Choosing Your Breast Implants

The sheer number of breast implant variations available to patients and surgeons can lead to confusion; however, careful measurement, proper analysis of your anatomy, and experienced decision-making can help give you the best breast enlargement possible. Unfortunately, some surgical recommendations are made on the basis of marketing, surgeon habit, or profit, rather than careful listening to the patient’s goals and concerns. As leading Minnesota aesthetic plastic surgery providers, our American Board of Plastic Surgery-certified plastic surgeons and experienced nursing staff help patients choose their breast implants with the benefit of extensive expertise and over 45 years of combined experience with thousands of patients. Since breast augmentation is performed so frequently at Minneapolis Plastic Surgery, Ltd., we maintain an extensive on-site inventory of breast implants in virtually every size and profile, in both silicone and saline. Your implants don’t have to be ordered in advance, you don’t have to worry about us having the “right ones” in surgery, and on-time delivery is not an issue—they are already here! Minneapolis Plastic Surgery’s AAAASF-accredited surgical facility is one of the first in the country to receive a consignment of Allergan Natrelle Inspira cohesive silicone gel implants, higher-fill implants designed to reduce visible implant rippling.

Breast Implant Information--What are the Options?
Types of Breast Implants

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.

Silicone or Saline? (How about fat?)

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, silicone gel implants were 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, 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 are not yet endorsing this procedure because approximately 50% of grafted fat dies, and can cause microcalcifications and scar tissue within the breast, which can interfere with the mammographic detection of breast cancer. 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), the majority of plastic surgeons (including those here at MPS) are not willing to risk your life for an unproven procedure, especially as 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 harvested by these liposuction techniques, or grafted haphazardly in big blobs, is damaged, unable to receive oxygen and nutrients vial adjacent healthy living tissue, and will not survive. Any breast enlargement thus achieved is lost as the dead fat is absorbed and carried away by the body. Breasts augmented with fat grafts that die, calcify, or become scarred nodules within the breast are far from “natural.” Any volume enhancement initially achieved is typically reduced by at least 1/3 to 1/2 as some of the fat dies, making lasting enlargement of more than half to one cup uncommon.

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 the even more “out-there” 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.

Cohesive Gel or Saline 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 is often unsightly and unnatural in 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 placement 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 the latest generation of 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, a majority of 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 used 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 “gummy bear” implants are 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 and request the implants of their choice, including silicone gel implants.

Smooth or Textured?

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). However, after the FDA restriction on silicone gel implants and the switch to saline-filled implants, placement above the muscle led to unacceptable wrinkling that could sometimes be felt or seen. This led to most surgeons switching to placement of 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. In 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 (in saline implants). 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 low rates of capsular contracture formation. It also moves with the patient’s position and therefore more natural and breast-like.

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.

Teardrop (Anatomic) or Round?

Breast implants come in round or teardrop (“anatomic”) shapes. While some plastic surgeons prefer the teardrop-shaped implants in some situations, the 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. When you are making your surgical decisions regarding breast implants, our plastic surgeons will, of course, help guide you throughout the process.

Textured surface implants have a thicker shell, are more likely to be felt externally, and have a somewhat higher leak rate (saline implants) because of the thinner or weaker areas in the tiny peaks and valleys of the shell surface. Since 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, by necessity 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 “gummy-bear” implants cannot and do not 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.  Teardrop or textured “gummy-bear” implants are also more costly than round smooth implants. The smooth round implant does just what a natural breast does: it is teardrop-shaped when the patient is upright, and flattens and drops slightly to the side when the patient reclines. Thus, the round implant is actually more anatomic than the teardrop or so-called “anatomic” implant.

Moderate, moderate plus, or high profile? (or ultra high?)

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.

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 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.

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 4 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!

What Implant Size is Right for Me?

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 implant to most closely achieve this 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). Photographic examples have proven to be much more accurate than the patient requesting a letter cup size, or trying to find a similar person who has had breast implants and whose anatomy and/or results approximate your goals. Don’t try to match your height, weight, or preoperative breast appearance to goal 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 muscle. 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.

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 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 the implants were simply placed close together in the center to give the full cleavage look, each nipple areola complex would then be positioned too far to the side, giving a “wall-eyed” appearance.

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.

Our plastic surgeons will, of course, work with you to determine the size and position of your breast implants. 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 your 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 healed, 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.