Breast Implants

Step 1: A DETAILED CONSIDERATION OF YOUR GOALS

This step is too often neglected in breast augmentation consults. Enhancement is not just a matter of going from one cup size to another. Over the years, I have discovered that more than half of the patients who come to me for augmentation surgery want to correct issues relating to asymmetry, volume balance, breast shape, breast projection, and the relationship of their breasts to the rest of their body. A thorough consultation should also cover lifestyle, activity levels, and plans for future pregnancies. When we thoroughly discuss these issues, I can be of best service to my patients.

Step 2: CAREFUL DIMENSIONAL PLANNING

After our conversation to assess your goals, I perform a detailed analysis of the dimensions of your breasts. The measurements I obtain are important to both of us because they allow me to narrow the focus to a range of breast implants that will meet your goals, but also respect your natural breast structure. As a general rule, a respect for the natural dimensions of your breasts is the key to obtaining a result that does not appear to be surgically created. This is because, for some patients, Mother Nature may have been unkind. One example would be a patient with very narrow breasts on a wide torso. In this case, we will go beyond what nature has given us and intentionally alter fundamental breast dimensions, but always with the goal of maximizing the natural look of the result.

Step 3: HELP VISUALIZING YOUR OWN BREASTS

We have an advanced digital photography system, so that as soon as I photograph your breasts, the image is transferred to a monitor in the exam room. This enables us to further the discussion and address subtle issues of breast form, structure, and symmetry when deciding on breast implant specifics. This process is much more helpful than just looking at your breasts in the mirror, because it enables you to step away from yourself and visualize your breasts in a more accurate manner.

Step 4: A BETTER SENSE OF RESULTS WITH CUSTOM BREAST SIZERS

Once we determine a recommended range of implant sizes, the next step is to give you a reasonable approximation of the effect these implants will have on your breasts. A common practice for many surgeons is to give you an implant of the specific size, which you place inside your bra. Unfortunately, this does not do a very good job of approximating what the implant will actually do when it is under your breast—especially if the implant is to be placed under the muscle. We help our patients to visualize the results of breast implant surgery through the use of custom breast sizers. These curved shells are the product of careful study into what a given size breast implant does to the actual shape of the breast. You will place a pair of these sizers on your breasts and hold them in place with a stretch bra. This process provides a much better simulation of the results of breast enhancement than any method we have used before. In my opinion, sizers are more helpful than even 3D imaging, because you can actually experience how your breasts will look in the real world. You can also see how your new breasts will look in clothing, which is an important consideration.

Step 5: 3D SIMULATION OF YOUR BREASTS WITH DIFFERENT SIZE IMPLANTS

There are several 3D systems that provide an approximation of how your breasts will look with various sizes and shapes of implants. This information presented this way can be helpful for some patients, but it is important to remember that this is only a computer simulation. None of the current software, in my opinion, is completely reliable in predicting breast shape. As long as you keep these limitations in mind, 3D simulation is one more piece of data that will help you make an informed decision. Most of our patients tell us that the custom breast sizers are more helpful than 3D imaging when it comes to actually getting a realistic sense of the effects of breast implants.

Step 6: A LARGE COLLECTION OF BREAST PICTURES (THANKS TO OUR PATIENTS)

Many of our patients have generously given us permission to use their before-and-after pictures for educational purposes. This often allows us to provide you with images of patients who have body types and breast shapes similar to your own. A 300 cc implant in an athletic 23-year-old woman will have a very different effect from a 300 cc implant in a 35-year-old woman who has breastfed three children. If we are able to find pictures that show the results of breast implant surgery in people whose bodies are similar to your own, this can be very helpful.

Advantages of Saline Breast Implants

1. They can be inserted through a shorter incision.
2. They can be adjusted to a specific volume, within a limited volume range.
3. They are less expensive than silicone gel breast implants.
4. If they rupture, the resulting leak is easy to detect, since the breast goes “flat.”
5. You do not have to worry about theoretical concerns about silicone gel and its effect on the body. The Internet is full of speculation, and if you are the type of person who is easily upset by such things, you may gain peace of mind by selecting saline implants.

