‘My breasts are sagging and I am a 36 B. I want to have breast augmentation to make them bigger. What worries is that my breasts are too spaced pretty far apart and I would like nice cleavage. How can I be sure that I will have good cleavage after my breast implant surgery?’
This is an incredibly common question and objective for many females considering breast enhancement. This patient has astutely observed her widely spaced breast ‘problem’ and is asking about it before surgery. Many patients, however, are unaware of their breast spacing but are equally expectant of good postoperative cleavage.
The amount of cleavage that can be present after breast augmentation will vary greatly depending upon the unique characteristics of each patient’s chest wall anatomy. Important variables include the width of the chest wall and rib cage, the prominence or lack thereof of one’s sternum, the natural separation of your breast mounds and nipples, the location of the nipples on the breast mounds and the amount of angulation or divergence of the breast mounds from the sternum. (sternal-rib angle)
To achieve the best and most natural look, breast implants need to be placed so that they are centered behind the nipple-areola complexes. The implants need to extend as much to the side of the chest wall as they do towards the sternum underneath the nipple. This implant location is more important than getting the implants close to the sternum for cleavage purposes. If the implants were to lie closer together than the nipple position would allow, the nipples will end up pointing outward creating a ‘wall-eyed’ effect or look.
In widely spaced breasts, therefore, natural cleavage may be impossible. Cleavage may only be obtainable in significant breast separation with the use of very large implants, which may be disproportionate for one’s body frame. It is important for such patients to realize that few women have breasts that will have cleavage, without a bra, after augmentation. ‘Synthetic’ cleavage (i.e., a bra) is needed by most women whether they have breast implants or not.
The spacing between your implants depends on the spacing you have naturally between your breasts before surgery. Some women have wide sternums or breast bones and some have narrow sternums. If the implants are placed too close together, an artificially-created cleavage will result. The skin over your sternum or breast bone is very thin and if the implants are placed too close, you will likely seem the edge of the implants.
Discuss your cleavage concerns with your plastic surgeon BEFORE your breast augmentation surgery. Find out what is realistic and what can be done given your anatomy and the location of your breast mounds. Good cleavage after breast augmentation, without a bra, is actually very uncommon.
1.Which is a better breast implant, saline or silicone?
Neither of them is better than the other. Both are FDA-approved and millions of women have both types of breast implants. But they do have some property differences between them that patients should know. Understanding their differences can help one decide which is best for themselves.
Saline breast implants have the advantages of being able to be placed through the armpit (leaving no scar on the breast) and are lower in cost. Its disadvantages are that one may be able to feel, and sometimes see, implant rippling and a deflation can occur (flat breast) should a hole or small tear develop in the containment bag.
Silicone gel breast implants have the advantages of a more natural feel with less rippling and will not spontaneously deflate if a hole develops in it. Its disadvantages are that they are more expensive and need a larger incision in the lower breast crease in which to be inserted.
2.Should breast implants be placed above or below the chest muscle?
The history of breast augmentation has seen implants placed both above and below the pectoralis muscles. Successful results have been obtained both ways. Each location has certain advantages and disadvantages.
Placing a breast implant above the muscle (subglandular) causes less pain after surgery and fills out a breast better that has some amount of skin sag. It is associated with a higher long-term risk of hardening (capsular contracture)and the outline of the implant may be more noticeable. With the commercial return of silicone implants in 2006, subglandular techniques are becoming more commonly used again.
Implant placement under the muscle (subpectoral) causes more immediate discomfort but creates a more natural look in the upper part of the breast. This approach significantly reduces the long-term risk of capsular contracture and is the preferred location for saline implants due to their rippling concerns.
3.Can implants help lift up sagging breasts?
As a general rule, no. This is a common misconception. Implants will not lift up significantlya breast mound that is drooping nor will it make the nipple move up higher on the chest wall. If the nipple is even slightly pointing downward or sits at or below the lower breast crease, one needs to consider a lifting procedure with their augmentation.
Breast sagging, or ptosis, is a frequent issue in the post-pregnancy breast which exhibits a deflated and downward appearance. Careful consideration in this common breast condition of the trade-off between breast shape and scars is essential to avoid an unhappy breast augmentation result.
4.Will my breast implants last my entire lifetime?
