DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

Breast Implant Shapes, Profiles & Textures


In the two previous section, How Do Silicone Gels Differ?, I discussed how silicone gels used in breast implants differ in their properties, and how the individual characteristics of these gels impact the behaviour of the implant, as well as the resultant look and feel of the augmented breast.

In this section, I will address some other important characteristics of breast implants – shape, surface texture and profile. All of these parameters come into play when selecting an implant for a particular patient. While I do not expect the patient to be able to independently and accurately select the best implant for their breasts (that is my role), I do think it is important for the patient to have a fundamental understanding of these principles so that they can participate in the decision making process.

What is the difference between round and teardrop (anatomical) implants?

Implants come in basically two shapes, round and anatomical. The anatomical implants are also known as teardrop implants. Currently, both saline implants as well as silicone gel implants are available in round (Allergan Natrelle, Mentor, Sientra) and anatomical shapes (Sientra).

When choosing breast implants, shape is an important consideration. The two basic breast implant shapes are round and teardrop. Breasts differ greatly from woman to woman, so the ideal breast implant shape for each patient must be determined with care. Let’s discuss the difference in shape, round versus teardrop first. Next I will address profile and surface (smooth versus textured).

Round Breast Implants. Of the two breast implant shapes, the round breast implant is the most common type used by most plastic surgeons for breast augmentation. Round implants are easier for the surgeon to work with. If a round implant is turned, it is still round. Many women choose round implants because they believe that round implants tend to provide the greatest amount of lift, fullness, and cleavage. This is in fact, not entirely true. If you have a breast that is small, with a tight skin envelope such as a young woman who never had children, then any implant, round or teardrop, will tend to give a very full, high, unnatural look especially if the implant is too large for that breast. It has absolutely nothing to do with the shape of the implant itself. If a saline implant is used and it is overfilled, then the same result will occur. All of these situations have nothing to do with the implant shape – it has to do with filling the breast envelope with too large an implant, or overfilling the implant itself, both situations of which will cause distortion and produce an unnatural breast with a very high, rounded look on top.

Some women, however, feel that the results produced with round implants appear artificial, so they seek out more natural-looking alternatives (anatomical or “teardrop” implant)*. Some women may prefer the “artificial look” and want to look like they have implants – this is the minority of my patients. Due to a round implant’s symmetrical shape, the shape of the breast is not compromised should the implant rotate. If the implant should rotate, and I expect that all smooth round implants do rotate, the shape is still exactly the same, round.

Teardrop Breast Implants. As the name indicates, a teardrop breast implant, also known as a contoured or anatomical breast implant, is shaped like a teardrop. Breasts attain a more gently sloping contour with teardrop breast implants. Teardrop implants better resemble the natural shape of the breast. There is greater preservation of the contour and fullness of the upper portion of the breast, and less overstretching, also known as “bottoming-out”. They require much more care in placement. When inserted, they are often tilted to better follow the natural contour of the breast. The degree of tilt requires more attention if the degree of symmetry is to be optimized. The teardrop-shaped implants often provide greater projection by volume. For women who want more naturally shaped teardrop breasts, these implants may be the ideal choice. Breasts with teardrop shaped implants typically excel in appearance in women who have loss of fullness and stretching secondary to pregnancy and lactation.

Which implant gives the breast a better shape, round or teardrop?

This is the million dollar question. The overall shape of the implant once it is implanted into the breast and is in a vertical position (patient standing upright) will determine its influence on the shape of the breast. If you placed a teardrop shaped solid block of silicone into the breast, it is my belief that in most cases, the breast will look more natural than if one placed a round solid block of silicone. However, we do not use solid blocks of silicone as breast implants – they are unacceptably too firm. That is why we use gel. And it is the behavior of the specific silicone gel and the surrounding shell that will determine the shape of the implant once it is within the breast. The more form stable the implant is, the more it will maintain fullness at the upper portion of the breast. Remember, this comes at a price – the implant (and the breast) will be firmer. These implants also are subject to collapse of the upper portion of the breast if the gel is not adequately form stable. The other key factor is the interaction between implant and breast. If the breast has a tight soft tissue envelope, such as in a young woman who has never been pregnant and has small breasts, the implant will tend to be compressed more and have more upper fullness that when that same implant is placed into a lax breast where there is minimal compression of the implant. In this case, the form stability of that implant will contribute more significantly to upper breast fullness than perhaps that same implant when placed inside a tight breast.

So why do so many people believe round implants have more upper breast fullness? The reason that some women think that a round implant gives you more upper pole breast fullness is threefold: a round implant larger than desirable for that person’s tissue may have been selected and that person was over augmented, the implant (saline) was overfilled at surgery making it tense which will retain upper pole fullness at the expense of implant shape as the contours of the beast become distorted and lastly the person’s tissue envelope may have been tight to begin with, which will result in more upper pole fullness than a lax tissue envelope (see the previous discussion about type I vs. type II breast types). You can achieve this unnatural, high look with either a round or teardrop implant, so the shape does not matter here.

It is my opinion, based upon critical review of my own cases, that in the case of both SALINE and SILICONE implants, that teardrop shaped implants give a more natural shape than round implants in the vast majority of cases. If one looks critically at the breast augmentation cases in my photo gallery, I believe that they will come to the same conclusion. It is important to note that in some women, particularly those with an adequate amount of good quality breast tissue to drape over the implant, that the shape of the implant may be less important to the overall aesthetic result. When making these comparisons, it is important to compare round and teardrop implants with the same degree of form stability, otherwise the comparison is not fair.