Disadvantages of Saline Breast Implants

1. The number one complaint about saline breast implants is that they do not feel as natural as silicone gel implants.
2. Saline implants are prone to rippling, which may be visible in certain portions of the breast, especially if you bend forward.
3. Some surgeons try to avoid rippling by over-filling implants, but this leads to another problem: an overly firm implant with a ball-like shape.
4. There have been reports of saline implants being colonized by bacteria or other microorganisms. I have never encountered this in a single one of my patients, but it is a theoretical concern.
5. Some surgeons think that saline implants are less durable than silicone gel implants. It’s very hard to get good data on this.

Silicone Breast Implants

Silicone gel implants are filled with a gel-like version of the silicone polymer. This feels much more like a natural breast. All implants currently available in the United States contain what is known as a cohesive gel. This means that the chains of silicone polymer are cross-linked so that they stick together even if the shell of the implant is broken.

Advantages of Silicone Gel Breast Implants

1. Silicone gel implants have a more natural “feel” when compared to saline implants. This advantage is particularly important for patients with limited natural breast volume, since there is less “covering” to camouflage the implants.
2. Silicone gel implants are less likely to ripple than saline implants.
3. It is now possible to select silicone gel implants with different degrees of cohesivity to the gel. This influences breast shape and the degree of fullness in the upper portion of the breast as well as the general “feel” of the breast.

Disadvantages of Silicone Gel Breast Implants

1. Silicone gel implants require a longer incision for insertion than do saline implants of the same size.
2. Silicone gel implants are more expensive than saline breast implants.
3. A break in the shell of a silicone gel implant is sometimes harder to detect than shell breakage of a saline implant.
4. There will always be speculation about possible ill effects of silicone gel implants, even though a large number of studies have shown no connection between breast implants and health problems. If you are inclined to worry about this type of speculation, saline implants may be a better choice.

Advantages of Form Stable Breast Implants

1. As with regular silicone implants, many women believe form-stable gel mimics the feel of natural fat better than saline does.
2. Also like regular silicone, rippling is less of a concern with gummy bear breast implants.
3. Form-stable silicone used to be available in only anatomic-shaped implants with a rough surface texture, but now comes in round breast implants with a smooth surface as well.

Disadvantages of Form Stable Implants

1. Because of form-stable silicone implants’ size, shape, and solidity, there are fewer incision options available for women choosing them.
2. Gummy bear implants cost more than saline devices.
3. Since form-stable silicone is designed not to leak out like salt water, it may be harder to tell if there has been a rupture of the implant shell.

High-Profile Breast Implants

A high-profile implant allows the maximum volume while respecting the breast base width. There will also be a greater degree of fullness in the upper portion of the breast. Since I am a naturalist, I generally prefer a breast that is not overly full in its upper portion—but there are some patients who desire this look. If you opt for a high-profile implant, I would generally recommend that the implant be positioned under the pec muscle, as this will soften the transition at the upper portion of the breast. If you have quite a bit of natural breast tissue in the upper breast and you desire a full look, you may want to consider a high-profile implant on top of the muscle. For patients who have very little natural structure in the upper part of the breast, I recommend against placing the implant above the muscle, as this will create very abrupt transition.

High-profile implants can be very useful for breast reconstruction. Under these circumstances I usually combine these implants with a procedure to give a natural curvature to the lower pole of the breast, along with fat transfer to soften the transition in the upper portion of the breast.

Intermediate-Profile Breast Implants

The majority of my patients choose intermediate-profile breast implants for their augmentation surgery. This reflects the taste of the patients who come to see me, as they tend to place a priority on obtaining a natural-looking result. Mediumprofile breast implants fill out the breast well, but don’t create an “overdone” look, especially when they are placed under the pec muscle.