While this is possible, one should not expect it. The filler material in a breast implant is encased in a plastic (silicone) bag. This bag will eventually develop a crack or tear due to fatigue from motion and intermittent deformation from outside pressures. Given the relatively young age (under 40) of many breast augmentation patients, it is not realistic to expect an implant to hold up for several decades.
There does not appear to be differences in failure for saline vs silicone breast implants. The differences is in the awareness of failure between the two. Saline implant deflations will result in an obvious change in breast size. Silicone implants may not be detected for some time after failure as an obvious change in breast size does not occur.
Fortunately, all breast implant manufacturers have lifetime implant replacement warranties and monetary compensation should it occur in the first ten years after surgery.
5.Will I have normal nipple sensation after surgery?
Most women maintain nipple sensation after breast implant surgery but there is a risk that it may be diminished or lost altogether. One of the major nerves to the nipple comes from the side of the chest wall at roughly the level of the nipple. This nerve’s path is very close to where the pocket must be developed for the implant. The nerve may be stretched or injured during the course of this dissection.
Fortunately, the likelihood of a completely numb nipple after surgery is low. More commonly, there may be some temporary changes in feeling which could be extra feeling (sensitivity) or some mild decrease. Recovery of complete feeling occurs within weeks to a month or two.
6.Can I breastfeed after surgery?
Yes. A breast implant is well removed from the location of the ducts under the nipple. This is particularly true when the incisions are in the armpit or lower breast crease and the implant is placed under the muscle. If the nipple incision is used and the implant is placed above the muscle, some disruption of the ducts are possible but unlikely.
7.How do I choose the right breast implant size?
Breast implant size is a personal choice and isdifferent for every patient. Show some pictures to your plastic surgeon and discuss what you think is appropriate for your body. There are, however, several anatomic considerations that can help one decide about the volume of the implant.
The size of the implant should not be more than your breast tissues can support over time. If it is too big, the implant will bottom out and drop down too low eventually. The thickness of your breast tissue and the tautness of your skin factors into this consideration.
The width (base diameter) of the implant should not be greater than the width of your own breast. This is a good simple measurement that can keep the implant’s size body proportionate. When the implant is wider than your breast width, it is not only likely too big but will also end up being too far to the side and may interfere with the swing of your arm.
Breast augmentation surgery through the use of implants naturally increases one’s breast size. And while all breast augmentation patients have great concerns about the final size they want to be, they also are often concerned about the final shape as well. While breast implants, whether they are saline or silicone, come in a wide variety of sizes they also come with different projections or profiles. The concept of breast implant profiling is relatively new and is an additional consideration that prospective patients needs to consider.
Profiling of a breast implant is a method of altering the shape of the implant, changing the height and width ratio. That may sound like geometry but what it does is allow more of the implant volume to create a ‘higher mountain’. This is real apparent when looking at to two different profiles of the same size implant when sitting on a table. The higher profile one will be slightly narrower (decreased diameter) but will sit up higher. When sitting on a woman’s chest that means the top side of the implant will be more full, creating a rounder breast shape. Lower profile implants will create more of a natural or teardrop shape. Every breast implant size comes in different profiles as well.
What I have found about breast implant shape is that women prefer one of two types. The teardrop or natural shape or the more full and rounder (some call this unnatural) breast shape. The profile of the breast implant will make a contribution to this final shape, a high profile implant for a round shape and a low or moderate profile for more of a teardrop shape.
I caution all patients, however, that the profile of a breast implant is but one contributing factor to the final breast shape. In reality, it may not even be the most important. The tightness or looseness of the existing breast size and the size of the implant may be more important. For example, small tight A or B cup breasts with a large implant will end up looking round no matter what the profile is used. Conversely, loose saggy breast skin that is implanted will almost always have a final teardrop shape unless a very large implant is used.
When considering breast augmentation, breast implant options include filler material (saline vs silicone), size in ccs, and height of profile. The concept of breast implant profile is relatively new and what its impact may be on the final shape of the breast should be gone over carefully with your plastic surgeon.
The image of a beautiful breast will vary greatly, dependent upon a woman’s perspective and tastes. I have found in consultation with patients that it is actually easier to have a woman describe what they don’t want their breasts to look like…and then work from there to figure out exactly what is acceptable to them. As I consult with patients here in Indianapolis on breast augmentation, I emphasize the following points.
