Breast augmentation generates more confusion than almost any topic I get asked about as a plastic surgeon. There are many misconceptions about breast implants: incision placement, implant position, saline vs. silicone, shaped vs. round, etc. I hope to clear up some of this confusion with this blog post.
First, let’s begin with some history. The first modern breast implants were designed in the 1960’s. Both saline implants and silicone implants were used during that time. There are advantages and disadvantages of both types of implants and that will be discussed below. In the 1980’s and 1990’s, a great deal of controversy surrounded the use of silicone gel breast implants. Initially the concerns centered on the belief that implants could be associated with breast cancer. Then questions were raised about the possibility of silicone implants causing lupus, rheumatoid arthritis and other autoimmune diseases. A number of class-action lawsuits were filed and in 1998 Dow Corning, the largest manufacturer of breast implants in the U.S. at the time, settled a multibillion dollar lawsuit, forcing the company into bankruptcy. During that time the FDA declared a moratorium on the use of silicone implants and therefore saline implants were used almost exclusively for over a decade in the United States. Since then a number of large medical studies have confirmed that there is absolutely no link between silicone implants and breast cancer or any systemic illness. In 2006 the FDA lifted its moratorium on silicone gel implants for cosmetic breast augmentation and they now represent the majority of the implants used in the United States. Silicone implants have evolved over time so that we are now into a fifth generation of implants including the cohesive gel implants and form-stable shaped (sometimes called gummy bear) implants.
So now that we’ve covered the history of breast implants, let’s discuss all of the options, along with their advantages and disadvantages:
Saline– Filled at the time of surgery with physiologic saline or salt water. Advantages- smaller incision possible, more adjustable sizing, in case of leakage or rupture saline gets absorbed by body. Disadvantages- tend not to feel as natural, may ripple, may tend to drop more.
Silicone– Prefilled with a cohesive gel that helps prevent silicone from migrating. Advantages- often look and feel more natural, less potential for rippling. Disadvantages- longer incision necessary (2-2 1/2 inches), higher cost.
Shaped implants– “Teardrop” or anatomic shaped implants with more volume at the bottom to recreate the breast’s natural slope. Advantage- may provide a more natural look. Disadvantages- if implant rotates or moves it could cause distortion of the breast, requires larger incision than round silicone implants, higher cost.
Form-stable (“gummy bear”) implants– a type of shaped implant with a highly cohesive, firmer gel that maintains the implant shape better. Even if the implant were to be cut, the gel would not leak from the implant. Advantages- this firmer gel implant retains its shape better than traditional silicone or saline implants, better able to impart a desired shape to the breast, less chance of rippling or wrinkling, lower rate of capsular contracture, less concern for leaking. Disadvantages- much less margin for error in choosing the right dimensions and volume of the implant as compared to traditional silicone or saline implants, almost always requires an incision in the breast fold, a firmer feel of the implants, larger incision needed, higher cost.
Round implants– By far the most common implant used in the United States. Advantages- provides better upper breast fullness and cleavage, rotation of implant is not a concern, smaller incision needed than shaped implant. Disadvantage- higher chance of visible rippling or wrinkling.
Above the muscle– Implant is placed subglandularly; under the breast tissue but on top of the pectoralis muscle. Advantages- quicker recovery, less pain and downtime, look better quicker, take less time to “drop” or settle, can provide more lift than an implant under the muscle. Disadvantage- more prone to rippling, wrinkling or visible edges of the implant, particularly in thin patients. In very thin patients with minimal breast tissue this may not be the best choice.
Under the muscle– Implant is placed partially or totally under the pectoralis muscle. Advantages- Lower rate of capsular contracture (the topic of another blog post), provides better coverage for implant, particularly in thin patients with minimal breast tissue. Disadvantages- longer and more painful recovery with longer downtime, takes longer for implants to “settle”, may look a little less natural than above the muscle.
In the breast fold– The most commonly used incision. Advantages- easiest and most direct way to place the implant precisely, allows for better adjustment of the fold in cases of asymmetry, less disturbance of the breast tissue and less chance for loss of nipple sensation. Disadvantage- scar may be more visible.
Periareolar– Incision around the edge of the areola. Advantage- small incision and in theory may result in a less visible scar. Disadvantages- more likely to cause loss of sensation, may interfere more with breast feeding, slightly higher chance of infection.
Axillary– Incision in the armpit. This surgery usually requires the use of an endoscope to allow for release of pectoralis muscle and precise implant placement. Advantage- a virtually invisible scar. Disadvantages- technically more difficult to get accurate placement of implant. If revision surgery is needed in the future, the surgeon may need to make a secondary incision.
So as you can see, there are a lot of options to consider when thinking about breast augmentation. It’s important to have an extensive talk with your plastic surgeon before proceeding. Ask questions. Look at representative before and after photos of the surgeon’s work. There is no particular implant style, placement location or incision that is better or worse. All of these factors are dependent on the patient’s specific situation, their anatomy, their goals, their budget as well as the surgeon’s preferences and experience. Truly, one size does not fit all!