Low-Profile Breast Implants

These are implants that have a relatively wide base for their volume. This means that the implant will not thrust as far forward as the equivalent-volume higherprofile implant.

I have found lower-profile breast implants to be particularly helpful for patients who have a relatively wide natural breast base, but who do not want to add a lot of volume to their breasts. In these cases, intermediate or high-profile implants would be too narrow for the breast and would not fill it out properly. A lower-profile implant’s wider base would create a better balance.

A Careful Analysis of Your Goals and Preferences Is Key to Obtaining an Excellent Long- Term Result

In my practice, we emphasize the importance of understanding your taste and preferences. This understanding, combined with a careful dimensional analysis of your breasts’ structure and form, allows us to tailor our recommendation to your needs. The availability of breast implants with a variety of projections and shapes has been helpful to this process.

The inframammary approach offers direct access to the subglandular, subpectoral, and subfascial planes, which are the three locations where a breast implant can be placed. If a particular patient’s breast implant surgery requires advanced techniques—such as repositioning the pectoral muscle, releasing a tight lower breast structure, or anchoring the fold—the inframammary incision gives the best access and allows for precision.

Another advantage of this approach is that there is minimal disruption of the breast structure. There is some evidence that this may help to diminish the likelihood of capsular contracture.

If it heals well, the inframammary incision results in what could be considered the least conspicuous scar. The breast fold is, after all, a natural crease. If you have a relatively light complexion and do not have any personal or family tendency to form thick scars, this can be a good choice for you.

If you have a relatively mature breast structure with a well-defined fold and a little overhang of the fold, the inframammary approach tends to work very well. You may want to discuss other possible incisions If you like to wear very small swimsuit tops that tend to ride up above the lower edge of the breast, if you enjoy topless sunbathing, if you lack a well-defined fold under your breasts, or if you are of African, Southern Mediterranean, or Asian ancestry and you have a likelihood of forming thicker scars.

Note that if an augmentation plan includes adjusting the position of the fold under the breast, Dr. Cook will locate the incision at the level of the new fold. One example of this would be a patient with a relatively high fold who desires an implant with a larger base dimension. In order to avoid creating a “top heavy” breast, the level of the fold must be reestablished at a lower position, so that the implant is nicely centered on the breast.

By far the simplest approach for a breast implant procedure is for a surgeon to cut straight down through the breast tissue after making the surgical incision. This can potentially speed the operation, but there may be disadvantages. First of all, if a surgeon cuts through breast structures, the breast implant will be exposed to bacteria that live in the breast ducts. We know that there is a greater risk of capsular contracture when implants are exposed to such bacteria. A second disadvantage is that when breast structure is cut, there may be confusing changes on mammograms.

When Dr. Cook uses a periareolar incision for breast implant surgery, he takes a different approach, which is a little more complex—but which is also better for his patients. Rather than cutting the breast structure, he opens up the natural plane under the skin and above the breast structure. He follows this curve down to the lower edge of the breast, then passes under the breast. From that point in the operation, he proceeds just like he would with an augmentation done via the inframammary approach. It seems to be common sense that keeping the breast structure intact and leaving the ducts alone is worth it.

From the standpoint of periareolar incisions, it is best to have a well-defined areolar border, since this hides the scar nicely. If the areolar border is less distinct—which is the case in 20 to 25 percent of patients—the scar will be more conspicuous.

Note that if you are planning to breastfeed, there is some evidence that a periareolar incision may be more likely to interfere with lactation than an inframammary incision. Even though the evidence about this is not definitive, it might make sense to avoid a periareolar incision if the ability to breastfeed is a priority for you.

