How To Select the Best Breast Implant

How To Select the Best Breast Implant

There really is no single breast implant that is “the best.” The title of this section should really be “How to select the breast implant this is most optimal for you,” as there can be more than one good choice. Let’s look at the different currently available implant types and examine the advantages and disadvantages of each one.

This section reviews the rationale for proper implant selection, how to maintain a “natural” look, discusses scientifically proven methods in implant selection and how 3D imaging and computerized simulation aid in the consultation process and implant selection.

Saline Implants

I want to get this one out of the way. They are very firm, far more so than silicone gel, and often have a lot of rippling. Some people request them because they believe that they are more “natural.” Saline implants have a silicone shell (envelope, bag) just like all silicone gel filled implants do, so what is so natural about that? The next thing I hear from those requesting them is that they are “safer.” If a saline implant gets a leak, or ruptures, it is true that the saline will be absorbed by your body and you will excrete it. Your breast will deflate in a couple of days. Now, the soft tissue envelope (your breast) will begin to contract against this empty space so it is advisable to fill it with another implant fairly soon (a few weeks) before the breast contracts so much that it will be difficult to produce a similar appearing breast with a replacement implant, even of the same style and size as the implant you had before the rupture.

These same people then express concern that if a silicone gel implant leaks, the gel will travel all over your body. The reality is that is not the case at all. Here is why: Whenever a foreign body such as a pacemaker, artificial joint, or breast implant is inserted into your body, the body responds to it by creating a scar tissue capsule around the foreign body, much like an oyster creates a pearl around a piece of sand placed inside. The scar capsule typically forms around a breast implant in about three weeks. Should a silicone gel filled implant rupture, and the gel comes out of the implant shell, this gel will remain trapped inside the pre-existing scar tissue capsule. The gel has no opportunity to travel anywhere. Silicone is inert anyway, which means that it will not react nor cause harm to the body and vice-versa.

So, in summary, in my humble opinion, considering todays choices in silicone gel implants, I do not believe that saline filled implants are optimal for anyone except a person who wants implants but is petrified of having a silicone gel filled implant inside their body. And that is an unjustified fear, but then again, you can only educate someone to try to resolve their issues. Should those fears persist, I know of no way to make them disappear. That is my only indication for a saline implant – unjustified fear of silicone.

Silicone implants

With the recent July 2019 recall of textured surface breast implants (both saline and silicone gel filled), the only silicone gel filled implants are round smooth implants. What about teardrop shaped smooth implants? No such thing. The textured surface anchors the implant to the surrounding tissues and prevents movement of the implant within the breast implant pocket. Without such adherence, the teardrop implant would rotate within the pocket, making your breast continually change shape – not a very desirable thing! If a round implant rotates, and it will, the shape of the breast remains constant. You will not even be aware of the implant rotating, if it should do so.

OK, so now we have round smooth implants? What is the variety? Well, there are several parameters to consider, even amongst a single manufacturer’s portfolio of implants. I like the Allergan Natrelle line of implants. I have used others, and they have all be good, but I have used the Allergan implants since 1994.

So how do the round smooth implants vary? The first parameter is size. Selecting an implant size is discussed more thoroughly here. Basically, it is very important to select an implant that fits properly within the available space created when the breast and pectoralis muscle are elevated off the chest wall. If you underfill this space, the breasts look too small, and if you overfill, not only does it look unnatural, but you are at greater risk for creating deformities, some uncorrectable, and the need for surgical revision much sooner than desired. Saline implants were available in less size choices than silicone because you could adjust the fill volume over a narrow range as desired. Silicone gel implants are pre-filled at the factory, so we need more size choices to make it possible to use the most ideal implant. For this reason, I often find it helpful to determine my size choice by measurements, then have a couple different “sizers”, which look like implants but are not for permanent implantation, to sue at surgery to fine-tune my choice of implant. This is especially helpful when there are size difference in the breasts, which is very common.

