American Society of Plastic Surgeons
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Not as simple as saline vs silicone – Things to consider before having a breast augmentation procedure

While most patients tend to research the procedures of their interest online before coming in for a consult, some breast augmentation candidates at my own Nashville practice are surprised by the number of factors they need to keep in mind when planning their plastic surgery.

Besides the obvious decisions to be made for implant size and projection, here are some other elements you may have to consider.


This is probably the first and most common topic we get questions on during a breast augmentation consultation. The right-sized implant is mainly dependent on each individual's anatomy, and therefore different for every patient! It is very important to go to a surgeon who understands the complex interactions between existing breast tissue and a new implant. This allows for implant selection that will yield beautiful, elegant and long-lasting results with the lowest risk of complications. A tissue-based paradigm focuses on considering relevant aspects of the patient's anatomy, such as chest base width and breast tissue subtype, to make the decision.


Breast implants can be either round or "shaped" (i.e. teardrop-like). Shaped implants were originally created for breast reconstruction candidates to have an implant option that mimicked the natural slope/tapering (with increasing projection from top to bottom) of most breasts before surgery and are now used with cosmetic augmentation candidates as well.

Both types have their pros and cons. Teardrop implants may be more natural-looking for many women but may require a slightly longer incision and may look unusual if they rotate within their breast pocket.

Round implants may be better for patients who have shallower breasts at the top and could benefit from increased upper pole fullness. Their shape also allows rotation to be less of a concern.

Further, newer gel types considered cohesive or "gummy" allow the possibility of varied levels of gel firmness in a round shape, increasing our ability to match the perfect implant to the patient's skin and tissue type.


Round implants may come in smooth or textured shells. To minimize rotation, teardrop implants usually come with textured shells that promote the formation of scar tissue to hold the implant in place. For primary augmentation, we often use smooth implants which allow for a very natural feel.


Never assume that breast augmentation with implants is a one-and-done procedure. While breast implants may be long-lasting with very low risk of their shells rupturing, they are not lifetime devices. Modern implants typically last for more than a decade before they need to be replaced. Breast implants come in silicone shells with either saline (sterile saltwater) or silicone gel filling. Saline implants used to be more popular, but this has changed dramatically with the newer generations of silicone gel implants that can give an increasingly natural feel and contour, and a much lower risk of rippling and wrinkling deformity.

"Gummy" or "gummy bear" implants—called so because of their solid-state gel—are the type of silicone breast implants most patients choose for their relatively more natural look and feel. Because of their ability to hold their shape (i.e. their "form-stable" quality), they have a much lower likelihood of leakage, even if their shells rupture.

Saline implants may be inserted through a wider range of surgical techniques as they don't require as long an incision – an empty shell can be filled with saline after its insertion. Silicone implants come pre-filled, requiring a relatively longer incision (although still tiny!) to create an opening for insertion.

Incision and insertion method

The placement of surgical incisions through which the implants are to be inserted depend on patient concerns and characteristics, as well as the type of implant to be used (as noted above).

There are four main locations that might be considered for incision placement.

  1. The periareolar incision that is made around the areola
  2. The inframammary incision that is made under the breast in its crease
  3. The transaxillary incision that is made in the axilla or armpit
  4. The transumbilical incision or TUBA (TransUmbilical Breast Augmentation) made at the belly button (pre-filled implants cannot be placed with this method)

Current literature and data support the usage of the first three above techniques. However, there is some data suggesting that the safest approach to help limit the risk of capsular contracture is the inframammary approach. Thus, this is the most commonly taken approach in my practice.

Implant pocket

The implant pocket is where the implant will be placed in relation to the mammary gland and chest muscle. It is an important aspect of the procedure as it affects both aesthetics and function.

  • Subpectoral or submuscular implants are placed either partially or completely under the chest muscle (also known as the "dual plane" technique, which was developed where I trained)
  • Subglandular implants are placed between the chest muscle and mammary gland
  • Subfascial implants are also between the muscle and gland, but the fascia (thin layer of connective tissue above muscles) is lifted to sit on top of them

Breast augmentation can vary widely from patient to patient. While the number of factors to consider can make it appear confusing or intimidating, the procedure is known to yield one of the highest rates of patient satisfaction and is consistently one of the most frequently performed cosmetic surgeries in the United States year after year.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.


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