Breast
How Do I Choose My Breast Implants?
Choosing breast implants involves more than picking a size. This episode organizes the discussion around implant fill, incision location, placement relative to the chest muscle, and volume. Each decision needs to fit your anatomy, goals and understanding of the risks.
In this episode.
Episode summary
Choosing breast implants involves more than picking a size. This episode organizes the discussion around implant fill, incision location, placement relative to the chest muscle, and volume. Each decision needs to fit your anatomy, goals and understanding of the risks.
In this June 23, 2020 episode of Plastic Surgery: Before and After, board-certified New York City plastic surgeon Darren M. Smith, MD explains the choices he discussed with patients at that time, including how 3D simulation could help them compare sizes.
Key takeaways
🔎 Fill affects the conversation.
Dr. Smith compares saline and silicone gel implants, including feel and how a rupture may become apparent.
🔎 Incision location affects the surgical route.
The discussion covers the breast fold, the areolar border and the armpit.
🔎 Placement has tradeoffs.
He discusses tissue coverage and changes that may occur when the chest muscle contracts over an implant.
🔎 Size is personal and anatomical.
Body proportions, aesthetic goals and 3D simulation all feature in his explanation.
⚠️ Complications belong in the decision.
The episode explains capsular contracture, when scar tissue around an implant tightens and can cause pain or a change in shape.
Questions this episode answers
Why does silicone implant rupture require follow-up imaging?
The episode explains that rupture can be silent, without an obvious change in appearance. A normal-looking breast does not confirm that a silicone implant is intact.
Does everyone need the same implant position?
No. Dr. Smith explains his 2020 preference for placement beneath the muscle and discusses muscle-related movement as a tradeoff. That preference should not be read as the only appropriate plan for every patient.
Can 3D imaging guarantee my result?
The recording describes simulation as a way to compare possible sizes and clarify preferences. It is a planning discussion, not a guarantee of the eventual appearance.
ℹ️ Current safety context
This recording predates the FDA's 2021 labeling changes. Breast implants are not lifetime devices, additional surgery may be needed, and silicone rupture screening can involve MRI or ultrasound. Review the device-specific patient decision checklist and the FDA's current patient information with your surgeon.
🔗 Related information
Explore breast implant options, breast augmentation, or request a consultation with Dr. Smith in New York City.
Originally released June 23, 2020. Show notes updated September 30, 2026. This is general education. Current recommendations, suitability, risks and expected results require an individual assessment.
Original show notes
Board certified NYC plastic surgeon Dr. Darren Smith reviews some of the most important decisions to make when you are considering breast augmentation. What kind breast implants should you get? Should your breast implants go above or below the muscle? How big should your breast implants be? And more...
Read the conversation.
[00:08] I'm board certified New York City plastic surgeon Dr. Darren Smith and this is plastic surgery before and after. Your source for the real deal about plastic surgery procedures, news about trends in aesthetic medicine, and candid sessions with industry insiders. We hope you enjoy today's episode. Today we're going to be discussing some key considerations in planning for breast augmentation. There are really four big decisions to make when you are thinking about this procedure. The first one is what kind of implant do you want? And there are two major choices here. The first one is silicone and the second one is saline. Silicone has become really the very much more popular option at this point. It looks and feels more natural than the saline option. There are some people, however, that feel comfortable knowing that if their implant ruptures, there is just salt water there. On the other hand, the silicone implants have been shown to be incredibly safe, and the gel really does just stay put at this point if there is some kind of implant rupture. In fact, the term silent rupture comes up because if the implant does break you would very likely not even know it. And it's for this reason that it's recommended that periodic MRI screenings are carried out after a silicone breast implant is placed. So for people that prioritize natural look and feel above all else, silicone is really the way to go. And for folks that would rather have the peace of mind of knowing that if their implant does rupture they'll know right away saline may be the right decision. There's also another unique kind of implant available called the ideal implant and that seeks to marry the benefits of a silicone implant with the benefits of a saline implant. Specifically the ideal implant is filled with saline but it actually has concentric shells of silicone within it. And these are called baffles. And the idea is they prevent the saline within the implant from sloshing around. And this is intended to make the implant behave more like a silicone implant would. But again, with the state of technology as it is today in 2020, those looking to prioritize look and feel would be best served with a silicone implant. And really, the data is overwhelmingly in favor of this being a very safe choice at this point. The next consideration when thinking about planning for a breast augmentation is how is that implant getting put into the breast, meaning where is the incision going to be made and it follows that that is where the scar will be from the breast augmentation.
