Breast Implant Choices

Andrew J. Wolfe, MD & Steven D. Vath, MD

by Andrew J. Wolfe, MD & Steven D. Vath, MD | August 10, 2010 @ 04:00PM

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Choosing to have a breast enhancement procedure is a major decision with long-lasting repercussions. Just as breast shape and size vary from person to person, so do the factors which motivate someone to undergo breast enhancement surgery. For some women, it represents the culmination of a lifelong desire for larger breasts. For others, the motivation may stem from changes in the breast size and shape that are the result of childbearing or significant weight loss. Success in breast enhancement surgery is only possible when the desires of the patient are considered as carefully as the anatomy.

Dr. Steven Vath and Dr. Andrew Wolfe of the Center for Cosmetic Surgery are experts in breast enhancement surgery. At their Denver area practice, Dr. Vath and Dr. Wolfe use their considerable experience to analyze each candidate for breast surgery with regards to her individual goals and physical characteristics. A detailed personal and family history is combined with a thorough physical exam, and Dr. Vath and Dr. Wolfe will fully explain all the options available to the patient.

Anyone researching breast augmentation surgery will find a tremendous amount of information out there, especially on the Web. While some valuable knowledge can be obtained this way, much of the material is misleading or incorrect. How can someone tell the difference? Consultation with an expert in breast augmentation is obviously the most important step.

We recently spoke with Dr. Vath and Dr. Wolfe at their Denver area office concerning choices in breast enhancement surgery. "There are many factors which must be considered when recommending a treatment plan for a particular patient," says Dr. Vath. "Implant size, shape, and shell texture are all important issues. In addition, we must help the patient choose a location for the incision, and decide whether the implant will be placed above or beneath the chest muscles." The sheer volume of information that must be conveyed to the patient during a consultation is considerable. "The consultation generally lasts an hour or more," says Dr. Wolfe. "Any less and I feel that I'm rushing the patient. There are a lot of decisions to be made, and they're all important in achieving success."

There are many different types of breast implants. One of the major distinctions is between saline and silicone implants. "The shell of all implants is a silicone-based plastic that can be filled with a silicone gel or saline," explains Dr. Vath, who also notes that saline implants are available to all, while silicone is reserved for certain types of patients. Dr. Vath continues, "Patients who are candidates for silicone implants are those who are either reconstructive cases after mastectomy, revision cases after previous augmentation, or patients who require a breast lift at the time of their augmentation. In addition, certain breast or chest wall deformities may qualify a patient for silicone implants." Dr. Wolfe stresses that there are benefits and drawbacks to both types of implant. "The main advantage of silicone is the natural feel. In most patients, a silicone implant is virtually undetectable, while a saline implant can often be felt within the breast." Saline implants do have some advantages that may offset the less natural feel.

Saline implants are less expensive, more precisely adjustable, and can be inserted through a smaller incision. "More significantly, saline implants are easier to deal with if they leak, as they just deflate," says Dr. Vath. "Leaking silicone can cause a buildup of scar tissue around the implant that requires more extensive surgery to correct." Both Dr. Wolfe and Dr. Vath stress to their patients that the "silicone scare" of the late 80s was a combination of speculation, bad science, and media hype, and that silicone implants are safe. "Saline implants may be a bit safer in the long run, especially in cases of implant rupture," says Dr. Vath. "But silicone has an acceptable safety record, as well."

Implant shape is another consideration for a patient undergoing augmentation. Implants are either round or anatomic. While some surgeons prefer the anatomic, or "tear drop," implants, Dr. Vath and Dr. Wolfe more frequently use round implants. "Gravity gives round breast implants an anatomically correct shape when the patient is standing, and the implant rounds out when the patient lies down, as a normal breast would." Additionally, anatomic breast implants can rotate after they are implanted, resulting in an obvious deformity, while round implants are immune from this.