Also, some areolae are not large enough to allow for the placement of a breast implant—at least through the standard periareolar incision, which runs along the lower edge of the areola, from the 3 o’clock to the 9 o’clock position. One possibility is to extend the incision into the adjacent skin of the breast, but this may make the scar more noticeable. The other possibility is to encircle the entire areola with the incision and release the skin that surrounds the area, but this can have its disadvantages as well.

Another concern with the periareolar approach is the possibility of a greater likelihood of capsular contracture—a tightening of scar tissue around the implant, which can distort the shape of the breast and produce an undesirable firmness.

By far the simplest approach for a breast implant procedure is for a surgeon to cut straight down through the breast tissue after making the surgical incision. This can potentially speed the operation, but there may be disadvantages. First of all, if a surgeon cuts through breast structures, the breast implant will be exposed to bacteria that live in the breast ducts. We know that there is a greater risk of capsular contracture when implants are exposed to such bacteria. A second disadvantage is that when breast structure is cut, there may be confusing changes on mammograms.

When Dr. Cook uses a periareolar incision for breast implant surgery, he takes a different approach, which is a little more complex—but which is also better for his patients. Rather than cutting the breast structure, he opens up the natural plane under the skin and above the breast structure. He follows this curve down to the lower edge of the breast, then passes under the breast. From that point in the operation, he proceeds just like he would with an augmentation done via the inframammary approach. It seems to be common sense that keeping the breast structure intact and leaving the ducts alone is worth it.

From the standpoint of periareolar incisions, it is best to have a well-defined areolar border, since this hides the scar nicely. If the areolar border is less distinct—which is the case in 20 to 25 percent of patients—the scar will be more conspicuous.

Note that if you are planning to breastfeed, there is some evidence that a periareolar incision may be more likely to interfere with lactation than an inframammary incision. Even though the evidence about this is not definitive, it might make sense to avoid a periareolar incision if the ability to breastfeed is a priority for you.

Also, some areolae are not large enough to allow for the placement of a breast implant—at least through the standard periareolar incision, which runs along the lower edge of the areola, from the 3 o’clock to the 9 o’clock position. One possibility is to extend the incision into the adjacent skin of the breast, but this may make the scar more noticeable. The other possibility is to encircle the entire areola with the incision and release the skin that surrounds the area, but this can have its disadvantages as well.

Another concern with the periareolar approach is the possibility of a greater likelihood of capsular contracture—a tightening of scar tissue around the implant, which can distort the shape of the breast and produce an undesirable firmness.

If you have the type of skin that heals well and you are very concerned about having a scar anywhere on your breast, the axillary approach may be a good choice for you. This may be particularly true if you have very small breasts that lack a well-defined natural fold.

So-called “blind” axillary augmentations rely on relatively crude instruments to create the pocket for the breast implant and don’t allow for accuracy. When Dr. Cook performs axillary breast implant surgery, he always makes use of an endoscopic system in order to increase the accuracy of his work in the lower portion of the breast.

If you are of an ancestry that makes it more likely you will have a thick or dark scar, remember that the axillary location is not particularly ideal in terms of healing. Only the periareolar incision can make this claim. Remember that the inframammary and periareolar incisions will be hidden by clothing and swimsuits, while the area under the arm is not. As a consequence, if an axillary incision doesn’t heal well, it will be visible every time you raise your arms.

A significant percentage of Dr. Cook’s patients require sophisticated technical maneuvers in order to achieve the best surgical result. These are usually best accomplished via an inframammary incision.

One question that often comes up in consultations for breast implants is whether the release of the lower edge of the pec muscle affects muscle function. This is especially important to patients who are very athletic. Fortunately, pec function remains the same after release of the muscle edge.

