One of the questions I’m asked most as a plastic surgeon by patients considering breast implants is, “how do I know what size and shape I need?” The answer has changed dramatically throughout the 25 years that I’ve been performing breast augmentations.
Along the way, I’ve learned that the words that our patients use to describe what they want or don’t want can be completely misleading into what I interpret their meaning to be. Therefore, if you are considering breast augmentation, I like to request that you bring in photos of what you like and don’t like. Fortunately with the internet, there is a multitude of sources where these photos can be downloaded. By looking at your desires, I can get a better understanding of what you want.
As for trying implants “on”, we no longer recommend that you place the exact implant on top of your breasts and then place a stretchy bra over it to give you an idea what that implant under the muscle would look like after surgery. That method will always exaggerate what the actual result will be. However, if you are going to use a sizing type method, then Mentor makes a shell sizing system that accommodates for the sizing difference between the actual implant and what it would like.
Our preferred method is a 3-D imaging system called Vectra® that we have been using since it started. At your visit, a three-dimensional photograph of you is taken and you and I are able to review your options together using your image on a large television. We can place all of the different implants that are available and decide what size, shape, fill ratio, and height to base width relationships will look best for you.
Silicone gel breast implants come either round or shaped. They also come with either a textured or smooth surface. There are advantages and disadvantages of every scenario and combination of those choices, and I specially tailor my choice to each patient. Most of the time a round smooth implant placed under the muscle works very well for breast augmentation patients. Sometimes we choose a textured implant, as they tend to migrate less in the pocket due to some frictional resistance to motion, which is why all shaped implants are textured. An added reason to choose textured implants is that the capsular contracture rate is less than for smooth implants, especially when implants are put above the muscle.
We like to start with a measurement of the base width of the breast. We then subtract about a centimeter and a half off of that number to ensure enough coverage of breast tissue over the implant, and use that number to find corresponding implants. If we go larger than that number, which sometimes patients will want, we know that it increases the risk for more problems. For instance, larger implants may migrate below the natural breast crease and when that happens, they can create a second crease in what we call a “double bubble.” Large implants can also thin out the breast tissue, because of the added pressure.
After we have the base width, our next choice is the projection to correspond with our decision. There are typically four choices ranging from fairly flat (low-profile) to progressively more height (ultrahigh-profile). More commonly used for a natural look are the ones in between: moderate profile and moderate profile plus. We would choose the taller profiles for patients who want a larger look than their natural base with would allow or have a fair amount of loose overlying skin that we’re trying to hold up.
Patients will often present with breasts that are different sizes. One of the options to correct this is to use breast implants of different sizes in order to create a more symmetrical appearance. A newer method is to do a hybrid breast augmentation, where the patient has matching silicone gel implants placed and the overlying breast tissue can be made to look the same in volume and shape by using fat grafting. This allows for the patient to fluctuate more in weight and age and the breasts are more likely to have the same or similar sizes. When it comes to symmetry, I like to tell our patients that they should consider their breasts to be sisters that live across the railroad tracks from each other rather than twins.
There are also shaped implants. Rather than being perfectly round, these implants can either be taller than they are wide or wider than they are tall. For patients with very widely spaced breasts and a large breastbone, a shaped implant that’s wider than it is tall can help hide that a little bit. Shaped implants are also an option for a patient with skin laxity after childbirth or great weight loss; when the nipple is just at the level of the inframammary crease, we can sometimes get away with a tall implant to give the appearance of a slight lift without having to do a mastopexy.
A new style of silicone gel implant has recently surfaced that is filled to a higher volume in the shell. This allows for a round smooth implant to collapse less in the upright position mimicking more of the look of the shaped implant. When patients show me a photo of a very rounded upper part her breast, I would likely choose one of these higher volumes implants such as the Natrelle Inspira® silicone gel breast implant.
By spending some time before the operation takes place, using the Vectra® 3-D imaging method with computer animation, we can decide what type, shape, and ratio of width to height would best serve your needs. Doing this avoids the placement of sizers at the time of surgery, which, in my opinion, have a few negative implications, including additional cost and unnecessary disruption to the breast pocket, increasing bleeding risk.
With proper preoperative planning and flawless execution of breast augmentation, this can be one of the most satisfying aesthetic plastic surgery outcomes for both patients and physicians.
