The Four Cardinal Decisions in Breast Augmentation

The Four Cardinal Decisions in Breast Augmentation

Posted on February 11, 2013

When considering breast augmentation surgery, a patient needs to make four cardinal decisions guided by her plastic surgeon:  1) implant type, 2) pocket/placement, 3) incision selection, 4) implant size.  These decisions will ultimately set the foundation for a natural and aesthetic result.

    1. Implant type – The first decision a prospective breast augmentation patient needs to make is implant selection.  Implants are broadly divided into two categories:  saline and silicone.  Silicone breast implants are now sub-divided into cohesive silicone gel or high-strength cohesive gel (“gummy bear”).  High strength cohesive gel (“gummy bear implants”) are a recent addition to the breast implant lineup after receiving FDA approval in 2012.

Saline implants:  saline implants are constructed from a silicone shell and come from the manufacturer unfilled.  The implants are filled during surgery.  As a result, the placement of saline implants can be performed through a slightly smaller incision than silicone implants.
Silicone implants:  widely regarding as feeling much more “real,” silicone implants come in a wide variety of shapes and sizes for every body type.  The new silicone gel is highly cohesive that allows for a very real feel.  Numerous studies have been performed demonstrating the safety of silicone breast implants; most notable is the report from the Institute of Medicine.

High Strength Cohesive Gel implants:  high strength cohesive gel implants are a new type of silicone implants.  Widely available outside the United States, they approved FDA approval in 2012.  These implants are also known as “Form Stable” and affectionately called “Gummy Bear Implants.”  Gummy bear implants can keep their shape a little more readily than some of the other implants.  In the event of a shell failure, it is less likely that a gummy bear implant will leak silicone.  However, gummy bear implants are slightly firmer than standard cohesive gel implants.

Each type of implant has advantages and disadvantages.  Because saline implants come unfilled and the saline is placed in the operating room, they can be placed through a smaller incision.  Saline breast implants are also slightly less expensive than silicone gel breast implants.  On the other hand, silicone breast implants generally possess better performance characteristics with respect to feel, rippling, and palpability.  Most patients have indicated that silicone implants look and feel like the real thing.

    1. Pocket placement – Implants can be placed either submuscular (under the muscle) or subglandular (above the muscle).  For the vast majority of the patients, placing the implant under the muscle offers the best long term soft tissue coverage of the implant and maintains as many options for the patient in the long term.  In certain instances, placing the implant above the muscle may be indicated.  Done correctly, a submuscular (under the muscle) implant has a recovery and down time similar to that of a subglandular implant.  There are specific indications for placing an implant above the muscle.  These include the patient who is borderline in need of a lift (mastopexy) but wants to avoid the scars on the breast or a patient who is an extreme athlete (e.g. Olympic or world class level) for which any alteration of the muscle might be noticeable.  This decision is best made in conjunction with a board certified plastic surgeon.


    1. Incision placement – a variety of incisions for implant placement are available.  The three most common are inframammary crease (breast fold), peri-areolar (around the nipple), and axillary (armpit).  Of the three, the inframammary crease incision is the most commonly used incision in the United States.  The inframammary crease incision offers many advantages for the placement of a breast implant.  First, it is very well concealed in the breast fold, usually heals very well, and becomes very difficult to see.  It is also a very versatile incision allowing the use of the same incision for any future surgeries.  The axillary incision is good for placement of saline implants.  However, the incision can be very painful and implants placed by an axillary approach have a tendency to ride high.  The peri-areolar incision is also very well concealed;  however, it places a scar at the nipple, it may be associated with a higher risk of capsular contracture, and can cause scarring and deformation of the nipple-areola complex.


  1. Size – the decision of size is extremely important.  Implants that are too small may not fill the breast skin completely and may be prone to bottoming out or looking bottom heavy.  Implants that are too large can lead to damage of the breast tissue and skin leading to problems down the road.  Although there is not a “correct” size, there is indeed an acceptable range for sizing.  The acceptable range is determined by evaluating the tissue and skin dynamics of the individual patient and accounting for the aesthetics of the patient’s body to achieve a natural and beautiful outcome.  Your board certified plastic surgeon will participate in this discussion to guide you in the right direction.  This is probably the most important concept to understand during your consultation.  Although there is not ONE size that is correct, there certainly is an ACCEPTABLE range from which your implant should be selected.

These decisions should be made in conjunction with a board certified plastic surgeon at Liu Plastic Surgery.  Only a plastic surgeon has the background and training to help you understand the decisions that will impact your long term outcome and our guidance will help you achieve a natural and more youthful appearing breast.  As board certified plastic surgeons, we have a variety of techniques that we have developed to enhance your operation and recovery.  Schedule a consultation to discuss which techniques are right for you.

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