There is, however, one issue that patients who are to undergo subpectoral augmentation should be aware of: When the pec muscle contracts, the breast will move. For most patients, this one issue is outweighed by the advantages of having the breast implant under the muscle:

1. Subpectoral breast implants have a natural slope in the upper portion of the breast. For patients who want to avoid the top-heavy obviously augmented look that is all to common, subpectoral augmentation is a good choice.
2. It is easier to get good quality mammograms when the breast implant is beneath the pectoral muscle than when breast implants are just under the breast structure.
3. Particularly in thinner patients with a modest amount of natural breast structure, subpectoral placement helps to camouflage any imperfections in the breast implants and provides a more natural “feel” to the breast.
4. There is some evidence that submuscular breast implants have a lower likelihood of developing capsular contracture (hardening) than subglandular breast implants.

Subpectoral breast implants also have some disadvantages when compared to subglandular implants:

1. The surgery takes a little longer and requires more skill. This should not be an issue if your surgeon is certified by the American Board of Plastic Surgery and is an experienced breast surgeon, such as Dr. Cook.
2. For the first few days after augmentation surgery with subpectoral breasts implants, you will be more uncomfortable than if you had implants placed in the subglandular plane.
3. When you contract your pec muscles, such as when doing a bench press or pushing down on the edge of a swimming pool to bring yourself out of the water, your breasts will move. As a practical measure, most patients don’t find this to be an issue. It might be a concern if you are a competitive body builder.
4. If you have very well-developed pec muscles, there may be technical challenges in obtaining a nice breast shape.

A large percentage of patients who come to Dr. Cook for revisional surgery after getting breast implants have their implants positioned in the subglandular plane. A less–than-ideal outcome from subglandular breast implants is often associated with two specific situations:

1. When the breast implants are very large, especially if they are filled with saline.
2. When the breast implants are placed in a patient with thin natural breast tissue in the upper part of the breast.

It mystifies Dr. Cook why some doctors force very large, saline-filled breast implants into the subglandular plane. These breasts do not look or feel natural and often develop problems over time. Very large subglandular breast implants follow a predictable course: The weight of the breast implants stretches the lower part of the breast and leads to early drooping that only gets worse over time. The mechanical force of the breast implants leads to a thinning out of the remaining breast tissue, so that there is very little left to camouflage the breast implants.

This is particularly unfortunate with saline breast implants, since there will be rippling and irregularities. Surgery to revise this situation, while usually possible, can often be complex and expensive. If you lack sufficient thickness in the upper portion of the breast, it is usually best to avoid subglandular breast implants. Such a placement thrusts the breast implants forward off the chest in a very unnatural way. A soft look is a natural look.

Dr. Cook uses the subglandular plane less frequently than the submuscular plane, and he prefers silicone gel breast implants for most patients. Here are some advantages to the subglandular placement of implants:

1. For patients who have enough breast structure in the upper portion of the breast and who want a full look, the subglandular plane may be a consideration.
2. Patients who want to avoid breast motion that occurs when the pec muscles contract might consider subglandular breast implants. Patients who have limited amounts of their own natural breast structure must realize that, for them, subglandular breast implants may have an artificial look. There are strategies that sometimes help these patients, including the placement of breast implants in the subfascial plane, and, with careful discussion, the use of fat transfer to add structure to the upper part of the breast.
3. For patients whose breasts are just a little settled or droopy after pregnancy or weight loss, breast implants will provide a limited lift to the breast. This lifting effect is more powerful in the subglandular plane than in the submuscular plane. Another good option is to reposition the lower portion of the pec muscle in a way that preserves muscle coverage in the upper part of the breast implant but allows the implant to sit under the lower part of the breast.
4. Subglandular augmentation requires a bit shorter of an operation than submuscular implants and can be carried out with limited anesthesia techniques in the right patients.
5. Patients with subglandular breast implants have a less painful and generally easier recovery than patients with submuscular breast implants.

That said, for many women, subglandular breast implants have disadvantages when compared to submuscular breast implants. Unless you have a generous amount of natural structure in the upper portion of your breasts, subglandular implants will cause the upper breast to have a less natural look.

