Breast implants come in numerous sizes (100cc – 800cc, or about 3 to 27 ounces each), shapes (round, oval, or teardrop “anatomic”), surface characteristics (smooth or textured), and fill material. Most breast implants are filled with saline or silicone gel, and occasionally other materials (though none of these “other materials” are FDA approved at the present time). Silicone gel implants presently come no larger than 800cc, but 800cc saline implants can be “overfilled” to volumes higher than this when requested in select patients.

Since the material inside breast implants is what gives them their “feel,” filler material choices have generated much controversy and media interest, not to mention scientific debate. We can provide both the science and years of expertise to help you determine whether saline or silicone is best for you.

Until March 9th, 2012, only two manufacturers produced breast implants FDA-approved for use in the United States (Mentor Corp., now part of Johnson and Johnson; and Inamed Corp., previously McGhan Medical, now owned by Allergan, Inc.). For the first time in 20 years in the United States, a third company (Sientra) has received FDA approval to sell their Silimed brand of silicone and saline implants, including textured anatomic silicone gel implants.

Prior to the FDA restrictions of 1991-1992, numerous companies produced breast implants with different designs, surfaces, and filler materials, including polyurethane-coated silicone gel implants, silicone-saline double-lumen implants (the Becker implant), and PVP hydrogel filled implants designed to pass mammography X-rays and have a feel more like silicone than saline (the Bioplasty Misti-Gold implant). After the FDA restrictions, these implant options and companies were lost to USA patients, though some of these companies and options remain available in other countries.

In the United States, besides the presently-available Mentor, Allergan, and now Silimed implants, several companies have produced investigational implants that are not yet FDA-approved and are implanted only by plastic surgeons associated with the FDA investigation/approval process.

At Minneapolis Plastic Surgery we offer both saline and the latest cohesive silicone breast implants.

Saline identical to intravenous fluid was the most common type of breast implant filler material used in the United States from 1992 until November 2006, when the FDA re-approved the use of silicone gel-filled implants for primary elective breast augmentation. Prior to the 1992 FDA restrictions,and again after 2006, silicone gel implants are utilized in over 85 percent of all breast augmentation procedures in the United States, and remain the most commonly used breast implants worldwide.

Other types of filler material have been evaluated over the years prior to the introduction of silicone gel implants in 1963, and one or more problems are associated with these. Paraffin, sponges, and other unusual materials were used in early efforts to enlarge breasts; results were dismal until silicone came into use in the 1960s.

More recently, during the FDA restrictions from 1992-2006, soybean oil-filled implants were studied extensively, and were used in many patients in Europe, as well as a few U.S. patients in FDA studies. Breakdown of the oil, rancid smell, and other concerns ultimately led to withdrawal of this implant (Trilucent™) in the US and in Europe. Fat as implant fill material has the same concern, and is not used.

Fat graft injections of a patient’s own liposuction fat (directly into or beneath the breasts) have been performed by some physicians. Among other names, this has been termed “natural breast augmentation” since the surgeon uses the woman’s own fat tissue (and you have to pay for the liposuction used to obtain the fat)! The American College of Surgeons and the American Society of Plastic Surgeons have been cautious in endorsing breast augmentation via fat grafting because 30-50% of the transferred fat always dies, and can cause microcalcifications, scar tissue lumps, and/or oil cysts within the breast. These can be seen on mammography, and may confuse or obscure diagnosis of early or small breast malignancies.

Though many radiologists state that they can tell the difference between dead-fat microcalcifications (from fat grafting), and dead-fat microcalcifications (from possible breast cancer), many plastic surgeons (including those here at MPS) are not willing to risk your life for a procedure that remains unproven regarding long-term safety, especially since 1 in 8 or 9 women will develop breast cancer in her lifetime. And also since implants are still a superior choice lacking these mammographic concerns.

