Understanding the Four Variables of Breast Augmentation

Breast augmentation: why is it so misunderstood? The surgery of breast augmentation is really straightforward. However, like all decisions, sometimes what we objectively know is best is not what we want and so we make subjective decisions. Whenever we choose a variable that is not “objectively” ideal, we are making a subjective choice, which may or may not be wise. In the case of breast augmentation it might mean bigger, smaller, rounder or looser, because that is what we think looks best. Remember that what is being created is a “fit”. Think in terms of best fit in clothing or” hand to glove” or “pillow to pillow case.” There are four main variables that control the fit or look: Implant size, Implant type, placement under or over the muscle and incision location. There is enough scientific literature to support well drawn conclusions, we may anecdotally disagree but that is not what the science says. So buyer beware. In the next several posts, I will give a simplified view of the objective choice of the four variables. So here is the first one:

How to choose the right size implant: As a breast ages,from age,weight loss,pregnancies, or any combination of the three, at any age, the breast deflates. The dimension of the breast that does not deflate is the “ideal” width of the base of the breast. This diameter should span the woman”s chest wall from breast bone, centrally, to the outside front border of the axilla,or armpit. In other words the width of the pectoral muscle. As this diameter is related to the chest wall, it does not deflate with age. Further, it can be measured and is not subjective. The surgeon should measure the width of the chest wall and then match the diameter of the implant to the chest wall. The next step in choosing the right “fit” depends on how loose or tight is the breast envelope. If the skin is tight choosing an implant that is wider than the measured base or higher projecting forward will create a tight round fit. It will eventually stretch and thin the skin and lead to earlier aging of the breast. If on the other hand the skin is loose, the excess must be filled up by either choosing an implant that is wider than the measured base or takes up the excess skin by projecting more forward. This means moderate or higher projection implants. Remember that fit can be measured just like clothing to determine look. Best fit means best judgement. Different looks can be created by manipulating fit, that is subjective. It may be worth the trade as long as it does not increase the risk of the surgery.

The second variable in achieving a great result from the surgery is choosing wether the implant goes under the muscle or over the muscle. Here is how to figure out what is best for you. Depending on your anatomy there is a “best” choice. Factors to consider are: (1) how thick is the existing breast tissue, (you can estimate by pinching anywhere above the horizontal plane of the nipple) and (2) when standing upright, is the nipple above or below the horizontal mid line of the breast or even lower near the fold of the breast. This cannot be examined lying down.

If you are like most patients your tissue will be thin, not able to “pinch an inch.” Also, regardless of age, pregnancies, or weight loss, most patients have always been an A or B cup, so their breast simply cannot “deflate” very much. In this scenario potential visibility of the implant is higher, than in the thicker, deflated, breast of the minority of patients. Because of the potential visibility, in the majority of women seeking implants we go under the muscle. True there is a lower risk of hardening and some improvement in mammogram reading. However, these risks remain low in either position. Choose based on tissue coverage and if you are asking the implant to create a never before shape and size, than go “sub-muscular”. If however, you have a low nipple and thicker tissue and once had size and shape, most of the time your implant should go on top of the muscle. Remember that the implant has to go under the nipple, not necessarily the muscle. If your nipple is low and you put the implant under the muscle, the implant will appear to high and the breast tissue will hang off. The so called double bubble. Further, if the job of the implant is to reestablish lost volume, it will be most effective above the muscle.

What type of implant do I choose? This used to be an easier choice, from 1994-2006 the only implant available for general use was a saline filled implant from either Mentor or Allergan. However, the market today has become much more sophisticated with a lot of different choices and now three manufactures competing. Direct to consumer advertising has biased the patient with preconceived ideas what is right for them. Induced by sexy commercials, with beautiful models, patients picture their new beautiful figures a certain way. “I saw it on the internet or Vogue,” so it must be true…they can’t lie on the internet, right?
Well, here is the skinny. Most patients today get silicone implants because they are skinny. The reason most women get implants is they start with very little of their own breast tissue, with little size or natural shape. they just don’t have a lot of breast tissue that will be covering the implant. Common sense is that the less covering the implant the higher chance of seeing the implant underneath. Therefore, clue #1, a bag of silicone is softer and wrinkles and ripples less than a bag of saline. So the thinner you are the more you consider silicone and vise versa for saline.

Patients are still concerned with the safety of silicone. Understandable but not really based on science. The scientific studies have not demonstrated any link between health risks and silicone implants. This is beyond the scope of this discussion. However, you can read more on my website, www.drbortnick.com also you can follow the link to breast implant safety.org. Silicone implants do have a slightly higher rate of hardening compared to saline. They have a slightly higher rate of mammography distortion when placed above the muscle compared to saline and they are more expensive than saline. All of these have to be balanced with the more natural feel, equal safety, equivalent lifespan and rupture rate.
Implants today are available in shaped, form stable gummy bear style, smooth surface and textured surfaces and have a mind boggling array of projections, dimensions, and firmness. There is no one right or best implant for everybody. There is however, a best implant in terms of predicable outcome for each patient. Talk to your surgeon! Make sure they understand and explain to you why they are recommending a certain choice.

Price, value and personal comfort should always weigh into your decisions. Like life and investing for the future consider where you are now and where you want to be in 10 years and 15 years, etc. Trust your surgeon’s experience, it is more reliable than the internet! Make a check list before your consult, ask me why I recommend Silicone or saline, textured or smooth, round or shaped, moderate mid or high profile, Allergan or Mentor. Relax during the consult, have an open mind, interact and learn.
Call 913-754-4939, Bortnick Plastic Surgery, educating, for twenty years!