1. Subglandular breast implants have a greater likelihood of showing ripples and other irregularities, as well as to have an unnatural feel.
2. It may be more difficult to obtain a good quality mammogram when breast implants are in the subglandular plane.
3. Some studies suggest that subglandular breast implants are more likely to develop significant capsular contracture than submuscular breast implants.
4. Subglandular breast implants are more likely to cause a thinning out of the natural breast structure, especially if they are large.

Submuscular augmentation in a settled or droopy breast can lead to a double contour. There will be a fullness from the breast implant and a second area of fullness from the breast that hangs off the implant. Needless to say, this is not desirable.

Subglandular augmentation is not restrained by the muscle, so the breast implant does a better job filling out the breast, thereby avoiding the double contour. Unfortunately, subglandular augmentation has its own set of disadvantages.

When the pec muscle is freed from its attachments to the under-surface of the lower breast, it will move to a higher position under the breast. The breast implant is now able to fill out the lower part of the breast as in a subglandular augmentation, but the upper part of the breast implant will be hidden by the pec muscle, so there is a smooth transition in the upper breast.

Bi-planar augmentation is an easy procedure in concept, but it can be difficult for a patient to maintain excellent long-term results.

As a plastic surgeon who does a considerable amount of revisional breast surgery, Dr. Cook has learned much from the patients referred to him, as well as from a critical analysis of his own long-term results. There are some potential disadvantages to the bi-planar approach.

1. The natural structure of the lower breast will thin out, especially if larger breast implants are placed, in the same the way it does with big implants in a standard subglandular augmentation.
2. It is very important to preserve the natural attachments of the inframammary fold (the fold at the lower edge of the breast). If this is not done, the breast implants tend to drift over time to a position that is too low.
3. There can be a tendency for breast implants to stretch out the lower portion of the breast, especially if they are large. This creates too long of a distance between the bottom of the areola and the fold under the breast, so that the nipples ride too high on the breast.
4. A little repositioning of the pec can be a good thing, but too much is too much! Dr. Cook has performed revisional surgery on patients whose pec muscle is sitting near the top of the breast. This is possibly due to technical issues with the original surgery.

Bi-planar augmentation can be a helpful technique for patients who have mildly settled breasts after pregnancy, but the long-term results depend on technique.

Natural Breast Tissue Can “Melt” and Reveal Rippling or OtherBreast Implant Irregularities

When a large breast implant is placed in the subglandular plane underneath a relatively small breast, it will exert a pressure on the undersurface of the breast. Very often, this will lead to a thinning out of the natural breast tissue over time. What you are ultimately left with is nothing but skin over a breast implant. Under these circumstances, the breast implant will reveal its imperfections. This is particularly true with saline breast implants.

Since Dr. Cook has a referral practice, he sees a number of patients dealing with this problem every year. The good news is that we now have a number of advanced techniques at our disposal, such a fat transfer, that have enhanced our ability to fix these breasts. That said, it would be much better if the problem were avoided from the onset by better surgical judgment.

Big Breast Implants in Breasts that Have Settled Will Gradually Make the Breasts Droop More

Natural forces have a way of always winning over time. The bigger the breast implant, the more gravity will stretch out the lower pole of the breast. What may look good a month after surgery will gradually stretch. A droopy breast will become a droopier breast with a breast implant, making it look bottom heavy.

Some surgeons try to solve this problem by “revising” the surgery with even bigger breast implants. This will only further aggravate the problem over time.

When a Big Breast Implant Is Placed Under a Droopy Breast with a Narrow Width, the Body May “Remember” the Original Breast Structure and Result In a Double Breast Contour

Dr. Cook does consult with patients who originally had breasts that were relatively narrow in their base width, but that have “settled” over time. An original augmentation surgeon may have tried to “solve” the problem by placing a large, wide breast implant underneath the breast. This can leave the patient with a double contour. The first contour is formed by the breast implant, while the second contour is formed by the original breast. This double contour can be quite frustrating for the patient.