Breast Implant Options in NYC

In this guide

What you are actually choosing

Breast augmentation is not one decision. It is a set of them, and they interact: what the implant is filled with, how large it is, what shape it is, how far it projects, what its surface is like, whether it sits over or under the chest muscle, and where the incision is placed.

Which combination is right depends on measurements rather than preference alone. The width of your chest and of your breast base, how much breast tissue you have and where it sits, the quality and thickness of your skin, the position of the fold beneath the breast, and any existing asymmetry all constrain what will work. Dr. Smith takes those measurements at consultation and works through the options with you, with reasons, rather than handing down a single recommendation.

Seeing the options before you decide

The practice uses the Canfield Vectra system for three-dimensional imaging. Photographs are captured and rendered as a three-dimensional model of your own anatomy, and different implant sizes, shapes and profiles can be simulated on it. It is a planning tool rather than a promise of a result, and it is most useful for narrowing a range and for showing what a particular volume actually does on your frame, which is difficult to judge from photographs of other people.

Where the choices constrain each other

Some of these decisions limit others. A narrow chest limits how much volume can be added before the implant sits wider than the breast that covers it. Thin tissue at the upper pole limits how well the edge of an implant can be concealed, which affects both the fill material and the placement. A preference for a particular look sometimes points to a different implant than the one a patient arrived expecting. Dr. Smith will say plainly where that is the case.

Silicone or saline

Both are available, and silicone is what Dr. Smith uses in the vast majority of cases.

Silicone implants

A silicone implant is a silicone shell filled with silicone gel. It is the more common choice because the gel more closely resembles breast tissue in feel, and because visible rippling at the edges is less likely. Form-stable implants, often called gummy bear implants, are a type of silicone implant made with a more cohesive gel that holds its shape; they are firmer than standard silicone implants and are available in round and shaped forms.

A silicone implant rupture may not cause an obvious change in how the breast looks or feels. Many ruptures are silent, which is why follow-up imaging is recommended even without symptoms.

Saline implants

A saline implant is a silicone shell filled with sterile salt water after the shell has been placed, which allows a smaller incision. If a saline implant ruptures, fluid can leak out quickly or over several days, causing the implant to lose size or shape. A suspected rupture should be evaluated by your surgeon. The trade-off is feel: saline implants are firmer than silicone and show rippling more readily, particularly in patients with little breast tissue covering them.

Manufacturers

Four manufacturers make FDA-approved breast implants for use in the United States. Dr. Smith selects among them case by case, based on the sizes, shapes and profiles each range offers and on what your measurements call for. He will tell you which implant he is proposing and why before you decide anything.

How long implants last

Breast implants are not lifetime devices. On average they last around ten years, though some remain in place considerably longer and some need to be exchanged sooner. Planning on the basis that further surgery will be needed at some point is more realistic than planning on the basis that it will not, and it is worth factoring into the decision at the outset.

Imaging after silicone implants

The FDA recommends screening with MRI or ultrasound beginning five to six years after silicone implant placement, and then every two to three years thereafter. The purpose is to detect a leak that would not otherwise be apparent. This screening does not apply to saline implants, where a rupture shows itself.

Shape, profile and surface

Round or anatomic

Round implants are circular seen from the front and symmetrical seen from the side, so they give an equal amount of fullness in the upper and lower parts of the breast. They are what is used in the majority of aesthetic breast augmentation, and in the majority of cases in Dr. Smith's practice.

Anatomic implants, also called shaped implants, are roughly teardrop-shaped in profile, with more volume in the lower pole than the upper. They are used more often in breast reconstruction than in aesthetic surgery. Where a patient needs proportionally more lower pole volume than an upper pole that is already adequate, a shaped implant can be the better answer.

Profile

Profile describes how far an implant projects forward from the chest wall for a given volume. Manufacturers use their own terms, but the general categories are:

• Low profile. The least projection for a given volume, spread over the widest base.
• Moderate profile. Intermediate between the two. The majority of the implants Dr. Smith uses fall in this range.
• High profile. The most projection for a given volume, on the narrowest base.