Scientific studies confirm that fat cells removed via “standard” liposuction are mostly destroyed and non-living; improper storage of the fat for later use (freezing) kills even more cells (ice crystals puncturing cell walls kill the fat cells), so this is worthless and potentially harmful. The same goes for fat harvested with SmartLipo (laser destroys the living fat cells) or excessive ultrasonic liposuction (too much ultrasonic energy ruptures the living fat cells). Dead fat cannot turn into living grafts that maintain volume.

Unless your surgeon uses appropriate fat harvest technique, and transplants the still-living fat globules into carefully-spaced tunnels with tiny fat grafts surrounded by abundant healthy tissue for blood supply, fat damaged by poor liposuction techniques, or grafted haphazardly in big blobs, will not survive. Any breast enlargement initially achieved is gradually and ultimately lost as the dead fat cells are absorbed and carried away by the body—potentially leaving scars, lumps, and calcifications. Pretreatment with Brava suction devices may enhance fat “take,” but at best, most women realize no more than ½ to 1 bra cup size enlargement via grafting.

Breasts augmented with fat grafts that die, calcify, or become scarred nodules within the breast are far from “natural.” And as the dead cells are removed by the woman’s body, the once-larger breasts gradually lose size, making lasting enlargement uncommon. We see many unhappy former fat graft breast patients who return for the implants they should have had in the first place.

The latest marketing “hype” around fat grafting for breast enlargement uses the term “stem cell breast augmentation.” This is the same procedure as fat grafting, but with the possible addition of centrifugation or addition of blood plasma to “concentrate” or “enrich” the “stem cells.” Until peer-reviewed scientific research validates breast augmentation via fat grafting (or stem-cell breast enlargement), this should be considered experimental only! Soft, natural, and lasting breast augmentation is (still) best achieved by skillful placement of breast implants.

Over the past decade, advancements in silicone gel implants have been developed and introduced, including a more firm, teardrop-shaped, textured-surface cohesive silicone gel (the “gummy-bear” implant). Like all cohesive implants, this “highly-cohesive” implant retains its form and innate integrity even when its outer shell is punctured. This implant is more firm (like a “gummy bear” or silicone bathtub seal) than the softer, latest-generation, cohesive silicone gel implant, and requires a larger 2.5 inch incision for placement. (It’s also more costly.) This implant–Allergan (formerly McGhan) style 410–has recently been FDA approved, but we feel this implant configuration is usually more appropriate for reconstructive or “rescue” operations than for primary cosmetic breast augmentation.

Between 1992 and 2006, FDA restrictions on the use of silicone gel implants for elective, first-time breast augmentation meant that most women received saline-filled silicone-shell implants. Minneapolis Plastic Surgery has many satisfied patients with saline-filled implants who underwent their breast augmentation during these years, and many are shown in our photo gallery. Because of our significant numbers of patients who received them during this period, we also became well-aware of the pros and cons of saline-filled implants.

Numerous scientific studies were performed during these years of implant controversy, and to date, there has not been one credible peer-reviewed study that shows cause-and-effect relationship between silicone gel or saline implants and any sort of auto-immune disease or illness. Saline implants can leak and deflate, particularly if they are not filled properly, and they have also been shown to have a higher visibility of rippling or wrinkling on the implant surface. This rippling can cause unsightly and unnatural breast appearance, and tends to be worse when bending over or when wearing swimsuits or cleavage-revealing clothing. Implant placement below the pectoralis major muscles reduces saline-implant ripples, and usually eliminates or significantly reduces them when silicone gel implants are used.

Saline implants cost less, and can be inserted via a slightly shorter incision, though we continue to be surprised by the length and position of breast augmentation incisions (both saline and silicone) in patients we see from other practices. Incision length is much less a factor of saline vs. silicone than choice of surgeon. We have also found that the cost differential between saline and silicone gel implants is not always passed on to the patient, making saline implants more profitable than silicone in some doctors’ offices.

