Frequently Asked Questions (FAQ's) Concerning Breast Augmentation
Rippling Types and Causes
Q: I have rippling following my breast augmentation. It didn't appear until about 6 months after the operation. What causes it, and how do you correct it?
A: Rippling is not a simple issue.
Two types of rippling occur: 1) UNDERFILL rippling and TRACTION rippling. Rippling can occur with ANY type of implant! It has nothing to do with type of implant. Whether or not rippling is visible depends on the amount of tissue covering an implant, the degree of fill in the implant, and the type and size of the implant. All smooth implants fall to the bottom of the pocket.
TRACTION RIPPLING: A large (>350cc) implant (textured or smooth) in a thin patient can produce rippling by pulling on the capsule around the implant as it falls to the bottom of the pocket. The pull on the capsule can be transmitted to the skin and produce visible rippling in any area of the breast (traction rippling). Traction rippling can occur with an implant over or under muscle. If the implant is under muscle, the rippling may not be visible above, but can be visible at the inner, outer, or lower portion of the breast.
UNDERFILL RIPPLING: Any implant that is underfilled by the tilt test, regardless of how much it may be filled past manufacturer's recommendations, can produce rippling. By filling an implant outside the patient, a surgeon can tilt the implant vertically (the position it will be in the patient) and test fill (the tilt test). With the implant vertical, if the upper shell of the implant collapses downward and folds, the implant can produce rippling in the patient! Whether this rippling is visible depends on how much tissue is overlying the implant. If an underfilled implant (smooth or textured) is put under the pectoralis muscle above, the muscle can help hide visible rippling in the upper breast, but rippling may nevertheless be visible in other areas of the breast. The larger the implant and the thinner the patient, the greater the risk of traction rippling as the larger implant pulls on the thin tissues over time-regardless of the type of implant! Any underfilled implant risks rippling and early shell failure from shell folding. The only way to prevent these risks is to add adequate fill. Any implant, regardless of implant type or type of filler, will be firmer when it is adequately filled to prevent shell folding. You can decide-would you rather have adequate fill to prevent shell folding, and accept a slightly firmer implant, or would you rather risk rippling and earlier shell failure that could mean a reoperation?
Modern saline implants are made with thicker shells to increase shell durability-both smooth and textured. If you are thin, regardless of the type of implant, and if you can feel your ribs with your finger, you'll likely be able to feel an edge of your implant-regardless of where it's placed. An implant is not necessarily "rippled" just because you can feel the shell.
Rippling is MUCH easier to PREVENT than CORRECT! How do you prevent rippling?
1) Ask your surgeon to fill the implant adequately to pass the tilt test! Accept that overfilling past manufacturer's recommendations will void the warranty. This is only necessary with ROUND implants. With ANATOMIC implants, the manufacturer's recommended fill volumes are adequate to prevent underfill rippling.
2) If you have thin tissues (less than 2cm. thick by pinch test) measured by pinching higher on your chest, above your breast tissue, put the implant under muscle. If you have thicker tissues by measurement, above muscle is a good option.
3) Be careful with implant size, especially if you have thin tissues. Ask your surgeon to carefully explain to you how the implant size you select may affect your tissues over time! Write down what the surgeon says, and ask the surgeon to sign it! Be very careful about decisions now that can negatively affect your breasts as you get older. Remember, the larger the implant and the thinner the tissues, the greater the risk of traction rippling.
Another question and answer about rippling:
Q: I'm beginning to think I have a slow leak. I feel like I am shrinking each day. I have round smooth submuscular implants 275 filled to 300. I have rippling on the outer edges and underneath. Today, I noticed rippling on the right boob, cleavage area. I am 5'1" 95 lbs. I that this problem could be avoided with round submuscular implants but that's what I have! What can I do?
A: Rippling cannot be prevented by any type of implant or any single surgical technique. Three requirements to prevent rippling are 1) an adequately filled implant, 2) adequate soft tissue cover over the implant, and 3)an implant size that does not excessively stretch and thin your tissues long term. 1) If you have a round implant, even though your implant is filled past manufacturer's recommendations (possibly affecting the warranty), the amount of fill may still not be adequate to prevent implant shell collapse and rippling. The only way to assure adequate fill is to fill the implant outside the patient and perform a tilt test. 2) If you are thin and have thin tissues overlying the implant, you will likely be able to feel or see the implant shell or edges. Submuscular placement can retard, but not totally prevent visible and palpable edges. In the cleavage, if the muscle is divided to allow more narrowing of the cleavage, you sacrifice muscle cover and the implant is lying beneath the thin skin over the breast bone (sternum) where it is more easily felt and seen. 3) The larger the implant you select, the more chance the implant will stretch and thin your tissues over time, pulling downward on the capsule and skin envelope overlying the implant and producing rippling. Once rippling occurs, correction is difficult at best. The best correction is to make the right decisions to avoid rippling at the first operation. The standard correction of placing a larger implant is often successful short term, but fails long term as the larger implant puts more stretch on the skin envelope, producing recurrent traction rippling. Ask your surgeon about your specific case.
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