Looking at the matter in reverse, if I were asked to review my own cases but blinded by which implant was placed and asked to identify which patient had a round and which patient had a teardrop implant, I believe that I would be lucky to be correct more than 50% of the time. The difference is not that much. I think the only fair way to answer this question is to place a round implant into one breast and a teardrop into the other and then see which breast looked better (assuming the breasts were fairly similar before surgery). No one would do such a study, but this is really the only accurate way I know to see if there is truly a significant difference.


Round Implant (smooth surface, low form stability)


Anatomical Implant (textured surface, high form stability)

Smooth vs. Textured

All implants consist of a silicone shell which can either have a smooth surface or a “fuzzy” or textured surface. The textured surface was developed many years ago in an attempt to reduce the rate of capsule contracture. Whether or not this has worked is somewhat debatable. We believe that when the implant is placed under the muscle, the textured surface seems to reduce the rate of capsule contracture, but not so when placed above the muscle.

An implant with a smooth surface can freely move and turn within the breast pocket, but an implant with a textured surface “sticks” to the underside of the breast and muscle and on top of the chest wall (ribs) in a fashion not to dissimilar to Velcro. A textured surface will keep the implant anchored in position so that it cannot rotate. This is of no concern with a round implant. When using a teardrop shaped implant, rotation of the implant will result in a continual alteration in breast shape.

The two different surfaces give the surgeon some additional choices in optimizing the breast augmentation results.* In the case of a patient with better quality breast tissue, with good thickness, a textured implant will attach to the chest wall and the underside of the breast tissue or muscle, and may result in less stress on the lower portion of the breast because all the weight of the implant isn’t sitting on the bottom of the breast. This is somewhat theoretical. In the case of a patient with very thin tissue, a textured surface will attach to the underside of that tissue, and may be more likely to demonstrate visible rippling as when the implant ripples; it pulls the breast tissue in with it, causing a visible ripple in the breast surface.

In the case of teardrop implants, there really is no choice. One needs attachment to the surrounding tissues, or else the implant will rotate within the pocket and the breast shape will constantly change as the implant rotates. This is not an issue with round implants because if they rotate, the shape remains the same. The advantage in choosing a teardrop implant, be it saline or silicone, is a more natural shape and, in especially the case of the silicone teardrop “Gummy Bear” implant, with better preservation of that shape over time as compared to a round implant.

Shown below are a comparison of four augmentations performed using round smooth saline, anatomic textured saline, round smooth silicone gel implants and anatomic textured silicone gel implants (“Gummy Bear” implants) -all placed under the muscle: In the case of the silicone gel implants, it is in my opinion impossible to tell by visual inspection only which breasts contain round and which breasts contain teardrop implants.

330 cc Round saline implants
270 cc Anatomical saline implants
304 cc Round silicone gel implants
310 cc Anatomic silicone gel

In the case of silicone implants, I think that the coherent nature of silicone gel changes things. Silicone gel implants are less firm than saline implants, so the breast tends to retain its natural shape tendency, rather than have it influenced by the firmness of a saline implant. There are anatomical silicone gel implants called form stable implants which received FDA approval in February, 2013. These implants have been in use in other countries for about 15 years prior to their obtaining FDA approval in the United States. The main advantage of these devices is the superior preservation of the shape of the breast over time as compared with all the other types of implants. However, in July 2019, due to concerns about an association between textured surface implants and the development of Anaplastic Large Cell Lymphoma (ALCL), Allergan voluntarily removed their textured devices from the market. I personally would not recommend at this time using textured implants. The risk of developing ALCL, although quite small, is simply not worth taking for what might be a very modest improvement in breast contour, and I am not even sure one could state at this time that there exists any superiority in contour with teardrop implants. This not withstanding the 1-2% risk of teardrop implant rotation causing annoying changes in breast shape. At this time, I only recommend using round implants.

Implant “Profiles”

Round silicone gel filled implants come in four “profiles” as demonstrated below: low, medium, high and extra-high profile. For a given volume of implant, a low profile has a wider base width but less forward projection, a high profile has a narrower base width but a greater forward projection, and a medium profile lies in between the two. Restated another way, “the higher the profile, the narrower the base width for a given implant “volume”.


A higher profile can enhance the forward projection of the breasts, which would otherwise require larger breast implants with wider bases. However, such devices are associated with greater thinning of the breast tissue, chest wall deformities and creation of uncorrectable deformities. I find that the medium profile implants seem to give the most consistent, natural results in the majority of women, and the low profile implants work well in women with little breast tissue and very tight soft tissue envelopes.*

Natrelle is Allergan’s brand of silicone gel filled implants. The top row is Allergan’s name for the profile shape, the bottom is my assessment of the profile, probably the easiest way to remember them.


“Moderate Profile” Low Profile


“Moderate-plus Profile”
Medium Profile


“High Profile”
High Profile


“Extra High Profile”
Very High Profile

The teardrop 410 “Gummy bear” implants are shown below. From February 2013 when they first attained FDA approval up until July 2019 when they were voluntarily withdrawn from the market by Allergan, these implants were available in “full” or “moderate” height and “full” or “moderate projection” yielding a combination of only four “shapes”, shown below:


When selecting an implant profile, one must take into account the tissue envelope. Trying to achieve more forward projection with a high profile implant in a tight tissue envelope will not work because a tight envelope will simply limit the amount of forward projection that you can have and will furthermore probably result in atrophy of breast tissue and possibly even a chest wall deformity (depression in contour). An important point to remember is that probably all breast implants will result in some atrophy of the breast tissue, so it is paramount to choose an implant size and profile to minimize this deleterious effect upon the breast tissue. The solution is to go with a lower profile implant. My personal opinion and recommendation, for the vast majority of cases, use either low or medium profile to avoid damage to the breast tissue in terms of atrophy.

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