According to Dr. Wolfe, "All round implants are not the same. We now have the ability to match an implant's diameter to that of the breast we are treating." Dr. Wolfe is referring to the variety of implant profiles that are now available. The "profile" of an implant is the ratio of an implant's diameter to its projection. Dr. Vath explains, "A high profile implant will have more projection and less width for a given volume than will an implant with a lower profile. Right now we have three different profiles: High, moderate, and low profile." Both Dr. Vath and Dr. Wolfe agree that the moderate profile works well for most women. "A patient of average build who wants a moderate increase in breast size is well-served by a moderate profile implant," says Dr. Vath. "Patients at either end of the spectrum, however, may get real benefit from a high or low profile, depending on the circumstances. A petite patient who wants a relatively large implant may choose a high profile, while someone with a wider breast may want a smaller, lower profile implant." Dr. Vath adds, "Dr. Wolfe and I use measurements of the chest wall and breasts obtained at the consultation to customize our recommendation for the optimal breast implant for each patient."

Dr. Vath and Dr. Wolfe usually use smooth breast implants rather than the textured style because they feel the textured shell is thicker and more palpable within the breast. "There is evidence that textured breast implants are more likely to stay soft when placed above the muscle," explains Dr. Vath, "but smooth and textured implants located beneath the muscle have similar rates of thick capsules." He notes, "All anatomic implants are by necessity textured, as they need to hold their position within the pocket, while round implants may be smooth or textured."

Implants may be placed above or beneath the chest wall musculature. Both surgeons at the Center for Cosmetic Surgery prefer the submuscular plane for the majority of their patients. "The benefits of going beneath the muscle outweigh the drawbacks," says Dr. Vath. "First of all, the pectoralis muscle provides additional soft tissue coverage for the implant, helping to camouflage the implant. Capsular contracture, or thickening of the scar surrounding the implant, is significantly reduced when implants are submuscular. Finally, mammograms are more effective when implants are placed beneath the muscle, as the breast gland is less distorted." Dr. Vath stresses that breast augmentation does not increase the risk of cancer, nor does in necessarily delay the detection of cancer, should it arise in an augmented breast.

While some surgeons utilize one incision exclusively, Dr. Vath and Dr. Wolfe strongly believe that no one approach is ideal for every patient. "Some incisions work better for certain breast shapes," states Dr. Wolfe. "A small breast may have a poorly-defined inframammary fold, making it difficult to accurately predict where the scar will ultimately end up. In these patients, I recommend the periareolar approach. On the other hand, patients with well developed folds and/or larger breasts may find that an inframammary incision is better for them. Ultimately, it's that patient's scar, and they should have the right to choose where it's going to be."

Implants alone may not be enough to correct some of the changes brought on by childbearing and age. Dr. Vath states, "Breast volume is only part of the equation. If there is too much skin, that needs to be addressed as well." Mastopexy, or breast lift, is often performed in conjunction with an augmentation to further improve breast shape. Dr. Vath continues, "There is this mistaken impression among some people that an implant can somehow lift the breast. If anything, it's the opposite. The more a breast weighs, the more it's going to sag." By removing skin and tightening the breast, mastopexy reverses many of the effects of age and breastfeeding. Both Dr. Wolfe and Dr. Vath favor the so-called "short-scar mastopexy," which avoids any extension of the scar into the fold beneath the breast. The scars tend to be inconspicuous, but Dr. Wolfe stresses that they are rarely invisible. "You are trading scar for shape, plain and simple."

Given the wide variety of options surrounding breast enhancement surgery, how is a patient supposed to choose? The surgeons at the Center for Cosmetic Surgery believe they have the answer. "The simple truth is that there is no one best method of performing breast surgery, and a cookie-cutter mentality is simply unacceptable," says Dr. Vath. Dr. Wolfe agrees, adding, "No two patients are exactly alike, and one size definitely doesn't fit all. As surgeons, we have to consider individual variations to help patients chose what is right for them." To do any less, they feel, would be a disservice to their patients. "It's a bit more time-consuming," says Dr. Vath, "but the extra effort definitely pays off in the end."

For more information, visit Dr. Wolfe & Vath's Website 

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