Surgeons who tend to promote the use of saline implants may do so out of training, their own experiences, habit, or profit motive, but those who scare patients with (disproved) autoimmune illness association, or tell them of the (outdated) FDA recommendation for MRI scans to check for “leaks” in silicone implant patients (unnecessary for all latest-generation cohesive silicone gel implants), only serve their own interests, not those of their patients. These are old, outdated, and inapplicable “concerns” that have been exhaustively studied and we believe no longer apply.

Leak and deflation of saline implants require surgical replacement (the implant manufacturers provide free lifetime implant replacement, and will cover a majority of the surgical costs for the first ten years after initial implantation). But another operation is needed, including time off from work or social activities, and restrictions during healing. When saline implant leak requires re-operation, most patients choose cohesive silicone gel implants to replace both of their saline ones, ensuring that leak and deflation can never again occur. Significant numbers of MPS patients who initially received saline breast implants have undergone a second procedure (whether they had a leak or not) to replace their saline implants with the latest generation of cohesive silicone gel implants. Rippling is eliminated or significantly reduced, softness and natural “feel” is enhanced, and leak or deflation is no longer a concern. Many also use this opportunity to choose a larger size. Whatever the reason, and despite the fact that many happy saline implant patients remain without concerns and with excellent results, a majority of our patients now choose silicone gel implants.

The newest generation of cohesive silicone breast implants provides incredibly natural-looking and feeling results, and also a high level of safety. The latest types of silicone gel breast implants have been used as part of the more general FDA study since 1992, and are soft, yet still a cohesive solid gel that cannot leak. These implants do not leak even if the shell is cut or punctured, and can be inserted via a 1.5 inch incision. Slicing open one of this latest generation of breast implants is like cutting Jell-O—you get two solid intact parts and leakage does not occur. (These implants are often erroneously called “gummy bear” implants since they are cohesive, though the true first “gummy bear” implants were the Allergan style 410s.)

Now that a third implant manufacturer (Sientra) is producing implants that are FDA-approved for use in this country, additional options exist for patient and surgeon choice. Sientra markets their version of high-strength cohesive silicone gel implants (smooth, round, textured, and teardrop-shaped) as “gummy bear” implants, further confusing this designation, which should probably be abandoned since it no longer describes a single type (or company’s) implants! Sientra has decided to sell their products only to American Board of Plastic Surgery-certified plastic surgeons (a laudable position), whereas Mentor and Allergan will sell their implants to any licensed physician, regardless of specialty. (This is how Dermatologists, Family Practitioners, and doctors with little or no plastic surgical training can legally obtain breast implants, and insert them into unwitting patients who think that these “cosmetic surgeons” have the same training and certification as ABPS-certified plastic surgeons.) Whether or not this will confer better statistics, outcome studies, or lower complication rates than the other companies’ practices remains to be seen.

Sientra also was the first company to receive FDA approval for their own brand of “high-strength” cohesive, textured-surface, teardrop-shaped (form stable) silicone gel implants, as their approval pre-dated Allergan’s style 410 FDA approval. This further confused individuals who use the “gummy bear” moniker to describe the Sientra version of the Allergan Style 410. For this reason, I personally believe that although the term “gummy bear” is descriptive and “catchy” to use, it has now become confusing, since each implant manufacturer has its own version of textured-surface, shaped, cohesive, “high-strength,” or “highly cohesive” silicone gel implants. Plus, the “regular” smooth round silicone implants (from all 3 breast implant manufacturers) are also cohesive. So they’re ALL “gummy bears” and they’re NOT all “gummy bears,” depending on how you define the term.

With silicone gel or saline breast implants, microscopic silicone molecules can still enter a patient’s body, just as liquid silicone does in the patient who has an injection with a needle lubricated with liquid silicone. No scientific study to date has provided credible evidence that silicone has any cause-and-effect relationship with autoimmune diseases or conditions such as rheumatoid arthritis, lupus, scleroderma, or so-called “human adjuvant illnesses.” With these studies in mind, silicone gel breast implants were FDA-approved in November 2006 for elective first-time cosmetic breast enlargement in women over the age of 22. Use of silicone gel implants in women under age 22 is considered “off-label” use and is perfectly legal. We support the right of properly-informed women between the ages of 18 and 22 to consent to and request the implants of their choice, including silicone gel implants.

