People throw around the phrase “boob job” very casually these days, which is no surprise as breast surgery has become the most performed plastic surgery procedure in the United States. But even though it seems like everybody and their mother is trading up, the reality is that getting breast implants is still a serious surgery and not to be taken lightly. Navigating and researching the decisions that need to be made can be overwhelming.
A good breast augmentation is one that looks completely natural and does not raise eyebrows. The first step is to find the right doctor, which is why the vetted recommendations of plastic surgeons in Charlotte’s Book are so important. Once you’ve decided on a doctor, there are still a whole host of questions about breast implants that need to be answered. Whether you want to add some volume after pregnancy, give them a little lift to combat gravity, or because you feel like you’ve never had enough, here are the four key decisions you need to make about breast implants: Where to insert them? Where to make the incision site? Should you use silicone or saline implants? How big should they be? Here’s what I tell my patients.
Placement Plane: Deciding where to place your implants.
Breast implants can be placed above or below the chest (pectoralis) muscle. There are excellent reasons to choose each option.
The implant is often placed above the muscle and under the breast gland when the patient has ptosis, or sagging of the breast. Because the pectoralis muscle does not need to be stretched when you place the implant above it, it is also the less painful option. But if you do not have a substantial amount of natural breast tissue, you may be able to feel the outline of the implant and the transition from your chest to your breast may look less natural.
A submuscular approach has the advantage of a lower rate of capsular contracture—that’s when the capsule which your body naturally forms around the implant hardens, becomes painful, or distorts the breast shape. It also leads to a more natural transition from the chest to the breast and you are less likely to see rippling in the implant. On the flip side, if you have a sagging breast, unless your breast is surgically lifted at the same time, you may see a “double-bubble” which means that the implant and the natural breast form two separate mounds. Placing implants underneath your muscle is also more painful and requires more time to recover.
My favorite technique is using a dual-plane where the top aspect of the implant is underneath the pectoralis muscle and the bottom is under the gland. This allows the surgeon to take advantage of both techniques leaving the implant less palpable, giving the patient a more natural breast shape, and reducing capsular contracture rates.
X Marks The Spot: Where should you make the incision?
The incisions for breast augmentation are strategically located to conceal any evidence of surgery. There are four incision choices: underneath the breast (inframammary), a hemi-circle at the bottom of the areola (periareolar), under your arm or through the axilla (transaxillary), and through the umbilicus or belly button (transumbilical).
An incision under the breast is used in 90% of cases in the United States as it heals well, is well hidden, and provides the surgeon with excellent visualization. Although the periareolar incisions (an incision at the bottom of the areola) are also very popular, studies have shown that they can lead to higher rates of capsular contracture and desensitization of the nipple. The transaxillary approach (or under your arm) is the third most popular choice—a good plastic surgeon should leave no trace of tell-tale scars that can be revealed when wearing a sleeveless top. Transumbilical incisions limit the surgeon to using only saline implants and are not a popular option.
Implant Options: Saline or silicone?
This decision often takes the longest to finalize. When the implant is placed underneath the pectoralis muscle, it matters less which implant you choose because it is deep within your body. Several years ago, most of my patients opted for saline implants, but today, my practice now has overwhelmingly transitioned to silicone.
The FDA banned silicone implants in 1992 because they were suspected of increasing the risk of systemic illnesses. After further review, silicone implants were shown to be safe and returned to the market in 2006. Since then, silicone implants have gained in popularity because they have less visual irregularities than saline implants, like rippling or wrinkling, as well as a lower rate of deflation over time. On the other hand, silicone implants have a higher rate of capsular contracture than saline implants because there’s often a slow leakage of silicone into the capsule surrounding the implant. One misconception is that if the silicone implant leaks, it will leak silicone into your entire body. But what really happens is that the silicone remains contained within the capsule or scar tissue that surrounds the implant and there’s often no loss of volume. The newest silicone implants have a thicker shell and a more cohesive gel, so they are much less likely to rupture or leak than silicone implants that we manufactured just three years ago. In fact, if you cut the new Sientra implant in half and hold it upside down, no silicone will leak from the shell. Because it is unclear if a silicone implant has leaked, the FDA suggests that women have an MRI every two to three years to check if the implant is still intact. New research suggests that ultrasound technology may replace the need for MRI testing, but MRIs remain the gold standard for detecting a leak. But before you get your heart set on silicone implants, know that you have to be over 22 years old to have them, according to the FDA.
Saline implants have advantages as well. For starters, the size is adjustable down to a cc of saline—that’s about one fifth of a teaspoon. Whereas silicone implants come in standard sizes, the amount of saline injected into a saline implant can be adjusted in the operating room to fine tune asymmetries. Additionally, because a saline implant is deflated when it is inserted into your body, the incision can be smaller than one created for a silicone implant. One downside though is that that rippling is more significant, so a thin woman with little breast tissue may have more visual irregularities. When a saline implant leaks, the saline or salt water is absorbed by your body and your breast becomes flat.
Many patients tell me that they find the silicone implants feel more real. They often state that the saline implants felt colder.
Calculating CC’s: How Big Will You Go?
Deciding how large you want your implants to be can be a stressful decision. Much of the decision is based on the width of your ribcage. Narrower patients will need smaller implants as larger implants would extend under their arms. I often suggest to my patients to come into the office and try on implant sizers. It’s best to bring two different types of shirts—a fitted T-shirt and a looser button down or sweater—to get the best idea of what the additional volume will look like when wearing clothes. Beyond taking into consideration your own ideals or visions, you also have to consider the goals you are trying to achieve, your lifestyle, and your age. It is important to discuss all of these variables with your doctor.