[03:12] So the most popular option here is what's called the inframammary approach. That is a small incision, usually three to four centimeters in the fold under the breast. And this provides very nice direct access to the plane in which the implant will be placed. And it's fairly straightforward and yields a very nice result. Other options include the periareolar approach, which is a small incision going around the lower border of the areola. And this also allows direct access to the breast, however you have to dissect through breast tissue to get to the plane of implant insertion. And the downside here is that there is a greater chance of interfering with the potential for breastfeeding and also a greater chance for infection. And it follows from this that there might be a greater chance of having capsular contracture. And that's something that we'll discuss a little later on in the episode. Finally, you can also put the implant in through a transaxillary approach. And that transaxillary refers to a small incision being made under the armpit and that way there is no scar on the breast at all. However, this approach has similar disadvantages to the periareolar approach in that there is a greater chance of infection and likely capsular contracture with this approach as well.
[04:45] Taking all of these things into account the inframammary approach remains the most popular approach in most practices and that's certainly the case in my practice. So the next issue that you'll want to address is where is the implant going and the answer obviously is in the breast. But more specifically is it going to go above the muscle or under the muscle and in this context the muscle is the pectoralis major that's the major muscle of the chest. The advantage to putting the implant under the muscle is primarily that it leads to a more natural looking feel, and that's simply because there's more stuff between the implant and the outside world that way. You have muscle, you have breast tissue, and skin. Whereas alternatively, if you put the implant over the muscle in what's called the sub glandular plane, that means it's under the gland of the breast, the only thing between the implant and the outside world is really breast tissue.
[05:45] and skin. The only real reason to put an implant in this position is in someone who is extremely athletic on the order of a professional beach volleyball player or something of that order. you might have a more significant animation deformity, which means when that muscle fires, if there is a implant under it, the implant can be deformed by the contracting muscle and that could look odd. So for someone who's extremely muscular, you might want to be putting the implant over the muscle, but otherwise the implant is going under the muscle in the vast majority of cases. And the last consideration with breast augmentation, Is that the size of implant that you're interested in having and that is an extremely personal decision and that takes into account your aesthetic ideals as well as your body type and body shape.
[06:40] And something that we find very helpful in our practice is advanced 3D imaging, where we take a 3D scan of our patient, and then we simulate different implant sizes so that the patient can see themselves at different implant sizes and get a sense for what they might be most comfortable with. We'd also like to just address one of the terms that I mentioned earlier, which is capsular contracture. And that is a complication that is possible with breast augmentation, where essentially when you put any kind of an implant in the body, a scar forms around it to wall it off from the body. That's how the body knows that that implant or that device is not part of itself, but it is remaining in place in the body at that location.
[07:32] And that's normal. Every time you put a breast implant in, you're going to get a scar around it. And we refer to that scar as a capsule. However, what's not normal is that in a very small percentage of cases, that capsule can contract or get smaller. And if you imagine that round... or spherical scar getting smaller and contracting around a breast implant, which has a fixed volume that can cause pain, it can cause a change in implant shape, or it can actually cause a change in implant position as well. So that is something that you should be aware of as a possibility when getting a breast augmentation, although a very unlikely possibility. And it could mean that the implant has to be removed.
[08:17] So, summing up, breast augmentation remains one of the most popular procedures that is performed across the country and the world in aesthetic plastic surgery, and it's certainly one of the most popular procedures in our practice, and it's something that is extremely gratifying for the patient. And hopefully, this overview will help you in your decision-making process. as you consider the kind of breast enhancement that you're looking for.
Sources and context.
Original Captivate episode. Original release date: 2020-06-23. The recording is the source for the transcript and episode discussion. Later context in the written summary is identified separately.
Behind the conversation.
Darren M. Smith, MD, FACS