In general, the focus on what is achievable in most breast augmentations is primarily on mound creation (big or small), mound shape (round or tear-drop), and cleavage….in exactly that order. Many variables of a breast we as plastic surgeons cannot control, such as the quality of the skin, how widely spaced are the breasts, breast asymmetry, differences in nipple shape and position, the chest wall shape, and the length of the torso.
Mound size is, obviously, highly influenced by the size of the implant. While any implant size can be placed in most women, it is desireable that the base diameter of the breast implant not exceed the natural width of one’s breast base. This keeps from having the breast implant being too far to the side. If more size is needed than one’s breast base diameter will accomodate, then a high-profile type implant should be used. More implant going forward, less to the side. The same principle applies to loose skin or saggy breasts, a higher-profile implant will pick up slightly more skin.
Mound shape, while influenced by a breast implant’s projection (low, moderate, high) is also controlled by the quality and amount of the overlying skin. The tighter and smaller a woman’s breasts are to begin with, the more likely the final breast shape will be more round, regardless of the implant projection used. Looser, more sagging breasts will just not end up with a round, very full breast, unless the breast implant is exceedingly large. While it is good to have different breast implant projection styles, it is my opinion that the amount and quality of the breast skin is the single most important issue that controls a round vs tear-drop breast shape after breast augmentation.
Cleavage is always an issue for most women, as no woman wants a wide space between the two breast implants. It is important to remember, however, that in most cases cleavage is ultimately made by a bra. It is unusual to create, by the placement of breast implants, a lot of cleavage. It is difficult and often ill-advised to release a lot of the pectoralis muscle to get the breast implants very close. Quite simply, widely-spaced breasts will end up with breast implants that are not that close together.
Understanding these basic issues of what breast augmentation can do is important in providing a patient with realistic expectations after breast augmentation. The key point is…you can make a woman’s natural breast bigger through breast implants, but breast augmentation can not alter some of the features that nature has already given the breast.
The most important choice a woman makes in breast augmentation is the choice of filler material of the breast implant. As of 2006, silicone gel implants became available again and thus one has to choose between saline (which has been the only implant option available since 1992) and now silicone. The thing to remember is…..neither type of breast implant is perfect. If one was so much ‘better’ than the other….we would have only one implant type, not two. Both can satisfactorily increase breast size equally well, they just have some different features (pluses and minuses). Knowing what their benefits and liabilities are can help you make the right choice for you.
Saline implants have the following benefits: 1) They are put in deflated, rolled up, and inflated after they are in proper position. Therefore, they can be put in through very small remote incisions such as the armpit, 2) They cost less than silicone, typically $1,000 less per operation, and 3) They are the most natural material (salt water) so if they leak, you are essentially just taking a big drink of water. Saline implants have the following two liabilities: 1) They have the phenomenon of wrinkling or rippling. In other words, you will be able to feel, and sometimes see, ripples along the bottom and sides of your breasts. Most saline breast implant patients will experience this ‘normal’ appearance, 2) The risk of spontaneous deflation (rupture of the implant) is ever present and increases the longer the implants are in place. When a saline implant fails (ruptures), you will know it almost immediately because you will develop a ‘flat tire’ quite quickly. While some saline breast implants may never deflate, it is unlikely they will last beyond 10 to 20 years.
Silicone implants have exactly the opposite benefits and liabilities of saline implants. On the positive side, 1) Silicone breast implants do not have the ripple phenomenon that saline implants do. Therefore, they feel the most natural. It can be very difficult, by feel, to ever know that a breast has a silicone implant in place, and 2) While a silicone gel implant can rupture, the filler material is cohesive and does not come flowing out. As a result, the breast does not deflate in size or get smaller. The ruptured implant is essentially undetectable, and as long as the breast remains soft and pain-free, you can live with a ruptured silicone breast implant without the need for further surgery. On the liability side, 1) Silicone implants come pre-filled, thus needing a larger incision to surgically implant it. The most common incision location for silicone implants is in the inframammary crease (breast fold). Remote incisions like the armpit, and often even the nipple, are not big enough to insert the implant through. And 2) they cost more than saline, at least $1,000 more in most cases.
The best way to chose which type of breast implant is for you……which of the negatives can you live with the best……risk of rippling and deflation (saline)……or higher cost and a bigger incision (silicone)…the choice is truly yours!
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.