The present soft cohesive silicone implants made by Allergan are Natrelle implants, and newer Natrelle Inspira cohesive silicone implants are identical to the previous Natrelle implants, but with additional gel “fill” in the silicone shell, about 95% vs. 85%. Increased fill with the same soft (level 1 cohesivity) gel in the Inspira implant reduces visible rippling in thin patients with little tissue coverage. For even thinner patients that might still have ripple issues, Allergan now offers “Soft-Touch” level 2 cohesivity implants, with increased crosslinking to decrease rippling, and Natrelle Inspira “Cohesive” level 3 cohesivity implants, to decrease rippling further. Each increased cohesivity level is slightly less soft, more expensive, but offers progressively less potential for rippling in women with little tissue coverage.

If your silicone implants were produced before the FDA restrictions of 1992, they were previous-generation devices that had a thinner shell and less-cohesive gel filler. In other words, if one of these older implants was damaged or defective, the silicone gel could indeed “leak” into surrounding tissues, eventually causing scar formation and capsular contracture. MRI studies proved to be more effective at detecting these kinds of implant damage and leak than physician exam, leading to this “recommendation” from the FDA.

However, since all 3 USA breast implant manufacturers now make cohesive or highly cohesive silicone gel implants, “leakage” does not occur, and since the shells are thicker and much more durable, implant rupture from manufacturers’ defect is extremely rare, and surgeon damage during insertion is the most common cause of implant “rupture.” Use of the Keller Funnel decreases forces on implants during insertion, and taking care to avoid contact with needles, instruments, or other sources of implant damage can virtually eliminate rupture. Since present-day solid cohesive silicone gel implants (from all 3 manufacturers) cannot “leak,” many plastic surgeons, including both plastic surgeons at MPS, do not believe there is value in MRI evaluation of asymptomatic breast implant patients. In fact, there is also a “false positive” rate of 21%, where absolutely normal intact implants are erroneously read as “ruptured” by MRI. I do not recommend MRI on asymptomatic patients whose breasts are soft and implants move normally.

How long do implants last? This is a common and appropriate question, since it takes an operation to replace them for any reason, including request for different size. No implants (by any of the three USA manufacturers) are intended to be lifetime devices. That being said, barring complications regarding size, position, contracture, or infection, we believe that the latest cohesive silicone gel implants will last much longer than the majority of their human recipients. They cannot “leak,” rarely have a manufacturer’s defect or rupture (requiring extreme injuring force or surgeon damage during insertion), and if kept from becoming bacterially contaminated at the time of surgery or subsequent dental work, they do NOT require “replacement” after ten years, or usually ever. We certainly have a significantly lower re-operation rate than the 47% in 7 years quoted in some of the implant manufacturer data. But then again, that data includes doctors of any type who decide they want to place implants, even without training and certification by the American Board of Plastic Surgery—hence, the higher numbers.

The surface of present-day breast implants can be smooth or textured, and the filler material silicone gel or saline. When silicone gel implants were used prior to the FDA restrictions of 1992, placement above the muscle was also the preferred implant position for many plastic surgeons. (Capsular contracture was also common.) Texturing the surface of the silicone gel implant reduced the incidence of capsular contracture in this position (above the muscle and just below the breast tissue).

Once the FDA restriction on silicone gel implants led to the increased use of saline-filled implants, placement above the muscle led to unacceptable wrinkling that could sometimes be felt or seen. This caused most plastic surgeons to place saline breast implants below the muscle to increase tissue coverage and reduce these concerns. Even placement of saline-filled implants below the muscle will not always eliminate implant wrinkles, particularly in thin patients and/or patients with very little overlying breast tissue. Now that silicone gel implants are again available, more patients will be able to avoid the “water-balloon” feel and rippling seen in some saline implant patients. Although each patient’s circumstances are unique, our experienced plastic surgeons frequently use silicone breast implants to provide the most natural looking results. Of course, at Minneapolis Plastic Surgery, Ltd., we will help you determine the appropriate size, shape, surface configuration, and filler material to meet your needs.

