Operations using breast implants, whether for augmentation or reconstruction, account for a large proportion of my cases. How a particular implant is chosen for each individual patient may be surprisingly simple or complex. This month, I’ll present my approach.
When choosing an implant, I have no agenda, other than having a happy patient when I have completed the operation. I do have constraints, however, such as chest width and tissue quality. These factors may give each woman few or many choices to meet her goals.
First, I help the patient choose between silicone or saline implants. Silicone looks and feels better, but may cause greater local scarring (contracture and granulomas) and requires periodic MRI scans for surveillance. Saline has less local scarring, requires no special imaging to detect a leak (it just deflates), but may cause rippling in patients with little or thinned out breast tissue. I usually recommend silicone to augmentation patients who have thin tissue coverage and who feel the benefits outweigh the risks of the material. I recommend silicone to most reconstructive patients as their tissue is usually quite thin after expansion (see the breast reconstruction section), and insurance will help defray any future maintenance costs. For those with good tissue coverage or who have any anxiety regarding silicone, I recommend saline. If you would like more detailed information, we have extensive literature provided by Allergan, the implant manufacturer.
Second, smooth or textured is decided. Smooth implants are less palpable and have less rippling. In the below muscle position, the have a low associated rate of contracture. Textured implants are thought to help minimize contracture in the above muscle position and help minimize rotation of shaped implants. I usually use smooth, but will occasionally use textured in patients who are at particularly high risk for contracture.
Third, round or shaped is decided. I almost always use round implants. They appear flat when the patient is lying flat and appear tear drop shaped when the patient is upright. If the rotate, it’s okay – they are round. Finally, they are less expensive. Shaped implants are used by many excellent surgeons, but most currently use round devices. As implants become more advanced, shaped devices may become a better option. As always, my mind is open.
Fourth, the profile is chosen. Profile refers to projection, or how far the implant pushes out from the chest. High profile implants are more rounded while low profile are flatter. Most patients are best served with a happy medium, the moderated or mid-range profile. Those with relatively narrow chests and good tissue quality may be candidates for high profile implants while patients with very wide chest who don’t want to be too big may like low profile implants.
Fifth, the implant diameter is chosen. A caliper is used to measure the breast width. The implant diameter range is generally one centimeter above or below this measurement. Going outside this range, particularly wider, risks lots of problems. There are tables of available implants for each diameter. Silicone implants have a single volume number measured in cc’s (cubic centimeters or milliliters). Saline implants have a fill range (i.e. 300-330), but usually the top number is chosen. Under filling causes more rippling and may lead to earlier deflation.
Sixth, it’s time to look at the example book and play what we call the rice game. In general, the larger the implant, the greater the rounding at the top of the breast. Some women seek this augmented look while others want a more “natural” look. Thin women with little breast tissue will always have some degree of rounding while women with larger or more sagging breasts will have less (see the example gallery). The desire to be an A,B,C, or D cup helps me understand what each patient is looking for, but Plastic Surgeons think in cc’s.
There are only so many possible implants and so many cc’s that will safely fit on each chest. My job is to counsel patients on which implant size will best meet their goals and to avoid placing too large an implant. Implants that are too large for a chest will cause irreversible tissue thinning, implant rippling, and drop out (descent of the implant down the chest). Even appropriately sized implants can cause these problems, so it is best to only use as many cc’s as necessary. If I recommend an implant size range smaller than the patient desires, it is not because I don’t want them to have large breasts; it is because I have treated the significant problems caused by too large an implant for a particular breast and don’t want my patient to have that potential problem too. Remember, you’re problem is my problem, and I don’t want any problems.
Finally, a medical assistant helps the patient try on a bra using rice as a sizer. The number of cc’s that I think will best achieve the patient’s goal is tried first and different volumes are tried from that baseline for comparison. This method is not perfect by any means, but most patients find it to be very helpful. A common pattern I see is patients who start off wanting to appear more natural and end up accepting more rounding to achieve the size that they like.
Breast Reconstruction patients using expanders have a little different approach. As the expander is inflated over time, one can see what that volume with look like on the chest. The expander usually looks a bit larger than a final implant of the same volume. The expander is also usually overinflated to allow more room and to account for tissue contracture once the final implant is placed. Based on observation and estimation, the proper implant can be narrowed down. Nonetheless, exact size desired and contralateral symmetry are very hard to achieve.
So, over a thousand words later, that is how I help patients decide their implant size. It is a shared decision which is made in the exam room and not in the operating room (which can really be very inexact and unpredictable). Using this method has helped me give my patients what they want in a safe manner while minimizing the need for implant exchanges.
