Breast Implant Choices

The ABC's of plastic and cosmetic surgery: Breast implant choices.
By Dr. Mathew C. Mosher

From Spring 2002 Issue

Breast implant choices: What you need to know
There's a dizzying number of factors to think about once you decide to have breast enhancement surgery. In this installment of Dr. Mosher's regular feature on plastic and cosmetic surgery, some of the key factors related to breast implants size, shape, and implant filler are explained.

In this issue of drmosher.com, we feature an interview with Marlane Potts, a patient of mine who recently underwent breast augmentation. When you read her story, you'll see the profound influence breast surgery can have on a woman's life. breast surgery is by far the most frequently requested surgery that I offer as a plastic surgeon, and every year I perform about 200 breast surgeries. The procedures include breast augmentation, breast reduction, and breast lift. In this column, I focus on several key factors to think about when you're considering breast augmentation.

Size: Do I just pick a cup size?
Selecting an implant size is a team decision involving you and your plastic surgeon. Input from your partner, relatives, friends, and the surgeon's staff can also be helpful. Looking at photographs of women who have breast shapes that appeal to you can be very helpful when deciding what may be achievable for your body. Unfortunately, photographs do not tell the whole story of individual tissue characteristics, which strongly influence the outcome of surgery.

• There are some general principles that strongly guide the decision-making process:
  
  Adequate tissue coverage over the implant is essential.
• The characteristics of your breast tissue strongly influence the size selection.
• Larger implants have more downsides, particularly over the longer term.
• An implant size should be selected on long-term goals.

Should you decide to have a consultation with me, I will assess the features of your breast tissue and your current breast size and shape, and ask you about your goals for the surgery. The final size and shape of your breasts will be determined by a combination of the implant size, implant shape, implant location, your existing breast shape, your existing breast tissue characteristics, and your goals. Of these factors, your tissue characteristics are the most important. Based on these factors, I will suggest minimum and maximum dimensions for breast implants to achieve a proportional breast augmentation. This range will minimize the risk of problems with your breast shape over the long term.

"Breast surgery is by far the most frequently requested surgery that I offer
 as a plastic surgeon, and every year I perform about 200 breast surgeries."

It is impossible to make accurate predictions about the bra cup size after surgery. Although cup size is what most women are used to thinking about, it's an arbitrary measurement. I'll encourage you to think about the visual changes that you would like to see in your breast.

Sometimes patients want to choose an implant size that is larger than the size I recommend. I will decide if your tissue can accommodate the implant that you prefer in the short term and support the implant you prefer in the long term. We have all seen examples of some celebrities who chose a disproportionately large implant. In most cases, excessively large breast augmentations are possible, but require careful consideration. If you choose an implant that is larger than recommended, you will need to sign a consent form that confirms that you understand the consequences of that decision.

Shape: Round or anatomical?
The shape of your breast implant is an important area for discussion and continues to be an area of confusion and some controversy. The basic choices are round implants and anatomical implants, which are shaped and contoured breast implants. Because plastic surgeons have had more experience with round saline implants than with any other implant, the strengths and weaknesses of this type of implant are well understood by experienced plastic surgeons. Anatomical implants were developed more recently in hopes of creating a more natural-looking breast augmentation result.

Unfortunately, nothing is ever as simple as it sounds. Let me try to clarify the issues for you and share my thoughts about the choice of implant shape.

A round implant is designed with a round base and when properly filled creates a more rounded appearance to the breast. In many cases, this also results in an upper breast contour that's more bulging or has a more globular shape. The degree to which a round saline filled implant maintains this look is dependent on how much saline is placed in the implant and the tissue characteristics covering the implant. When round-saline filled implants are filled within the manufacturer's recommended guidelines, the upper portion of these implants partially collapses when the implant is upright. This can work to our advantage as this diminished bulge in the upper breast shape is a more natural shape. However, there is also a potential downside to this shape change when a woman is standing. Partial collapse results in the implant shell folding creating the potential for this fold to be seen or felt as a wrinkle in the breast. Theoretically, this could also lead to an area of wear in the implant shell and increase the risk of implant deflation.

Anatomical implants were designed to better maintain a more natural and less rounded shape regardless of the implant position. They definitely have a more natural shape outside the body when we compare them to round implants. However, when anatomical implants are inside the body and filled to the recommended volumes, they too can have problems with partial collapse and development of folds and wrinkles. Studies comparing the shape of round and anatomical implants once inside the body have demonstrated very little difference when the patient was upright. Furthermore, when lying down these implants create a tapered shape that is unlike a normal breast in this position. These implants can also become rotated in the body, which creates an unnatural look that requires revisional surgery.