Based on the choice of saline or silicone, textured or smooth, and the patient’s unique body type, appropriate surgical placement will be determined. Using textured breast implants below the muscle can cause unnatural adherence to the chest and restricted natural movement of the breast. With textured saline implants, the lack of gel to act as a lubricant inside the implant (saline is a poor lubricant) can allow flexing and creasing of the implant shell surface with each movement or breath of the patient. This can ultimately lead to a higher risk of failure at one of the low spots in the textured surface, with leakage and deflation of the saline implant. The textured implant shell is also thicker and more palpable. Submuscular placement already reduces the incidence of capsular contracture, so smooth breast implants in this location are preferable to adherent textured-surface implants. The smooth-shell saline-filled implant placed below the muscle is soft, less palpable, and less likely to deflate (if properly filled), and has lower rates of capsular contracture formation. It also moves with the patient’s position and therefore more natural and breast-like. Yet, saline implants (even below the muscles—”unders”) have increased rates of visible rippling in the cleavage areas or sides of the breasts.

However, smooth-shell silicone-gel-filled implants are even more homogeneous with breast tissue and provide the softest, most breast-like, and most natural “feel” of any implant. Since the newest generation of silicone gel implants is also cohesive, they cannot leak or deflate. While the vast majority of patients are again choosing silicone implants for their breast enhancement surgery, we believe that the best and most experienced breast surgeons offer their patients a choice of either silicone or saline breast implants. With careful evaluation of the patient’s individual requests and needs, and detailed discussion of the pros and cons of the two surface textures available, our ABPS-certified plastic surgeons can help you choose not only the implant but the location and proper profile for your anatomy.

One final consideration should be noted regarding textured implants (either saline or silicone)—in 2011, an unusual type of lymphoma (BIA-ALCL: Breast Implant Associated-Anaplastic Large Cell Lymphoma—a cancer of the immune system) was reported in small numbers of breast implant patients who developed symptoms including breast enlargement, pain, asymmetry, lump in the breast or armpit, overlying skin rash, hardening of the breast, or a large fluid collection typically developing at least more than one year after receiving an implant, and on average after 8 to 10 years. BIA-ALCL is a rare and highly treatable type of lymphoma that can develop around breast implants. BIA-ALCL occurs most frequently in patients who have breast implants with textured surfaces. This is a cancer of the immune system, not a type of breast cancer. The current lifetime risk of BIA-ALCL is estimated to be 1:3817 – 1:30,000 women with textured implants based upon current confirmed cases and textured implant sales data over the past two decades. When caught early, BIA-ALCL is usually curable.

BIA-ALCL has been found with both silicone and saline implants and both breast cancer reconstruction and cosmetic patients. To date, there are few confirmed BIA-ALCL cases that involve only a smooth implant. BIA-ALCL patients seem to have a reaction to textured devices over many years. Given this information, we are happy to report that the vast majority of MPS breast augmentation patients over the past two decades have received only smooth implants.

Breast implants come in round or teardrop (“anatomic”) shapes. While some plastic surgeons prefer the teardrop-shaped implants in some situations, smooth round implants are generally the softest, most natural in appearance (upright and lying down), least likely to be felt externally, and (for saline implants) least likely to leak. Round, smooth implants also cost less than teardrop-shaped textured implants, yet are superior in most cases.

Teardrop-shaped implants must have proper positioning and must stay in that position (sloped part up, rounded part down) to take advantage of their innate shape. (Upside-down teardrop implants really would look weird.) They are textured so that the body’s tissues can adhere to and maintain the proper position of the implants. Thus, the teardrop or textured “anatomic” implants cannot move as the patient changes from a standing to a reclining position. Also, the teardrop implant remains teardrop-shaped when the patient is lying down, whereas the natural breast flattens out and assumes a round appearance. Tissue adherence makes initial positioning critical—textured implants do not settle or drop over time. Post-op tissue swelling and tightness diminish, giving a softer feel, but position (by definition) is determined by initial placement and adherence of the textured surface to the adjacent tissues. The smooth round implant does just what a natural breast does: it is teardrop-shaped when the patient is upright, and flattens and moves slightly to the side when the patient reclines. Thus, the round implant is actually more anatomically realistic than the teardrop, or so-called “anatomic implant.”

