There are numerous options when it comes to breast augmentation. While some of the choices may not be available in every case and some options not offered by every surgery, there are still many decision to be made by the patient and the surgeon. The choices are mutually exclusive and many are binary options:
- Shape – ANATOMICAL or ROUND ?
- Surface texture – TEXTURED or SMOOTH ?
- Fill material – SILICONE or SALINE ?
- Profile – LOW or MODERATE or HIGH or ULTRAHIGH ?
- Surgical Access incision – UMBILICAL or PERI-AREOLAR or INFRA-MAMMARY or AXILLARY ?
- Tissue plane – SUB-GLANDULAR or SUB-MUSCULAR or DUAL PLANE ?
As you can see, even with only a few options in each choice, the number of possible combination are quite impressive, and this is without even considering size! This means that there is the possibility of tailoring the operation to the patient – but also induces some anxiety in the patient.
“How can I be sure that I’ve made the right choice?”
While there are no “right” and “wrong” choices, some options may be more suited to your particular case. Each option has some advantages and some disadvantages and during the consultation we will consider each option. My role is to highlight the options which are most suitable but your preference will direct the final decision. Where an option is clearly not in your best interest, I will make this clear. Pros and Cons are inherent in EVERY choice – otherwise there these choices would not exist if another option was clearly better. Below I have briefly described them.
1. Shape – ANATOMICAL or ROUND?
The shape of the implant can be round or anatomical (also called teardrop, form stable or “gummy bear” implants). It is interesting to note that all implants (even round) will assume some form of teardrop shape when subjected to gravity in the vertical position. See the picture below.
The real difference is that the anatomical implants have the gel shaped in that position, and the shape cannot be altered with muscle contraction, or patient position. Obviously, this makes the anatomical implants stiffer than rounds. I use anatomical implant predominantly for breast reconstruction due to the shape characteristics. In breast augmentation, their main use is to expand the lower pole more significantly than the upper pole. This makes the upper breast slope more natural when using a larger implant. In most patients round implants are the ideal choice. For patients with modest sagging of the breasts, this implant, especially if used in the dual plane position may be ideal. Anatomical implants are only available in TEXTURED shells. In South Africa, less than 10% of implants used are anatomical, and my own practice reflects this. It is also important to note that anatomical implants cost significantly more than round. Another consideration with anatomical implants is that the surgical access incision is usually larger, due to the stiffer nature of the gel.
2. Fill material – SALINE or SILICONE?
In countries outside the US, silicone is used in the vast majority of cases. This is a result of a nearly 10 year-long moratorium by the FDA, on the use of silicone implants for aesthetic reasons. This applied only to US surgeons while the rest of the world continued to use silicone implants. In 2006, the FDA reversed the decision and silicone implant popularity in the US has sky-rocketed. In South Africa, less than 1% of implants are saline. In my practice I use SILICONE implants exclusively.
The latest generation silicone implants are incredibly safe and strong. Many patients have seen images of rupture “generation II” implants from the 1980s (see picture).
These implants had thin shells and more fluid silicone gel. Modern implants (generation IV and V) have highly cohesive gels and very thick shells. These improvements are the result of advances in technology and engineering with time, just as cars and computers have improved. Most modern implants have a lifetime warranty against manufacturing defects resulting in rupture which shows the commitment from the manufacturers to their bioengineering processes. Just how strong are modern implants? Could you drive a car over one? Naturally, I had to find out … see the video !
Are silicone implants heavier than saline implants? No. Both implants have a shell which is made of siloxane (a silicone rubber compound). The density of the silicone gel is 0.968 grams per cc and saline 1.0046 grams per cc. This means that silicone implants are very slightly lighter than the same volume of saline. This can be easily shown by floating a silicone implant in water (see below!).
3. Profile – LOW or MODERATE or HIGH or ULTRA-HIGH?
The profile refers to the amount of projection the implant has for a given base diameter (or “footprint”). Although there are occasional indications for low profile, moderate and high profile are the most popular implants. In South Africa, moderate and high profiles account for over 80% of implants. The major difference that profile makes is the amount of “fullness” of the upper pole of the breast. Higher profiles result in greater upper pole fullness. The downside of increasing the profile is a moderate increase the firmness – the higher the profile, the firmer the implant.
In my opinion, moderate and high profile implants offer the best overall compromise. The patient’s decision about natural look and feel versus upper pole fullness dictates the choice of implant. Interestingly, my experience with low profile, textured sub-glandular implants is a tendency to lower risk of traction ripples in the upper pole and this may merit consideration in selected patients.
4. Surgical Access – INFRA-MAMMARY or PERI-AREOLAR?
Although there are the options of trans-umbilical breast augmentation (TUBA) or the axillary approach, I personally do not offer these techniques. The infra-mammary approach is the most common access site, with lengths of 4 to 6.5cm, depending on implant and patient factors. The scar is usually fine and well hidden. There is minimal disturbance of the glandular tissue of the breast and dissection usually straightforward. It may be the preferred approach for revision augmentation cases, especially if additional capsular procedures are indicated. The downsides are a potentially visible scar in bathing costumes or underwear, issues related to positioning of the scar if change in the fold is indicated and difficulty in modification of the constricted lower pole. There is also a higher incidence of implant exposure, as the weight of the implant rests directly on the surgical closure.