The next parameter is profile. For a given volume, you can make an implant that has a greater base width and lesser central projection, or a lesser width and a greater central projection. You can visualize this easily when the implants are lying on a flat surface, pointing upwards. You can read more about this here. The choices are basically low, moderate plus, high and extra-high profile. For a very tight soft tissue envelope, I find that a low profile implant allows one to better match the implant shape to the space it is being placed into and for most other breasts, I like a moderate-plus profile implant. I am not a fan of high and extra-high profile implants. These implants put too much force in a front to back direction, leading to atrophy (thinning) of the breast tissue, as well as deformities of the chest wall. This has been described in the plastic surgery literature, and the photos of these over-thinned out breasts and indented chest walls (ribs) are very compelling indeed. Sometimes I am asked if the higher profile implants give more upper breast fullness, something many of my patients want. The answer is absolutely not, and probably less so than the moderate plus and low profile implants. The reason for this is that when you are standing in the upright position, a high and extra high profile implant adds projection front to back, not up and down, because the implant is now lying on its size within your breast. For a given volume, a lower profile implant has a greater base width, and therefore more contribution to the fullness of the upper breast.

The last parameter is gel viscosity. Viscosity is the resistance to a change in shape of the gel. Think of some common household gels. Ketchup, molasses, honey, toothpaste. If you try to pour (or squeeze) them our from a container, they need to deform their shape from that of the inside of the container to one narrow enough to pass through the opening of that container. They all flow differently. This is what gives the “softness” to the gel. Gels that are more viscous are firmer. They hold their shape better and it takes more force to deform them. Toothpaste and ketchup are more viscous than honey and molasses, which would flow with much less force, essentially that of gravity alone – no need to squeeze the container to get it to flow out.

I already stated that gels that are more viscous are firmer. These gels need more force to get them to deform and flow out of the container. With a breast implant, the gel does not move out of any container, but it still takes some force to deform that gel – to get it to change shape. The more viscous silicone gel implants need more force to deform them. Said another way, these same implants are more “form stable” – they are more resistant to a change in shape. The gels that are less viscous need less force to deform them, they are less firm (softer) and less able to maintain their shape.

So now we have identified a tradeoff – the more viscous implants hold their shape better but feel firmer. Conversely, less viscous implants do not maintain their shape as well but feel softer. Which do you pick??? Ask yourself to prioritize – do you want more upper fullness and do not mind a somewhat firmer implant? Is a really soft feeling breast more important to you, and consequently you do not mind a lack of upper breast fullness. That said, the differences are not so much that you have to worry about a rock-hard breast that looks good or a saggy breast that feels great. It’s not like that at all. Saline implants have about fourteen times more rippling than silicone gel implants. Among the silicone gel implants, the firmer it is, the less rippling. Fact is, even the softest silicone gel implants rarely cause any visible rippling once implanted into a breast.

Currently, there are three different Allergan Natrelle gels to choose from. Natrelle Inspira “responsive” which is the least viscous, softest implant. It is considered “non-gummy.” More on that in a minute. There is also the Natrelle “Highly Cohesive” implant which is the most viscous, firmest implant. In between is the Natrelle “Soft-Touch” implant which is a nice balance between softness and shape. The latter two are considered “gummy” implants. The term “gummy” (like the Haribo candy “Gummy Bears”) just refers to a more viscous implant. It is totally arbitrary what is considered “gummy” or not. Just line them up from softest to firmest and draw a line in the sane as to what you want to call ”gummy.” That is all it is!

Is patient preference all that goes into selecting a type of silicone gel implant? I wish it was that simple. Breast tissue varies in thickness and quality. For a young woman who has not had children yet and has good quality thick tissue, I think that all three silicones will do well in her breast. With time, and some stretching and aging of the breast, the firmer implant will preserve upper breast fullness the most, but in my opinion, this woman will be happy with any of the choices. If she really wants the softest breast possible, then go for the responsive, non-gummy implant. If she wants the most upper pole fullness possible in the long term, then go for the highly cohesive gummy implant. If she wants a balance of both, then the soft-touch is a good choice. For older patients with more compromised tissue, thin tissue or revision patients (such as swapping out a textured teardrop for a round implant), I tend to prefer the firmer, highly cohesive implant. It is more ripple resistant, which can be a problem for those with thin, overstretched tissue. It will also best preserve upper breast fullness, which is also a nice feature for those with an existing breast pocket, although in many cases, a soft touch implant will work equally well.

In summary, selecting the optimal implant is about understanding the limitations, if any, of your own tissues, you preferences regarding softness and upper breast fullness, and the characteristics of each of the three different types of silicone gel implants. Do not get yourself crazy over this – I am here to help guide you to make a choice that best suits you. This is based upon my experience with thousands of breast implant surgeries.

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Interested in getting breast implants, but unsure of which size will work for you? Call (631) 689-1100 to schedule your implant sizing consultation with me today!




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Epstein Plastic Surgery Long Island NY

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Mark D. Epstein, M.D., F.A.C.S.
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