Loss of adherence with trauma or activity can allow rotation and distortion of appearance, and this is something noted only with shaped implants, since they are designed to remain in a given position. Loss of that intended positioning can be difficult to correct, as the adherence is now gone, and the implant can freely rotate in its pocket. Round implants do not have this rotational concern, since they look the same in any position. Textured implants should not be “massaged” post-op, as this can prevent adhesion.

Some implant manufacturers and plastic surgeons have suggested that the “anatomic” or teardrop- shaped breast implant has a more natural look than a round implant, and much advertising and marketing has been used to promote “anatomic” implants to the public. These implants are perfectly good devices, but are more expensive than smooth, round implants, and whether or not they are truly more “anatomic” is debatable (see above).

A recent study compared actual women with smooth, round implants to women with textured, teardrop- shaped implants. Mammograms were performed in upright and supine (laying-down) positions, and digital tracings computerized and compared. Both the round and teardrop-shaped implants had a sloped, teardrop shape when the women were upright. In fact, in upright patients, teardrop and round implants were indistinguishable on X-ray. But when a woman is laying down, the natural non-augmented breast flattens, drops slightly to the side of the chest, and assumes a round shape, as does the round smooth implant. The teardrop-shaped implant stays teardrop-shaped in the laying-down position, which makes this unusual appearance actually LESS anatomic or natural than the round implant! Still, in rare situations, the textured or teardrop-shaped implant may be an appropriate choice.

Both saline and silicone gel breast implants come in three or four profiles: moderate “classic,” moderate plus, and high profile. For example, a 400cc (Mentor style 7000) moderate profile silicone gel implant has a base diameter of 14.5cm and a projection (height) of 3.2cm. The 400cc (Mentor style 1000) moderate plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.0cm. The 400cc (Mentor style 4000) high profile silicone gel implant has a base diameter of 12.2cm and a projection of 5.0cm. Mentor also makes an ultra high profile (style 5000) implant with a base of 10.6cm and projection of 5.4cm for the 400cc size. Thus, various dimensions are available to help best match the desired size of implant to the patient’s breast dimensions.

Allergan Natrelle® implants also come in a total of four silicone gel profiles: moderate, moderate-plus, high, and extra-high profiles. To use similar examples, a 390cc (Natrelle style 10) moderate profile silicone gel implant has a base diameter of 13.6cm and projection (height) of 3.8cm. The 397cc (Natrelle style 15) moderate-plus profile silicone gel implant has a base diameter of 13.1cm and a projection of 4.2cm. The 400cc (Natrelle style 20) high profile silicone gel implant has a base diameter of 11.9cm and a projection of 5.0cm. As you can see by comparing these two manufacturers’ implant dimensions, near-equal volumes and profile implants from each company have nearly identical measurements. Allergan also makes an extra-high profile silicone gel implant (Natrelle style 45) with an 11.2cm base and 5.1cm projection for the 400cc size.’

The newest Allergan Natrelle® Inspira implants come in five profiles: low, low plus, moderate, full, and extra full. This allows even more surgical options for every woman’s anatomy and goals. Since Sientra implants also come in many different shapes and sizes, including smooth, textured, round, and teardrop-shaped styles, many more options exist for patient and surgeon choice.

At Minneapolis Plastic Surgery, Ltd. we first measure the patient’s breast dimensions, including base diameter, nipple to crease distance, nipple-to-nipple distance (cleavage diameter) and overall chest circumference, determine what final breast size she wants to achieve, and then see if a properly-chosen implant volume and profile can be surgically combined with her own breast tissues and skin brassiere to yield the desired results. Most of the time it can! In other cases, there , not to mention a very wide gap, unnatural-appearing cleavage.may need to be compromises to achieve a good result, or additional skin shaping and tailoring (via breast lift) may be necessary.