The peri-areolar approach is my personal preference in the vast majority of cases. It is placed at the junction of the change of colour and texture of the breast skin and the areolar skin. The scar is placed from the 3 to 9 o’clock positions. The diameter of the areolar dictates the scar length but with areolar diameters of less than 3 cm this approach becomes more difficult. Although the dissection is slightly more challenging, excellent surgical access is usual. The ability to modify the lower pole as well as the position of the fold are significant advantages. The final scar is almost always exceptional. The risks of implant exposure are minimal. The downsides to this approach are potentially increased risk of alteration in nipple sensation and decreased breastfeeding ability due to the surgical dissection though some of the breast tissue, even if a sub-glandular plane is chosen.
5. Surface Texture – TEXTURED or SMOOTH?
This is one of the most controversial. In South Africa particularly, there was a clear preference for smooth implants before 2009. From that time onwards, textured implants have become more popular, but it is uncertain if this been driven by the preferences of the surgeons, the patients or the manufacturers. At present, textured implants are more popular.
Once implanted in the body, the “pores” on a textured implant undergo blood vessel ingrowth – essentially “bonding” the implant to the patient’s tissues. This makes the integrated textured implant significantly less mobile. There is much less movement artifact with a textured implant, which makes them more applicable to highly active and sporting patients. This advantage is also responsible for their less natural feeling – natural breasts are highly mobile and textured implants feel less natural than smooth.
The ability of an implant to push out (or expand) the lower pole of the breast is related to the pressure the implant exerts on the tissue due to gravity. A textured implant does this minimally, since it is bonded in its position and lower pole “settling” or expansion is much less with a textured than a smooth implant.
There is some evidence that capsular contracture may be less with a textured implant. It is important to note that smooth implants are only recommended in the SUB-MUSCULAR plane. Interestingly, there is presently no cost implication in this choice.
6. Plane – SUB-GLANDULAR or SUB-MUSCULAR or DUAL PLANE?
Implant can be placed under various amounts of tissue – the tissue coverage affects both healing time and long term shape.
The first plane is the sub-glandular plane – commonly called the “overs”. Here the implant is placed under the breast tissue, but above the muscle. The amount of native breast tissue and subcutaneous fat will determine the thickness of tissue cover. The upper pole shows the distinctive semi-circular “line” of the implant edge and the edge may be palpable in thin patients. The chance of visible ripples is also higher, especially in very thin patients. The movement artifact is very small and the implant placement can be very close to the midline – decreasing the cleavage “gap”. In cases of mild sagging, placing an implant in this may be able improve the appearance, but this effect is usually temporary. There is also much less pain and quicker recovery related to the surgical dissection. It is recommended that only TEXTURED implants be used in this plane.In my opinion, patients who have a fair volume of breast tissue and subcutaneous fat or who perform significant arm strength exercises (rock climbers, weight lifters), this is a valid option.
The next plane is the sub-muscular plane – commonly called the “unders”. Here the implant is placed under the breast and under the pectoralis muscle. I usually lift a small portion of the serratus muscle and dissect partially under the rectus muscle too. It is impossible to achieve TOTAL sub-muscular coverage in a primary breast augmentation, but the upper pole, medial portion and about half of the inferior portion of the implant is covered with muscle. The inferior and lateral portions of the implant will be palpable. The increased muscle cover is associated with a smoother upper pole “take off” and almost no traction ripples. There is evidence that this plane of implantation is associated with lower rates of capsular contracture. The implants can only be placed as close to the midline as the anatomical attachment of the muscle allows – this may mean a wider cleavage gap. In cases of sagging, this plane offers the least improvement and breast lift may be required in some cases to prevent a Snoopy-dog appearance. There is significantly more pain and longer recovery associated with this dissection. All styles of implant are applicable to this plane of dissection. In my opinion, in young or thin patients or those with minimal breast volume this is ideal. For patients seeking the most “natural” look, this is also the best choice. Overall, this is the plane I most commonly recommend.
The final plane is the so-called dual plane. This involves dissection under the muscle, as well as release of the lower attachments of the pectoralis muscle as well as dissection above the pectoralis to a variable amount. This creates a single “pocket” where the implant is covered by muscle on its superior pole and most of the medial pole, but the lateral and inferior portions are covered by breast and subcutaneous fat only. This was designed to include the advantages of both of the above planes, but will obvious suffer from some of their drawbacks too – ultimately it represents the best compromise between the two planes. For patients with tight lower poles or those with a modest amount of sagging (especially if they are thin and still want the natural look) this is an option. In my opinion, some older patients, those with significant weight loss or those with tuberous breast deformity may wish to consider this approach. For patients who require or desire augmentation with ANATOMICAL implants, this plane is ideal.