Which profile suits you follows mainly from the width of your breast base. A low profile implant tends to read as less operated. A high profile implant is useful in a narrow breast, because it allows volume to be added forward rather than sideways, where it would sit wider than the breast covering it.

Smooth or textured

Dr. Smith uses smooth implants other than in very specific circumstances.

Textured shells were designed to adhere to the surrounding tissue and help hold a shaped implant in position. Capsular contracture, or tightening of the scar tissue around an implant, remains a possible complication with either implant surface.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon cancer of the immune system. FDA guidance identifies textured implants as having greater BIA-ALCL risk than smooth implants. The FDA has also received reports involving smooth implants, but previous implant exposure is often incompletely documented. Reports alone cannot establish which device caused the disease. Discuss the risks of each implant surface with Dr. Smith when choosing an implant.

Where the implant sits

The implant can go under the breast tissue and over the chest muscle, or under the pectoralis muscle. Under the muscle is what is used in most cases.

Submuscular placement

Placing the implant under, or partly under, the pectoralis major puts more tissue between the implant and the skin. That gives a softer transition at the upper edge, makes visible rippling less likely, is associated with a lower rate of capsular contracture, and makes mammograms easier to interpret.

The early muscle soreness can differ between implant positions, but Dr. Smith uses the same exercise milestones for conventional augmentation under or over the muscle when no lift is performed: light lower-body and core exercise at two weeks, light upper-body exercise at four weeks, and a gradual return to full exercise, including heavy lifting and running, from six weeks with clearance. The planner uses these exercise milestones when a breast lift is included as well; recovery still depends on the complete operation and individual healing. His breast augmentation recovery guide explains the full schedules for conventional augmentation, Preservé and breast lift.

Subglandular placement

Placing the implant over the muscle gives more direct access if further surgery becomes necessary. The implant is easier to see and to feel through the skin, particularly in a patient with little breast tissue, and the rate of capsular contracture is higher.

The situation in which over the muscle is clearly the better answer is a patient with a very developed pectoralis muscle, such as a competitive athlete or a bodybuilder. In those patients, flexing a strong pectoralis distorts an implant placed beneath it, which is called animation deformity. Outside that group it is unusual for subglandular placement to be the better choice.

Where the incision goes

An incision is needed to place an implant, and it will leave a scar. There are three usual locations, and they differ in how well the scar hides and in how much control the surgeon has over the pocket the implant sits in.

In the breast fold

The inframammary approach places the incision in the fold beneath the breast. It gives direct access to the pocket and the most control over exactly where the implant sits, and the scar is covered by the breast itself. This is the approach used most often.

At the border of the areola

The periareolar approach places the incision where the pigmented skin of the areola meets normal breast skin, usually along the lower half of that border. In a suitable patient the scar camouflages extremely well at the color transition. It carries a higher rate of capsular contracture and of infection than the inframammary approach, and it is not well suited to a small areola.

In the underarm

The transaxillary approach places the incision in the underarm, so there is no scar on the breast at all. It gives less direct control over the implant pocket and carries a somewhat higher rate of infection and capsular contracture than the inframammary approach.

How scars behave

Scars are raised and pink at first and fade substantially over the first year, after which they are generally difficult to see. How any individual scar matures varies between patients and cannot be predicted precisely beforehand, which is worth knowing before choosing an approach on the basis of the scar alone.

Every one of the decisions on this page is made together with Dr. Smith at consultation, on the basis of your measurements, your tissue and what you want. The consultation fee is $500 and is applied toward any procedure you go on to book.

Related procedures

For information about Dr. Smith’s approach with Motiva implants, explore Preservé breast augmentation in NYC.

Written by Darren M. Smith, MD, FACS, board-certified plastic surgeon, Manhattan.