Any surgeon who consistently recommends high-profile implants, for example, “because I like the look of those the best” or “high profile gives more upper pole fullness” [false, BTW] is selling some of his or her patients short. A narrow-chest small-frame petite woman who wants large breasts (but has virtually no breast tissue of her own), may require high profile breast implants to achieve the look she wants. But a tall, wide-breast base, large frame woman who only wants a modest enlargement (or has a fair amount of her own breast tissue), will not be served well by high profile implants—she needs moderate profile implants to get as much base diameter as possible for the small(er) size she has selected, in order to accurately fill her own breast base. Otherwise, she would have a narrow-diameter implant “sliding around” in a large-diameter breast pocket, not to mention a very wide-gap, unnatural-appearing cleavage.

Patients are often told (by some plastic surgeons, and often in on-line forums) that “High profile implants give more upper pole fullness.” Until implants drop over the 6-12 months needed for complete healing and “final” gravity-settled position, this is indeed true. But since smooth round HP implants have narrow widths (and more projection), they also have a less-tall height (vertical diameter) that leads to LESS upper pole fullness when the implants reach their proper position at the creases. Choose the widest (vertically tallest) implant profile that fits the breast base diameter for the most upper pole fullness.

Thus, implant profile is based on each individual patient’s anatomy, pre-operative breast measurements, and requests, not on a particular surgeon’s “habit” or “routine.” We believe it is not the surgeon’s job to decide what a patient should have, and certainly not to “routinely” use only one of the 5 available profiles, but rather to listen to the patient’s requests, examine and carefully measure the patient’s individual anatomy, and then use our experience and expertise to determine how to best achieve her goals, or at least come as close as the anatomy and details allow. One profile does NOT fit all, and the widest profile that “fits” your breast base will give the closest cleavage!

What is the right implant size for you?

Dr. Richard H. Tholen and Dr. Douglas L. Gervais have extensive experience in helping our patients choose implant sizes that are compatible with individual anatomy, while still coming as close as possible to personal goals. Every patient has a “perfect size” in her mind’s eye: all we need to do is figure out what that size is, and whether or not it will match appropriately with the patient’s chest and breast base dimensions, skin and muscle capacity, position of the nipple-areola complex, as well as a host of individual anatomic factors. We start with breast examination, careful measurements (everyone is asymmetrical), and ask you what your goals are. Based on these anatomic factors, we then determine if your requests can be achieved. For most women, the size you choose is not only possible, but perfect for you! If not, we will tell you, and will use our experience and expertise to plan how to best get as close as possible to your ideals.

Remember, you should never have surgery to please someone else, or to try to conform to someone else’s opinion; the same goes for choosing implant size.

One of the best techniques for choosing the size of breast implants is for the patient to bring photographs of models with the desired final breast size to their consultation, or at the time of surgery at our Minneapolis / St. Paul accredited office surgical facility. The proper size and profile of implants, added to your own anatomy, that most closely achieves your goal photo appearance is then chosen in the operating room. (Since we stock all sizes and profiles of saline and silicone gel breast implants in our surgical center, we do not have to “order in advance” and can change based on your choices right up to the time of surgery). “Wish photos” have proven to be much more accurate than requesting a letter cup size, or trying to find a similar person via internet search whose anatomy and/or results approximate your goals. Don’t try to match your height, weight, or preoperative breast appearance to the photos, and don’t use a stated implant size as a guideline for choosing your implant size—just find an “AFTER” photo you like.

Also, if your breast sizes don’t match (most women have some degree of asymmetry), we can choose different implant sizes and/or profiles to achieve as much symmetry as possible. In more severe cases, we can recommend appropriate procedures (such as breast reduction, breast lift, or other surgical options) to optimize size, shape, and position between mismatched breasts. Implant choices can be made to help camouflage chest wall or other skeletal asymmetries caused by scoliosis, pectus excavatum, tuberous breasts, Poland’s syndrome, or other genetic breast conditions.

