There is no unanimous choice for the best breast implant, best surgical approach, or best plastic surgeon, but there will be a choice that is best for you. The most important decision you must make is your choice of plastic surgeon, and then work together with your surgeon to find the best operation for you.
What follows is a description of the different issues you will need to consider when you come in for consultation, and your familiarity with these topics prior to consultation will allow you to be more confident in making a decision about surgery.
Saline Implants: A silicone shell containing salt water, these implants are limited by an unnatural feel, and visible ripples can be a problem, especially if you have low body fat. Deflation of the implant can occur, which would require further surgery, but this is not a common problem. Saline implants are commonly used for axillary augmentation, because they can be inserted through a small incision and inflated once they are in position.
Cohesive Silicone: The use of ‘cohesive’ silicone avoids the problem experienced with liquid silicone implants, in which the silicone would leak outside of the implant. Cohesive Silicone implants can be made form-stable or anatomic, to create a less rounded, more natural appearance. The shell of cohesive implants can be textured to hopefully decrease capsular contracture, and texturing is used to keep shaped implants from rotating or displacing over time. If you are looking for a more rounded appearance, then a round textured gel implant may be best for you. Smooth cohesive silicone implants are good for revision surgery where there is already a big pocket, and can also be used for augmentation by the axillary approach.
Should you go too big or too small? You should decide which error would make you more upset, as there is no size that will be perfect in all situations. Choose the size you want to be when you are naked, because you can always wear a padded bra to make yourself bigger when clothed. A too big implant is more likely to be trouble, as it is more painful surgery, it is more likely to cause wound complications, it can contribute to back pain, it is harder to hide behind clothing, and it will compress your natural breast tissues and leave you with saggy skin if you later choose to remove your implants or simply go smaller.
Canadians are fortunate in that the Poly Implant Prosthesis (PIP), a breast implant from France, was not sold in Canada, as they have been found to be flawed. The current manufacturers supplying Canada, Mentor and Allergan, both make a good quality implant that has stood the test of time. Ten-year studies have confirmed these implants do not decay over time. There is little to choose between Allergan and Mentor saline implants, but the Allergan cohesive gel implants are favoured by some because they have less rippling than the Mentor implants.
Over vs. Under vs. Dual plane
Implants positioned over muscle allow quick recovery, and avoid any impact on muscle function (important for performance athletes), but problems like capsular contracture are more obvious, and implant ripples will show unless there is already substantial breast tissue. Implants under muscle (through an axillary approach) sit high on the chest but can be the best option for young patients. Dual plane positioning is our commonest option, with the upper part of the implant covered by muscle to control implant position and hide ripples, and the lower part of the implant positioned for ideal cosmesis under gland alone.
Areolar or nipple incisions can hide well in some patients, but a bad scar will be very conspicuous, sensation and breast feeding may be affected, and exposure of the implant to bacteria is more likely. Inframammary (in the breast crease) incisions are best except when patient has very small breasts and the augmented breast won’t hide the scar. Axillary augmentation is ideal for the young, A-cup who has never had kids, because the the axillary scar can be imperceptible, and the high position on the chest wall of a submuscular implant will not be an issue.
Local vs. Travel
Most patients who travel to visit a surgeon do well, but always consider the small possibility that you may develop complications and need further care and possible surgery. The distance you must travel to see your surgeon may compromise your care, and ultimate outcome.
A surgeon who is good at nose jobs is not necessarily an expert at breast augmentation. Word of mouth from a satisfied breast augmentation patient can be useful. Message boards are a very good way to see if breast augmentation is a specialty of a surgeon, and you should be cautious in choosing a surgeon who has lots of negative comments.