Breast Augmentation Education
Breast Augmentation Education
Knowing some of the scientific terms and industry “jargon” will help you to better determine which procedure is right for you.
Breast Implant Size
There are numerous methods used for breast implant sizing. The fact, however, is that finding the correct size is very straightforward and simple. The distance across the base of the breast is the measurement used for implant size. It is measured from the breast attachment to the breastbone to its lateral position near the armpit (anterior axillary line). This measurement in centimeters is known as the Base Diameter.
Implants come in four sizes for a specific base diameter measurement: low profile, moderate profile, high profile, and extra high profile. The profile refers to how far the implant projects from the chest and how much fluid the implant will hold. A low profile implant will project the least distance from the chest, hold the least fluid, and is made to increase the breast about one cup size. The moderate profile will project farther, hold more fluid, and will generally give a two cup size increase. The high profile implant will project the most, hold the most fluid, and can increase the breast about three cup sizes. These generalizations reflect an average sized woman and can vary depending on how much breast tissue a woman has before breast augmentation.
As an example, an average breast will have a base diameter of about 12.5cm. For that base diameter, the low profile implant will hold 275cc, the moderate profile implant will hold 350cc, and the high profile implant about 425cc’s. These volumes may vary depending on the manufacturer and the type: saline or silicone. For saline implants, there is a recommended fill volume range such as 350 to 375cc’s. This means the manufacturer of the implant designed the implant to hold no less than 350cc’s and no more than 375cc’s. Underfilling the implant will result in more wrinkles or ripples in the implant which can distort the shape of the implant. Overfilling the implant will cause firmness as well as distortion. In addition, the implant warranty can sometimes be voided if the implant is filled to an incorrect volume. In my opinion, it is best to fill the implant to its maximum recommended volume because it will lessen the risk of implant rippling. For saline implants, I generally choose the smallest appropriate implant (base diameter) filled to the maximum recommended volume. Silicone implants come prefilled and have no recommended volume range.
CHOOSING A SIZE BEST SUITED FOR YOUR BODY TYPE
When choosing implant size, I believe it is necessary to always choose an implant with the appropriate base diameter. Fear of going “too big” or “too small” can cause some women to choose a base which might not fit their chest appropriately. The choice is always with the profile and not the base diameter. Also, it is important to remember not to compare implant volumes between two patients. A 325cc implant might be small for a taller woman with a wider base but be very large for a shorter woman with a smaller base. Accurate measurement of the base diameter is a reliable and sure way of finding the perfect implant size.
Finally, there are numerous sizing systems designed to accurately “predict” which implant is a perfect fit. These systems range from implants you can try on under a bra to imaging software designed simulate the augmented breast. We utilize 3D photographic imaging which helps visualize what the implant will look like. 3D imaging also gives patients the ability to visualize more accurately a large variety of implant sizes. While these systems can help, it is important to remember that they are not perfect and should be used in the proper context. It is most important to review your surgeons credentials and before and after results.
The breast implant can be placed directly under the breast tissue (subglandular), under the chest muscle (submuscular), or in a combination procedure known as a “dual plane.”
SUBGLANDULAR BREAST AUGMENTATION
Subglandular breast augmentation is less painful and gives a more immediate postoperative result. Because the implant in directly below the breast, the implant has a more direct effect on the breast making it a useful technique for tuberous or constricted breast deformity. There is also no muscular effect on the implant which tends to push the implant slightly higher. In patients with ptotic or “saggy” breasts, such as after pregnancy, the subglandular approach can be used to avoid an unnatural double bubble appearance.
Subglandular augmentation does not provide as much tissue coverage over the implant making the implant more palpable (easy to feel) and more visible. In thin patients, ripples in the implants are more visible with the subglandular approach. There is also a higher incidence of capsular contracture (problematic scarring around the implant) with subglandular implants which can result in hard, painful, and distorted breasts.
SUBMUSCULAR BREAST AUGMENTATION
Submuscular augmentation is more commonly used. Because there is more tissue covering the implant, there is less palpability and visibility of the implant. In thin women, placing the implant under the muscle gives a more natural appearance by hiding the edges of the implant especially in the inner and outer parts of the breast. Because the muscle retains most of its attachments to the breast bone (sternum) and rib cage, there is more support for the implant which tends to decrease ptosis (sagging of the breast) over time. One of the major benefits of submuscular augmentation is that there is a 50% lower incidence of capsular contracture using this approach.
Submuscular augmentation is slightly more painful and requires time for the implant to assume its final position. In the first several days ofter surgery, the muscle will be tight over the implant which pushes the implant upwards (riding high). Over time the muscle will stretch and relax so that the implant will lower itself into a more natural position.
DUAL PLANE BREAST AUGMENTATION
Dual plane breast augmentation allows for submuscular placement of the implant and creats release of the breast tissue above the muscle to allow the breast to position itself more directly over the implant and avoid a double bubble appearance. This technique is useful in cases of breast ptosis or pseudoptosis where the breast is somewhat droopy.
There are four incisions which can be used in breast augmentation. Incision choice will determine where on the body a permanent scar will be placed and can affect breast shape. The goal is to choose an incision which is least visible and permits the best access for precise implant placement.
The inframamory incision (IMF) is placed at the lower fold in the breast so that the natural shape of the breast will hide it from view. This is the most common incision and in most cases allows the best access to the breast pocket for precise surgical dissection.
