Preparation

Surgical decision-making can be complex. Careful consultation with the surgeon is necessary to be sure everyone is on the same wavelength. Sometimes, we physicians have to draw on our experience and training to help the patient understand that what she wants is not always feasible; not everyone comes into the office with a complete understanding of the options and issues. It is an educational process, and the decisions have tradeoffs. Bigger implants, for example, are thought to carry more risk for long term problems, such as sagging or more serious complications.

Most breast augmentation procedures enlarge the breast with an implant filled with salt water or "saline," similar to the water that makes up 70 percent of the body. Presently, the liquid silicone-filled gel implants are used only for reconstruction or to replace a saline implant. They may be available soon for first-time implants. Silicone implants are more natural-feeling, but may become firm (due to "capsular contraction") over time more often than saline implants. Perhaps 20 percent of silicone gel implants eventually develop unacceptable capsular contraction, while this occurs in only a small percent of saline implants.

Size and Style

When you come to the doctor's office for a consultation, he will help you choose the implant size and shape that is best for you. This is done by literally "trying on" different implants. The doctor and/or counselor will show you a variety of implant "shells" — plastic sacs filled to different capacities. You slip these into a bra to see their effect, trying on different sizes and discussing the options. The doctor may also measure your breast and chest to help determine which size will be the most effective and best complete your figure. This last idea — choosing an implant that completes your figure — is a very important one. Many women are so anxious to have larger breasts that they don't care about proportion. The diameter of the implant must be matched to a woman's chest size. "The bigger the better" is a common attitude. But if the size is too big, complications and sagging are more common.

Shape is important too. The new, modern implants come in regular, moderate profile, high profile, and teardrop shapes. The new "high profile" shape came out in 2002 and many surgeons view this as a superior implant because it typically produces much less "rippling" or visibility of irregularities at the implant's edge. The "profile" is slightly higher, but this is usually a quite natural effect. We now use these high profile implants for most of our patients. The teardrop shape, on the other hand, is not very popular because it is designed to look best when the patient is standing up: an unnatural concept. We don't currently use these implants. And although "textured" implants were originally thought to produce less scarring than smooth ones, this is now in doubt. We use smooth implants because they can't be felt as easily through the skin.

Patients may want to bring in a photograph of a topless model from a men's magazine or lingerie catalog showing what they consider to be ideal breasts. Of course doctors can't promise an exact match, but we can get an idea of the patient's expectations.

Silicone gel implants feel much more like normal breast tissue than saline implants, and in my opinion are usually preferable. However, in the early 1990s, the Food and Drug Administration, in a very conservative and controversial move, banned them for use in initial augmentation, unless some sort of breast lift or reconstruction is performed. This set off several billion dollars in lawsuits based on "junk science," or more accurately their "junk" opinion expressed by (then) FDA Chairman David Kessler. Currently, gel implants can also be used in implant replacement surgery, and soon may be available for unrestricted use. While scientific evidence proves the gel implants are extremely safe, the capsular contraction rate, or chance of becoming hard, is higher. It's all a tradeoff, and consultation with your surgeon will help you make the right choice.