Is there a simple answer to this problem? Unfortunately no. However, an experienced plastic surgeon can select the best implant shape for your body in order to best achieve the breast shape that you are looking for while minimizing the risks of unwanted problems.

My extensive experience with saline implants leads me to strongly favor round saline-filled implants for most patients. Varying the amount of saline placed into the implant can overcome most of the concerns discussed above. When standing there is some softening of the upper breast contour and when lying down a rounded and natural shape occurs. If the implant rotates in the body the shape of the breast will not change. Filling round saline implants closer to the maximum volume for a given implant size can further reduce the degree of shell collapse. Overfilling beyond the recommended volume for the implant diminishes collapse even more but will result in a more rounded and fuller look to the upper breast. If this matches your shape goals then this can be a good alternative. The other critical factor that minimizes the risk of seeing and feeling any folds in the implant is making sure that you have enough tissue covering the implant. The more tissue that covers the implant, the softer and smoother the contours of the breast. In most instances this means placing a saline implant behind your chest muscle (subpectoral) and occasionally behind other muscles as well (submuscular).

Round silicone gel-filled implants behave much like round saline implants but have a more natural feel. This means that there is less chance of being able to feel the implant. The increased viscosity of the silicone gel creates more natural movement of the breast as well. Newer cohesive gel-filled implants are firmer to touch and maintain their shape better than any other implant. Round and shaped cohesive gel implants are available and both can work well. These are what I recommend to patients who like the feel of silicone gel implants, desire a shaped implant, or want to lower the risk of feeling folds and seeing wrinkles.

Filler: Saline or silicone gel?
The choice of saline (salt water) or silicone gel as the implant filler is one of the most confusing areas for women considering breast augmentation. The US Food and Drug Administration (FDA) banned the use of silicone gel-filled implants in the United States in 1992, and Health Canada blindly followed suit shortly after. The ban was in response to anecdotal concerns about a possible link between leaking silicone gel implants and other illnesses. Prior to this ban, silicone gel implants were widely used throughout the world and were generally preferred over saline implants primarily because of their superior feel and diminished tendency to ripple.


Since 1992, women in North America have only had the option of saline implants. These naturally became the standard for breast augmentation and patient satisfaction has been generally very good. Saline inside of a breast implant certainly does not raise any health concerns and put most fears about leaking implants to rest. During this time, saline filled implants and the surgical techniques used to implant them improved greatly and generally created a very natural and satisfying result.


The number of breast augmentation procedures performed since 1992 has grown rapidly. When there is sufficient tissue covering the breast implant the satisfaction rate of saline-filled implants is usually very high. Unfortunately, these implants do not closely resemble the feel or movement of breast tissue. Consequently, for women who have thin tissue, saline implants do not feel very natural. In addition, these implants tend to partially fold during movement, and these folds are occasionally seen and often felt in the breast. In contrast to this, silicone gel filled implants more closely resemble the feel and movement of breast tissue, and are much less likely to lose their shape during movement.

In 2000, Health Canada elected to make silicone gel implants available by special request to surgeons and their patients, since there has been no scientific evidence linking silicone gel implants with any illness. In fact, the conclusion of many respected agencies is that based on the scientific evidence, silicone gel implants are as safe as saline-filled devices. In Canada, these silicone gel implants are still technically considered an unlicensed medical device and are available only by special request. Interestingly, this restriction is limited to North America as silicone gel implants are freely available in the rest of the world and are used preferentially.

Both traditional silicone gel implants and the newer cohesive gel-filled implants have improved shells to limit the risk of shell failure and silicone leakage. The traditional silicone gel implants are filled with a semi-liquid, sticky gel that is hard to remove completely if the shell ruptures. The new cohesive gel implants are appealing because they are filled with gel that adheres to itself, so even if the outer shell failed, the gel would remain together in the breast and would not break down into smaller pieces.

When you look at and feel saline and silicone gel implants, the silicone gel implants are much more natural, which is why many women prefer them. Choosing the right implant for you requires a discussion of these issues. When there is adequate tissue coverage available, the differences in performance of saline-filled and gel-filled implants are small. Having an alternative to saline is important for women who do not have a lot of their own tissue and are looking for a more natural feeling implant. I currently use about 70% saline and 30% silicone gel implants.

And that's not all
There are several other decisions we need to make prior to breast augmentation surgery, but space limitations prevent me from going into all of them here. Briefly, though, they are implant shell characteristics (smooth or textured), implant manufacturer, incision placement, and location of the implant pocket. Naturally, should you decide to have this surgery, we will discuss these issues in detail. It is important that you and your plastic surgeon discuss all the pros and cons so that you can feel confident that you have the best opportunity to achieve the breast augmentation you want.

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