The periareolar incision is usually placed at the lower and middle part of the areola just inside the pigmented skin. This incision generally heals very well making it difficult to detect. This incision is useful when the inframammory crease needs to be adjusted such as when correcting a constricted or tuberous type breast deformity. It is also useful when the skin of the breast needs to be tightened with a periareolar breast lift/mastopexy. The disadvantages of this incision are that the incision is placed on the most visible part of the breast. There can be damage to nerves which provide sensation to the nipple. Because this approach requires dissection through the glandular part of the breast, there can be internal scarring in the breast which can be problematic on screening mammograms. Lastly, there is a higher risk of infection with this approach because there are bacteria in the breast glands which can come into contact with the implant.
ENDOSCOPIC TRANSAXILLARY (TRANS AX OR ENDO)
This incision is placed in a skin fold in the armpit (axilla) which usually heals very well. Many proponents of this approach advertise it as “scarless breast augmentation.” While their intent is to convey the idea that there is no scar on the breast, the reality is that this approach is not scarless and the armpit scar is every bit as permanent as a breast scar. In most cases, it will heal very well but occasionally patients can develop unsightly scars in the armpit which will be visible in clothing which exposes the arm such as bathing suits, tank tops, dresses, etc. Because this operation is done from a “top down” approach, the dissection is slightly different. With the transaxillary approach, the inframammory crease or fold in released about a centimeter to make room for the implant. Over time this can result in an increased distance from the nipple to the inframammory crease giving the breast a rounder shape with the nipple in the center of the breast rather than a teardrop shape.
The umbilical or belly button approach is not commonly used because access to the breast is remote and difficult. Large tunnels are created in the subcutaneous fat over the abdominal muscles to gain access to the breast. In thin patients, this can result in ridging and contour irregularity of the abdomen. The dissection of the breast pocket is mostly done bluntly rather then precisely with surgical cauterizing instruments which can result in breast trauma, scarring, and bleeding. It is difficult to place the implant under the muscle using this approach. For these reasons, this approach is somewhat controversial and not widely practiced.
Saline implants feel less viscous than silicone and most people believe the feel is slightly less natural: like a waterbed. Saline implants will ripple more than silicone when filled to their recommended volume. Saline implants have a recommended volume range making them somewhat adjustable. This can be helpful in correcting differences in size between the breasts to give more perfect symmetry. Saline implants are placed into the breast without fluid and then filled once they are in the body. For this reason, the incision can be slighly smaller with saline implants compared to silicone. Saline implants are less expensive.
Recently, a multi-chamber saline implant has been FDA approved for breast augmentation. This implant is manufactured as the Ideal Implant. This implant is marketed as a "structured implant" referring mulit-chamber baffle shells. The Ideal Implant feels more similar to a silicone implant than a traditional saline implant. It also has a lesser degree of rippling with a lower deflation rate than normal saline implants.
SILICONE (Cohesive Gel)
Cohesive silicone implants have become the standard for cosmetic breast augmentation. Historically, silicone implants were widely used but controversy arose when some questioned whether a rupture in the silicone implant could cause health problems. The FDA exhaustively looked at all available data and determined that there was no statistical link between silicone implants and these health problems. For this reason, silicone implants were approved for cosmetic use in patients over age 22.
Silicone implants have a softer and more natural feel. They tend to hold their shape better and have less rippling. The new generation silicone implants are made of a “cohesive” gel which does not leak if there is a compromise in the outer coating of the implant. Because of the softer feel and less rippling, silicone implants are ideal for thin patients with small breasts.
Silicone implants come “prefilled” and there is no control over the volume once the implants are removed from the sterile packaging. Because they are prefilled, they require a slightly larger incision to place them into the body than saline implants.
Cohesive silicone implants also come in three different levels of cohesivity. In general, the more cohesive an implant is the more it resists gravitational forces. Also, more cohsive implants are more firm in feel. Highly cohesive implants will hold a round shape in the upright position giving a rounder look with more upper pole fullness and cleavage. Less cohesive implant have a softer feel and less upper pole fullness with a slightly more natural or teardrop appearance.
SHAPED IMPLANTS (FORM STABLE)
There are also a new generation of “anatomic” implants which are made to hold their shape against gravity. These implants are highly cohesive and require precise placement into the breast. These implants are often preferred in smaller women who do not desire upper pole fullness and want a more natural and less round shape. These implants are popular with athletic women due to their very natural look and resistance to distortion with chest muscle movement (animation deformity).
TEXTURED and SMOOTH IMPLANTS
Each of the above implant types come in either a textured or smooth coating. Smooth implants have a clear silicone surface. Textured implants have a "rough" surface which has been proven to reduce the risk of capsular contracture in subglandular augmentation. For submuscular augmentation, there is some debate as to whether textured implants reduce the risk of capsular contracture. Textured implants also hold their position in the pocket better than smooth implants making them more resistent to bottoming out. Bottoming out refers to an implant which sits low in the pocket due to the stretching of the lower pole skin over time. In very rare cases, texture implants have been associated with Anaplastic Large Cell Lymphoma (ALCL). This extremely rare type of breast capsule cancer is cured with removal of the involved capsule.
Breast Augmentation Without Implants: Fat Grafting
For a variety of reasons, some women desire to have breast augmentation without using implants. While breast augmentation remains the most popular plastic surgery procedure with an overwhelmingly positive patient satisfaction rate, breast implants do have a few drawbacks including implant palpability, rippling, capsular contracture, and possible need to have implant replaced.
For these women, fat grafting is a good alternative to the use of an implant. Fat is harvested using liposuction. This fat is specially treated and then reinjected into the breast to give a one to two cup size increase. While the majority of the transplanted fat survives and becomes permanent, some of the fat will be reabsorbed. When more augmentation is desired, the procedure may have to be repeated.