Saline vs. silicone? Under the muscle vs. over the muscle? Incision around the nipple vs. in the armpit or below the breast? Aren't there a lot of decisions? Not really. I will explain my approach to Breast Augmentation.
Silicone vs. Saline. As a general rule, silicone gel filled implants are softer and feel more natural than saline implants. I think they are the implant of choice for most patients. Saline implants are easier to insert, are adjustable in size on the OR table, and are cheaper. They are inserted in a deflated state, like an empty zip lock bag, whereas silicone implants are pre-filled and therefore require a slightly larger incision for insertion. Admittedly, breast augmentation has become slightly more complicated since the FDA approved silicone gel implants, after a decade-long moratorium. During that decade the only option in most cases was that of inflatable saline implants. Now there are two options: saline or silicone.
Under or over the muscle. Another variable is the location of the implant. Implants can be placed on top of or deep to the pectoralis major muscle.
The submuscular plane is usually preferred for three reasons:
Choice of incision. Implants can be inserted through an armpit incision, an incision around the areola or an incision in the fold under the breast. The choice is usually up to the patient although there are certain situations that lend themselves to one choice or the other. For example, I prefer not to use an inframammary incision when augmenting small breasts because the incision tends to be visible. Similarly, if the inframammary crease requires manipulation during the procedure (raising or lowering), I prefer a periareolar incision. Finally, if the patient has normal shaped breasts with small areolae and is committed to saline implants, an armpit incision is often chosen.
Size. The goal of augmentation is to provide the patient with the size she desires. On the other hand, smaller implants will look more like breasts, feel more like breasts and move more like breasts. It stands to reason that if an augmented breast is composed of more implant than breast tissue, it will feel and act more like an implant. On the other hand, if the augmented breast is composed of more breast tissue than implant, it will almost certainly feel, look and act like a natural breast.
To see before and after images, please click Breast Augmentation.