but will not affect your size. Find out if you should be considering a breast lift here: breast lift.

General Advice for those Considering Breast Augmentation

• Visit Breast Augmentation Tips for getting the best results and to help you minimize your risks, expedite your recovery, and get the best possible results from breast enlargement surgery.
• Do not believe websites which state that you will need to have your implants replaced every 10 years. You will only need to have them replaced if you are having a problem. See (Risks and Complications of Breast Implant Surgery). Whereas you might have a problem and need to have them replaced, you might not. The rule here is If it’s not broken, don’t fix it!
• As lifelong follow-up is important, find out if your plastic surgeon charges for visits after surgery.