Breast Augmentation

Most implant placement procedures are about an hour to an hour and a half in duration, depending on the incision approach, type of implants, and other factors. If you are having augmentation combined with a lift, the operation may take 2 to 3 hours. Other combinations are also possible, such as implants, lifts, liposuction, and a tummy tuck (also known as a “mommy makeover“).

Saline and silicone implants are both FDA-approved breast implants in the US. Patients have a variety of choices when deciding on implant size, style, manufacturer, profile, etc. Here is a simple list of pros and cons of various implant choices:

Saline Implants

• Saline implants are deflated when they’re inserted into the breasts; then, they’re filled with a sterile salt water filling. Because they’re deflated, they can often be placed through slightly shorter incisions, though it really depends on the pocket size and the ability of the surgeon to safely create the pocket through the planned incision approach.
• Saline implants may feel slightly firmer to the touch when the breast is handled; this is because the water in the bag is less compressible than silicone, and the shell can feel stiffer when the water is compressed much like a water balloon. Some patients want this firmer, stiffer look and feel, whereas others think this is less natural.
• Saline implants can leak and if they do, the implant will deflate, requiring replacement.
• Some surgeons believe saline implants are more likely to ripple, causing unusual waviness to the breast.
• Leaking saline fluid is harmless in the absence of infection, so some patients prefer this for peace of mind.
• Any patient who is a candidate for breast augmentation can have saline implants without age restriction.
• Saline implants generally cost a little less than silicone implants.
• Sometimes patients can detect sloshing of fluid in the implants, which may be annoying.

Silicone Implants

• Silicone implants are generally preferred by most plastic surgeons because they tend to feel more like natural breasts. There is a “give” when a silicone implant is squeezed, which can make the implant harder to detect inside the breast.
• Silicone implants are now manufactured with a next-generation silicone gel that is more cohesive, which means the implants are unlikely to spill out silicone if the shell loses its integrity. This is one of the main issues that originally led to problems with the older generation of silicone implants. The newer generation is often referred to as “gummy bear” implants because the consistency of the gel is more uniform and less likely to liquefy.
• A leaking silicone implant may not result in symptoms, as the gel stays together better and usually remains inside the capsule of the implant. In uncommon cases, silicone can leak out and cause a local reaction of painful hardening or swelling.
• If a silicone implant is shown to be leaking on mammogram or MRI, plastic surgeons usually recommend replacing it to reduce the risk of inflammatory reactions and give the patient peace of mind.
• The FDA recommends an MRI every few years after silicone placement in order to continue to gather long-term data and because the rare implant leaks may not show symptoms.
• The FDA recommends that only patients 22 and older have silicone implants.
• Silicone implants cost more to manufacture and test so they cost more to put in.
• Sometimes the incision needs to be larger, especially if very big implants are being put in since the silicone is already pre-filled in the implant.

Round implants are, well, round, while anatomic implants are tapered at the top and rounder on the bottom. Also known as “teardrop” implants, anatomic implants are considered to give a more natural, subtle look than round implants. One negative is that if an anatomic implant rotates, it can change the shape of the breast.

A “gummy bear” implant is simply a silicone implant filled with a highly cohesive gel. That means that if the implant was cut or ruptured, the filling will stick together rather than leak. Some surgeons feel that gummy bear implants give more natural results than other implants.

In general, implant volume is determined by a combination of estimating the patient’s own breast volume, choosing target cup sizes, and determining a range of additional ccs of volume that would be expected to achieve the goal. Implants come in a variety of “profiles,” which is a term that describes how much of the volume is used to create width vs. forward projection of the breast. Moderate profile implants are wider and flatter, while high and ultra high profile implants are narrower and taller, and “moderate plus” implants are somewhere in between. A patient with a very narrow chest wall and little native breast tissue is often a good candidate for a high profile implant, whereas patients with a lot of native breast tissue and a wide chest may do better with a moderate or moderate plus implants style.

When it comes to choosing an implant style and size for your breast augmentation, the best implant is usually one that fits in the breasts’ base diameter and is in the patient’s desired volume range. If a patient selects an unnecessarily narrow or excessively high profile implant (meaning, it sticks out prominently), she may end up with wide cleavage or implants that move too much in the pocket. However, the patient’s preferred degree of the profile should also be considered.

During your consultation for Dr. Sayed will take breast measurements of the chest wall and other features; he’ll then look at whether you need a lift, an areola reduction, or other approaches, as these can also impact the implant size that will give you the best result.

There is no “cookie-cutter” approach to sizing for breast implants to achieve a “natural” look or even a “done” look. Because breasts have significant variability that depends on native breast volume, shape, nipple position, descent (or “sag”), and symmetry issues, what one patient considers natural may differ from another patient’s perception. It is therefore very important to try to explain your cosmetic goals to your plastic surgeon during your consultation.

Pictures of models illustrating your ideal breast appearance can be helpful, but be careful not to assume that there is any guarantee of getting the exact same look with your breast augmentation. Many patients who end up with an “unnatural” look do so because of poor communication regarding their goals. But there are also intraoperative and some postoperative factors that can contribute your appearance. The dissection of the implant pocket by the surgeon is the most “controllable” factor in determining the final appearance. Using overly large implants for the patient’s chest wall measurements can contribute to an unnatural outcome. In addition, the placement of implants over the muscle may make them more visible and detectable, particularly in patients with relatively small breast volume before their procedure. The surgeon must take care to make a well-designed pocket for the implant – not too spacious, and not too tight – and this step is often aided by careful preoperative marking and review of photographs.

Because of these variables, we use surgical simulation software (Crisalix) in the office to visualize the effects of different styles, sizes, manufacturers, and even positions of the implants, which helps take a lot of guesswork out. This is typically combined with the use of a sizing kit designed by the implant manufacturer. The kit has a variety of inserts that the patient can put into her bra or into a tight-fitting top to simulate the effect of augmentation with various-sized implants. When combined with simulation software, this helps us agree on implant size, style, manufacturer, and other variables. We rarely have to revise our own results for size as a result of this careful planning. However, we are often called on to perform a revision on patients who had their procedure elsewhere.

Most breast augmentation patients have some breast asymmetry. The human body is not perfectly symmetric, although we aim to make the breasts as symmetric as possible when we perform plastic surgery. This starts with assessing whether you have had prior breast surgery and examining for prior scars, the nipple position, location of the greatest fullness in the breast, positioning of the folds below the breasts, and any other factors that may be contributing to the asymmetry. If you have prior breast implants, it will help to provide operative notes and records to help Dr. Sayed know what size and style implants you previously had. This is important information to help guide planning.

If your breasts are naturally asymmetric, Dr. Sayed will assess whether this is due to one side being significantly larger than the other, hanging lower than the other, and other factors. Some patients need one breast to be reduced in size during their procedure. Some require lifting one or both breasts, sometimes using identical breast lift techniques and sometimes using different lift methods. If you are undergoing breast augmentation and you are asymmetric, Dr. Sayed may reduce the larger breast in order to place the same style and size implants in both breasts. Alternatively, sometimes the right answer is to use different implants on the two sides. Treatment is a very personalized approach to every patient.