Trying on implants in a brassiere is another excellent way to provide some idea of desired final breast size and the implant volume needed to achieve that size; however, it is essential not to become overly attached to a specific bra cup size (B, C, D, etc.) or implant volume (400cc, etc.), since the implant size you like in a bra or top will always look smaller when it is under your own breast tissues and chest muscles. Typically, a woman who chooses a specific cc volume implant that she feels looks good in her bra will be disappointed (too small) after surgery if that exact volume implant is used in her body. This is because submuscular compression of the implants makes them look slightly smaller than when sizing in a bra. A good general rule of thumb is to add 10-15% to the implant volume you feel looks good if you choose to size in a brassiere. In other words, if you like how a 400cc implant looks in a bra, it will take a 440-460cc implant to look about the same size in your body. Final size and profile are chosen in the operating room where your surgeon can actually identify specific characteristics of your skin and muscle tone, chest wall (ribcage) configuration, and accurately measure your pocket diameter, not relying just on estimations of breast base width measured pre-operatively.

Minneapolis Plastic Surgery features a comfortable, discreet, implant sizing room where you can try on actual silicone implants in a stretchy top. Comfortable chairs and plenty of mirrors allow you and a spouse, friend, or confidant choose what makes you feel the best about yourself. We then take this information, goal photos, and any other input from you to help us achieve the best outcome possible.

In general, for an “average” height and weight woman, 250cc equals about one bra cup size. A 12 ounce can of soda = 360cc. Most patients cannot even see a difference of 50cc (3 tablespoons and 1 teaspoon), which is why implants are manufactured in 30-50cc increments (less than the threshold of visible difference). Thus, 400cc implants will cause an increase of about 1½ cup sizes to whatever breast volume the patient started with!

Since what this surgery accomplishes is increased volume, your own skin brassiere (pre-surgery breast shape) will determine your final breast shape after implants increase your breast size. Size and implant profile will also determine just how much breast mass extends to the side of the chest (armpit area), or into the cleavage region, since proper implant positioning is determined by the position of your nipple areola complex.

For instance, a woman with widely spaced nipples will need to have her breast implants positioned more laterally (towards the armpit area), since the implant pocket and final breast mound must be properly centered beneath the nipple areola complex. If too-narrow (high profile) implants were simply placed close together in the center to give a full cleavage look, each nipple areola complex would then be positioned too far laterally, giving the nipples a “wall-eyed” appearance. Wider- profile implants may therefore be necessary to give normal cleavage as well as position.

Similarly, a woman who has more medial nipple position would have a “cross-eyed” appearance if she requested lateral fullness and her implants were placed more to the side of the chest without taking into account the nipple position atop the new breast mound.

Clearly, not only size, but also the profile and exact position of your breast implants, is critical to your final result. Your own anatomy determines shape (unless you also need a breast lift, where incisions are made to lift or otherwise shape your breast skin, or reposition too-low nipple/areola complexes).

Most women seeking breast implants at our Minneapolis / St. Paul practice emphasize that they do not wish to be “too large” after augmentation. There is a natural hesitancy to make a change that is so dramatic that “everyone will know” or that might embarrass you at the health club, swimming pool, relative’s home, or church meeting. Most patients have these concerns, and many verbalize this. However, 6 to 12 months after surgery, when these concerns evaporate, and the social settings where “someone might notice” are successfully overcome, a surprisingly large number of patients admit they now wish they had chosen larger implants. Some undergo another operation to place new, larger implants. Fortunately, when size change is requested, the surgical pocket for the implant is already created, and recovery is often easier.

Although the choice of size is entirely up to each individual patient (with some anatomic limitations), choosing just slightly larger than what you consider to be optimal pre-operatively will help you to avoid re-operation for size change, including the cost of new implants, operating room, and anesthesia.