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Natural vs. Fake: The Dilemma of Breast Implants (Original Article)

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breast augmentation for women seeking fuller figures has been around since the 1960’s. The original operation involved the insertion of surgical sponges. It was fraught with problems.


The 1997 movie Breast Men is a semibiographical depiction of the pioneers of breast implants who first used silicone prostheses. Since that time implants, and the surgical procedures to insert them, have evolved in many ways. However, the original goal is still the same; achieving a natural look.


Although the definition of “natural” can vary significantly, I’ll try to outline the variables I work through with patients for breast augmentation. It is important that patients be informed of the various options because there are several decisions in which they should participate.


Size Matters

            The most common question I’m asked during breast augmentation consultation is “What would be a good size?” My first response is to remind the patient that implants are not breasts. They are basically bags of water (saline) or gel (silicone) that are placed to enhance the woman’s own breast tissue.


A simple formula is that the greater the patient’s own breast tissue, and the smaller the prosthesis, the more natural the result. The converse is also true: the less tissue and larger prosthesis, the less natural, or more fake the appearance.


Size is, by far, the most important variable in achieving a natural result. If there is any doubt just take a walk along South Beach. In my opinion, there is nothing worse than an attractive woman with distractingly large breast implants.


Breast size is also influenced by cultural factors. I’ve had the privilege of lecturing in many countries. When I survey plastic surgeons I find that average implant size increases from Asia to Europe to Latin America to the U.S. I tell my colleagues that here we suffer from what I call the “Pamela Anderson Syndrome”. Interestingly, surgeons everywhere, even in Vietnam, seem to be familiar with the Baywatch star.


The problem with choosing an implant size is that there is no precise language that the patient and doctor can speak. Women identify breast dimension by cup size of their bra. Unfortunately, as most women know, bra size can vary tremendously. In addition, implants don’t come in cup size. Manufacturers create implants in sizes based upon the volume, in cubic centimeters (cc’s) of the bags. However, the numbers (250, 300, 350…) are usually meaningless to the patient.


Each surgeon develops his or her own technique for choosing the right breast implant size. Sometimes patients will bring in photos or try on sample prostheses in the office. I like to ask patients what their goals are. Do they want to be understated? Proportionate to their build? Or do they plan to dance on tables? It’s not an exact formula but I perform many augmentations and this method has worked well for me over the years.


I also point out to patients that breast implants are not like a pair of shoes, where one size fits perfectly, but a size above or below won’t. The correct choice of implant falls into a range of potential sizes.


Shapes and Styles

            Breast implants come in various shapes and styles. These choices will also impact the aesthetic result of surgery. The first choice is between saline and silicone prostheses. Saline implants are silicone-shell water bags. Silicone gel implants have a filling similar to gummy bear candy. Gel implants are softer. They feel and look more natural and are lighter than the equivalent saline sizes.


Gel implants are the most commonly used breast prostheses throughout the world. They are more expensive that saline and have some restrictions which should be discussed at the time of consultation.


Saline and silicone implants come with either a smooth or textured cover and in round or teardrop shapes. The concern of the latter is that they can tilt and cause an uneven bulge.


Textured implant covering feels similar to Velcro. It tends to make the implant stiffer and more likely to cause unnatural rippling of the breast skin. In the U.S., the smooth, round implants are most common. However, patients should feel all the implant types at the time of consultation and then decide for themselves.


Surgical Technique: It’s All About the Cleavage!

There are several surgical incisions and approaches to breast augmentation surgery. The technique often will vary based upon the surgeon’s preference and experience. The patient’s goals are important here too. These choices include placement of the scar and the implant pocket. The specifics of these decisions should be discussed with the surgeon during the consultation.


One very important variable however, is the position of the implant pocket. All too often implants are placed too far apart and fail to close the cleavage gap. However, women certainly understand, it’s all about the cleavage!


Even though every woman presents with a different preoperative cleavage gap, the surgeon should focus on helping the patient achieve her personal best. With few exceptions, the gap should be narrower in almost all cases.


We’ve revised cases where the gap was so wide that when the patient laid down the implants would roll into the armpits. One patient even affectionately referred to herself as the “table top chest”. In my opinion, proper cleavage is second to size in achieving a natural result.


So what goes into a “natural” breast implant result? The answer is all of the above; size, shape, style, technique and cleavage. Obviously, these will vary by patient and her personal goals. They should all be discussed thoroughly at the time of consultation.


About the Author:

Dr. Perez is a member of the NOVO National Council of Leaders in Breast Aesthetics. He has served as a consultant for both Mentor (J&J) and Inamed (Allergan), leading breast implant manufacturers.

He has lectured internationally on the subject of breast surgery and has been selected among the Castle Connolly (U.S. News & World Report) America’s Top Doctors. More information is available at or or call (954) 351-2200.