Frequently Asked Questions (FAQ's) Concerning Breast Augmentation
Two Previous Operations and Desires Larger Implants
Paraphrased question: A patient wrote who had undergone two previous operations, one for an initial augmentation, and the second to increase the size from 310cc's to 510cc's . This patient described being very thin, and wanted an even larger, anatomic implant.
A: In your E-mail, you categorized me as "the expert" on anatomical implants. To me, an expert is someone who makes the right decisions for the right reasons, then stands by those decisions. The outcome is what eventually decides how expert someone really is. I personally would never use an anatomic implant in a reoperation in a patient with your story. You are now on your THIRD reoperation following a breast augmentation. An anatomic implant is MORE difficult to use than a round implant, and in a third reoperation, no plastic surgeon on earth can control the tissues that you have progressively stretched by persistently requesting larger implants. Once your tissue is stretched, it is impossible to make a pocket that will precisely fit the implant. With anatomic implants, if the pocket does not fit the implant, the implant can rotate, and you have created a new, additional problem. The new problem was not caused by the anatomic implant, it was caused by making the wrong implant choice for the wrong reasons in the wrong patient. I can't make absolute statements without personally evaluating you, but I can tell you that I would not consider an anatomic implant in a patient with your history of previous operations and progressively larger implants- regardless of how much experience I have with anatomic implants.
No implant can give you a good long term result because of the choices you have made. No measuring system, no magic technique, and no magic surgeon can escape the inevitable consequences of poor judgement and lack of common sense. Your tissues (and every other woman's tissues) can only support so much. You state that you are 5'2", 13% body fat, and have NO upper body subcutaneous fat. Could you or anyone else logically explain to me how someone as thin as you with a thin skin-subcutaneous fat layer expect your tissues to survive what you are trying your best to do to them? When you had your implants replaced in 1997 to get a larger size (310's increased to 510's), you started a predictable, inevitable cycle of progressively stretching and eventually, potentially destroying your soft tissue envelope (an envelope that was already thin and not capable of supporting larger implants). The larger 510cc implant did exactly what I would have predicted. It stretched the envelope, and then fell to the bottom of the pocket, putting traction on the capsule surrounding the implant. Visible traction rippling was the result, necessitating another operation or resulting in a permanent, visible deformity. Now you are wanting 720cc implants!! If your tissues wouldn't support the weight of a 510cc implant, what makes you (or anyone else) think that they will support the weight of a 720cc implant? Am I missing something? There is a message here. Let's see if we can define the message!!
Why do you think your skin stretched when you converted from 310 to 510cc implants? The answer: More weight in older, more stretched skin. The inevitable occurred- larger implant equals more weight that produces more stretch and sagging, and a high risk of traction rippling, regardless of implant type or pocket location. BIGGER IS NOT BETTER. YOUR TISSUES WILL ONLY SUPPORT SO MUCH. YOU ARE ASKING A SURGEON TO DO SOMETHING THAT CAN'T POSSIBLY GIVE YOU A GOOD LONG TERM RESULT AND COULD VERY POSSIBLY CAUSE ADDITIONAL COMPLICATIONS!!
What SHOULD you do? You won't want to hear it! Remove the implants and perform a breast lift (mastopexy) and do not replace the implants at the same reoperation, preferably never. You have already compromised your tissues with excessively large implants. Keep it up and you're likely going to have additional complications, operations, and possible permanent deformities- all caused by getting excessively large (and progressively larger) implants that your tissues can't possibly support. Your tissues are giving you a loud and clear message, and unless you and your surgeon want to face more problems, it's a good idea to listen to your tissues! If you just must replace an implant, be sure it's SMALL, and don't try to replace it at the time you have a mastopexy. Delay the implant replacement until your tissues are healed, at least 6 months.
Your tissues are not going to get better as you age, they get worse!! Check out your grandmother's breasts! You've already permanently compromised your tissues by thinking only about what you want, not what your tissues will reasonably allow you to have. Add to that the fact that you are considering a silicone gel filled implant that is underfilled by the tilt test. A larger implant- an underfilled implant that allows its shell to fold- in a soft tissue envelope that has already thinned and experienced traction rippling? Sounds like a guarantee of more problems to me!! One way or the other, you will face the long term consequences. It's time to use common sense and weigh the inevitable tradeoffs against your wishes for larger breasts! When the inevitable happens and you have complications, you, like many patients, will likely blame the implants or your surgeon long before you examine your own judgement and common sense.
Your last questions deal with contracture rates over or under muscle with silicone or saline implants. Having used every implant made in the past 20 years through every incision and every location (above and below muscle), let me give you some simple generalities based on this experience:
Over or under muscle is not best. Which is best depends on the type and thickness of tissues that the patient brings the surgeon to work with. Both have tradeoffs, neither is perfect, but the most important thing is to provide adequate soft tissue cover over any implant so that the implant edges are not visible. At the same time, choose implant size carefully so that you don't progressively make the tissues thinner, the coverage poorer, and risk visible edges and wrinkling.
Capsular contracture rates vary with 1) the type of filler material in the implant, 2) the location of the pocket, and 3) characteristics of the implant shell. With silicone gel filled implants, smooth shell implants have a higher incidence of contracture compared to textured surface implants. The difference is less marked with saline filled implants, but textured still offers a lower risk of contracture in my experience. Saline filled implants across the board tend to have a lower incidence of capsular contracture compared to the old silicone gel filled implants. Using smooth shell, silicone gel filled implants, the incidence of capsular contracture is lower with submuscular placement compared to over the muscle. Again, this difference is less marked when using saline filled implants. In thin individuals, assuring adequate soft tissue cover is the number one issue with both silicone and saline implants, hence submuscular placement is often a priority in thin patients. If you are thin, adequate soft tissue cover should be your number one priority. If not, you can consider over or partially under muscle options. Each has relative benefits and tradeoffs. You can find all of these on our website at plastic-surgery.com.
I hope that you'll find this information helpful. I apologize if I was too hard about some points, but I honestly believe it is in your best interest to know and face the facts. Best of luck with your upcoming surgery, and remember: Having no implant is better than having the wrong implant for the wrong reasons. You'll have fewer problems in the future.
Top of page / Home / Steps to the Best Breast